Nonarthroplasty options for glenohumeral arthritis and chondrolysis

History

Patients typically report deep shoulder pain, and often the pain is located posteriorly. The pain may also be described as dull or diffuse at rest with stabbing, sharp exacerbation with activity, especially when the arm is brought into the end-range position.

Articular cartilage lesions of the shoulder are often incidental findings discovered during preoperative imaging studies or during diagnostic arthroscopy. If asymptomatic lesions are treated, the true cause of symptoms may be ignored or missed, and the treatment itself may cause further damage to the chondral surface. With this in mind, it is crucial to determine if glenoid or humeral head articular cartilage lesions are truly symptomatic through the gathering of a thorough patient history. In patients with multiple shoulder pathologies and those who have undergone prior operations, it is even more challenging to determine if current articular defects were actually responsible for their previous, preoperative symptoms. In addition, patients with previous shoulder surgery and intra-articular pain pump placement are at risk for the development of postsurgical glenohumeral chondrolysis. Patient history is pivotal in differentiating between osteoarthritis (OA) and chondrolysis. OA is a longstanding pathology presenting with an indolent course including prolonged periods to adapt to a progressive loss of cartilage. In comparison, chondrolysis presents with severe pain and rapid functional loss. Therefore, time to presentation is an important factor in the distinction of chondrolysis from a more passive condition such as OA. During the initial office visit, the clinician should inquire about the following:

• Mechanism of injury - traumatic versus insidious onset

• Current symptoms - may point to alternative diagnosis

  • Locking

  • Clicking

  • Crepitus

  • Pain (e.g., rest pain, activity-related pain, night pain)

  • Stiffness

  • Inability to use arm above head

  • Instability

  • Numbness or tingling

• Previous nonsurgical and surgical treatment of the shoulder

• Response to prior treatment

• Patient’s activity level

• Post-treatment goals

  • Allows the surgeon to address patient expectations, ensuring these are aligned with treatment options and outcomes

Signs and symptoms

Patients with glenohumeral chondrolysis typically have a nonspecific presentation including activity pain, night pain, and motion loss. Popping or clicking sensations and shoulder swelling are often associated with articular cartilage pathology. However, soft-tissue injuries including rotator cuff lesions can also present similarly. Numbness and tingling of the involved extremity are typically not seen in these patients and should direct the clinician to an alternative diagnosis. Patients may also report sudden pain and locking in specific shoulder positions associated with engagement of articular lesions.

Physical examination

A complete bilateral shoulder examination should be performed for every patient being evaluated for symptomatic chondral defects. Range of motion (ROM), strength, sensation, and stability of the affected shoulder are compared with those of the contralateral shoulder. Loss of active or passive motion must be documented and corrected preoperatively. Early identification of stiffness allows time to restore deficits before operative treatment for chondral defects. Special shoulder tests should be performed when necessary to evaluate for comorbidities and to rule out other causes for the patient’s symptoms.

Common, nonspecific physical examination findings in this patient population may include the following:

• Tenderness to palpation

• Decreased ROM

  • Decreased forward flexion caused by an inferior humeral head spur.

  • Decreased external rotation caused by a flattened humeral head.

  • Decreased external rotation at the side (ERs) can indicate anterior capsular contracture, including the rotator interval, the superior and middle glenohumeral ligament, and the coracohumeral ligament ( Fig. 41.1 ).

    

  • Decreased abduction and external rotation (ABER) can indicate anterior and anteroinferior capsule contracture.

  • Decreased abduction and internal rotation (ABIR) can indicate posterior and posteroinferior capsule contracture ( Fig. 41.2 ).

    

  • Decreased abduction (ABD) can indicate inferior capsule contracture and possible involvement of the superior capsule or superior labral anterior-posterior (SLAP) region.

• Crepitus with ROM - painless versus painful

• Clicking, catching, or locking with ROM

• Normal strength and sensation

Imaging

Imaging studies such as radiographs, magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and computed tomography (CT) are routinely used in the evaluation of glenohumeral chondral lesions. Despite advances in imaging techniques, glenohumeral articular surface defects may not be easily seen on plain radiographs or with other advanced imaging modalities, and glenohumeral arthroscopy remains the gold standard for diagnosis. However, imaging remains helpful not only for diagnosis, but also for preoperative planning. Specific planning considerations include the chondral anatomy of the shoulder joint. Normally, the humeral head cartilage is thickest in the center (1.2 to 1.6 mm thick) and thinner at the periphery (less than 1.0 mm thick). In contrast, the glenoid cartilage is thickest along the periphery, tapering centrally to the bare area where it is completely devoid of cartilage. Knowledge of normal anatomy in conjunction with information supplied by imaging studies helps determine the significance of lesions based on their location along the humeral head and/or glenoid surface.

Radiographs

Every patient should undergo a standard radiographic series of the shoulder including an anteroposterior (AP) view, an axillary lateral view, a scapular-Y view, and a true AP view to assess subtle joint space changes. These views are useful in evaluating the joint space for glenohumeral arthritis and may show overt bony abnormalities. Other specific radiographs include the Stryker notch view to evaluate Hill-Sachs lesions and the Garth (apical oblique) view to evaluate glenoid bone loss ( Fig. 41.3 ). The earliest signs of glenohumeral wear are usually in the posteroinferior quadrant of the shoulder and may demonstrate joint space narrowing or subtle posterior joint subluxation ( Fig. 41.4 ).

Magnetic resonance imaging and magnetic resonance arthrography

MRI and MRA are the imaging modalities of choice for the evaluation of glenohumeral chondral surface lesions. In addition to evaluating the articular surface, MRI and MRA can detect subchondral bone changes and concomitant soft tissue ligamentous, labral, and rotator cuff pathology. ^, T1-weighted fat-suppressed three-dimensional spoiled gradient-echo technique are particularly helpful. Moreover, all sequences should be analyzed through the T2-weighted image (with and without fat suppression).

Computed tomography

CT images provide a global evaluation of the glenohumeral joint, and three-dimensional reconstructions add enhanced detail. Although not routinely obtained as part of a workup for suspected glenohumeral arthritis or chondrolysis, CT scans are useful for operative planning in patients requiring more invasive osteochondral reconstruction. CT scans can be especially useful for evaluating full-thickness cartilage defects that include the subchondral bone.