Wednesday, April 6, 2016

Chondrolysis of the shoulder - shoulder arthroplasty had mixed results in this series

Shoulder arthroplasty for chondrolysis.

These authors treated 26 shoulders with chondrolysis using shoulder arthroplasty.

All shoulders had a prior arthroscopic surgery that predated a phase of rapid joint destruction. In many cases, multiple arthroscopic procedures were performed, suggesting that the pathology was not well defined: SLAP repair+cuff repair, cuff repair+biceps surgery+labral debridement+distal clavicle excision, SLAP repair+cuff repair+acromioplasty, etc.

Twenty-three shoulders (19 total shoulders, 4 hemiarthroplasties) were followed up for a minimum of 2 years or until reoperation (mean, 4.0 years; range, 0.7-8.6 years). Six different surgeons were involved and performed multiple different types of arthroplasthy.

The mean age of the patients was 40 years (range, 21-58 years). 

Overall pain scores improved from 4.7 to 2.6 points; only 14 of 23 shoulders had no or mild pain. 

Of the 4 hemiarthroplasties, followup x-rays showed mild central glenoid erosion in 2 and severe central erosion in 1. Of the 19 total shoulders, 4 had Grade 1 lucencies, 5 had grade 3 lucencies, 1 had a shift in glenoid position, one had a grade 3 humeral lucency, and two had severe anterior subluxation.

Five shoulders required reoperation, 2 for glenoid loosening and 1 each for infection, instability, and stiffness. 

Subjectively, 8 patients rated their shoulder as much better, 7 as better, 4 the same, and 4 worse. 

Most recent American Shoulder and Elbow Surgeons scores averaged 64 points (range, 20-95 points).

Comments: While these authors were unable to determine the etiology of chondrolysis in the majority of their cases, the published evidence indicates that the preponderance of these cases are related to the intraarticular infusion of local anesthetics via a pain pump as discussed in this post.  The reason that clarifying the etiology is important is that prevention is much more effective that treatment for this condition.

We concur that this is a difficult condition to manage - patients are young, often have had multiple prior surgeries, have substantial pain and stiffness, are often functionally worse off than before their index arthroscopy, have destruction of the joint surfaces, and have abnormalities of their soft tissues that predispose the shoulder to persistent stiffness. 

Experience has taught us that (1) it is important to have extended discussions with the patient and family prior to arthroplasty to make sure that the challenges and risks of a poor outcome are well understood, (2) that postoperative pain management is clarified, (3) that the arthroplasty technique include vigorous soft tissue releases and careful balancing so that both range and stability are optimized, and (4) that the patient and surgeon be in close contact so that recurrent stiffness can be addressed with additional PT, a closed manipulation or additional soft tissue releases. 

We have managed chondrolysis with total shoulder arthroplasty and with the ream and run procedure. Posts of interest are shown here, here, here, and here.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'