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Fresh osteochondral allograft for shoulder resurfacing relieves pain
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Total shoulder arthroplasty is a reliable treatment for glenohumeral arthritis in older patients, but the treatment of large, bipolar chondral defects of the shoulder in young patients remains a challenge for even experienced shoulder surgeons. Shoulder arthritis in young patients may be caused by trauma, infection, avascular necrosis, chondrolysis, inflammatory arthritis or early-onset osteoarthritis. These young patients often have high demands and high expectations following surgery, which may lead to issues with patient satisfaction despite excellent technical results. Traditional shoulder arthroplasty would be expected to fail during a young patient’s lifetime due to component wear or loosening, and that has caused us to focus on biologic solutions to this challenging problem.
Dr. Gobezie has short-term and early mid-term success with arthroscopic total shoulder resurfacing using fresh osteochondral allograft in the treatment of selected younger patients with severe arthritis or large osteochondral defects. The age range for the patients he has done so far is between 25 years to 67 years with an average age of 49 years. This outpatient procedure is performed without violating the integrity of the subscapularis, which makes recovery faster and easier for the patient (Figure 1).
The patient is placed in the beach chair position, and the procedure is performed using standard shoulder arthroscopy portals. The grafts are introduced through the rotator interval using the anterior portal, which is enlarged to accommodate the introduction of a 20-mm to 25-mm fresh osteochondral allograft.
Figure 1. The diagnosis is confirmed.
Figure 2. The guide pin is placed.
Images: Streit JJ et al
Humeral head preparation
The first step is a standard shoulder arthroscopy to debride the glenohumeral joint and establish excellent visualization. A capsular release may be necessary to provide more laxity of the joint. Next, the chondral defect of the humeral head is identified and assessed from both the posterior and anterior portals to understand the location and shape of the articular cartilage defect. After clearly defining the geometry of the defect, a 25-mm targeting guide is introduced through the anterior portal and centered over the area to be resected. A transhumeral guide pin is then drilled antegrade through the humeral head with the starting point inferior to the axillary nerve (Figure 2). The guide pin should be advanced until it reaches the center of the targeting guide. The pin is then over-reamed with a 5.5-mm cannulated drill (Figure 3). A transhumeral sleeve is then introduced into the tunnel created by the drill. A threaded central pin is inserted through the sleeve, then connected to the appropriated sized cutting reamer, which is introduced through the anterior portal and rotator interval.
Once the cutting surface of the reamer is connected to the shaft pin, the reamer is started with minimal pressure on the articular surface then manually pulled in a retrograde manner to create a shallow bone socket of approximately 5 mm to prepare the site for the humeral osteochondral allograft. Prior to final placement of the humeral graft, attention is directed toward grafting the glenoid defect (Figure 4).
Figure 3. The retro reamer is inserted into joint and onto the retro pin.
Figure 4. The humeral recipient socket is shown.
Steps for glenoid preparation
For the first step of glenoid preparation, a glenoid aiming guide is introduced through the anterior portal and centered over the bare spot (Figure 5). The transhumeral sleeve, which remained in place following humeral preparation, is used to drill a guide hole in the glenoid. An antegrade reamer is then used to make space for a 20-mm glenoid graft.
Figure 5. The glenoid aiming guide is inserted.
Figure 6. Flush glenoid reaming is seen here.
Prior to seating the glenoid and humeral grafts, the joint should be inspected for any remaining soft tissue and bone debris that could interfere with placement of the humeral and glenoid grafts (Figure 6).
Figure 7. The glenoid inserter is seen.
Figure 8. The chondral dart inserter is introduced.
Graft preparation and insertion
The glenoid allograft is inserted and finalized before the humeral graft. The glenoid graft is obtained either from a glenoid allograft or a medial tibial condyle graft. The glenoid graft is introduced through the anterior portal and rotator interval using a glenoid inserter. Once it is positioned over the reamed surface, it is lightly tapped into place using a mallet and flat pin through the transhumeral portal sleeve (Figures 7 and 8). Final seating of the allograft is done using a graft impactor inserted through the anterior portal (Figure 9).
Figure 9. Use the sport impactor to seat the graft.
Figure 10. Use a humeral core fiber wire to aid in seating the humeral graft.
The surgeon may select any portion of the humeral head for use as a graft with this procedure. It may be helpful to use the area of the humeral head fresh osteochondral allograft that matches the defect in the patient. The fresh allograft is then placed onto an Osteochondral Autograft Transfer System platform (Arthrex Inc.; Naples, Fla.) and resected with a core reamer. A small drill hole is then made in the humeral head allograft to permit passage of a #2 FiberWire suture (Arthrex) that will be used to draw the graft into place via the transhumeral portal.
The humeral graft is introduced through the anterior portal. The suture in the graft is shuttled from inside the glenohumeral joint through the transhumeral sleeve using a nitinol wire with an end loop. The graft is seated by manually guiding the graft into the bone socket while pulling the #2 FiberWire suture retrograde through the transhumeral portal (Figure 10). The graft is fully seated using digital pressure or by moving the shoulder through a range of motion to compress the graft against the glenoid. Final assessment of graft seating is performed through both the anterior and posterior portals (Figure 11).
Outcomes include motion restoration
Figure 11. The final outcome is shown.
Patients have generally done well following this procedure. At a mean follow-up of 17.1 months (range 3 months to 29 months) in 20 patients, the mean VAS pain score had improved from 6.1 to 3.9, mean ASES score had improved from 32 to 61, and mean active ranges of motion had improved from 126 to 139 in forward flexion and from 31 to 39 in external rotation. Mean internal rotation reached the level of L4 preoperatively and remained unchanged. There have been 4 failures converted to shoulder arthroplasty and most of the patients have returned to their pre-injury level of activities. Early range of motion is allowed postoperatively because none of the soft tissue restraints of the shoulder are violated during surgery. Pain relief is usually substantial, and patients are often able to resume activities they previously had to limit due to shoulder pain. We do, however, caution against using this procedure in workers compensation patients since outcomes were substantially worse in this subgroup based on our experience.
Overall, this new arthroscopic, biologic total shoulder resurfacing procedure preserves bone stock and offers young patients pain relief and a potentially viable option for avoiding conventional shoulder arthroplasty that may give them the restoration of function and pain relief they are seeking. The longer-term outcomes for this procedure will, ultimately, dictate its place in the armamentarium of treatments for this difficult problem in the young patient.
Reference:
For more information:
Yousef Shishani, MD, can be reached at University Hospitals of Cleveland, The Cleveland Shoulder Institute; email: dy.shishani@gmail.com.
Jonathan J. Streit, MD, can be reached at Case Western Reserve University, Department of Orthopaedic Surgery, University Hospitals of Cleveland, 1100 Euclid Ave., Cleveland, OH 44106; email: jonathan.streit@gmail.com.
Disclosures: Gobezie receives royalties and research support from Arthrex and is a paid consultant for Tornier. Shishani and Streit have no relevant financial disclosures.