Saturday, February 11, 2017

Shoulder arthritis in the very young - is osteochondroal allograft a consideration?

Midterm results of osteochondral allograft transplantation to the humeral head

These authors report on 20 patients with an average age of 25±8 years having osteochondral allograft (OCA) transplantation for humeral head osteochondral defects.

The etiologies of the articular defects included intra-articular pain pump in 10 patients, recurrent anterior instability in 4, reverse Hill-Sachs in 3, and prominent suture anchors, prior thermal capsulorrhaphy, and non-identifiable causes each in 1 patient.

All patients had undergone prior surgical treatment to the operative shoulder, with the primary procedure being Bankart repair in 8 patients, superior labrum anterior and posterior repair in 5, capsulorrhaphy in 3, and superior labrum anterior and posterior d├ębridement, microfracture, biceps tenodesis, and capsular release each in 1 patient. The average patient underwent 1.9 surgical procedures (range, 1-5 procedures) before OCA reconstruction, with many patients undergoing arthroscopic capsular release, microfracture, and d├ębridement as temporizing efforts.

Eleven patients underwent concomitant glenoid surgery (microfracture or meniscal allograft resurfacing).
Follow-up was available for 18 patients at mean of 67 months.
Sixteen of the grafts healed by x-ray.
Eleven patients were satisfied.
Four patients required revision to a shoulder arthroplasty at mean of 25 months postoperatively (all after pain pump chondrolysis).
Pain pump patients who did not have revision to a shoulder arthroplasty arthroplasty experienced inferior satisfaction and outcomes compared with the rest of the cohort.
The authors concluded that OCA transplantation is an option for young patients with isolated humeral chondral injury.
Patients with glenohumeral arthritis or a history of intra-articular pain pump had poor outcomes.

Comment: It is of interest, as pointed out in this link, that the etiologies of the chondral defects in these young individuals were quite different than the usual indications for glenohumeral arthritis surgery - a number of which were iatrogenic as shown below.

It is now accepted that the dominant cause of glenohumeral chondrolysis is the intra-articular infusion of local anesthetics using a 'pain pump', whereas a short while back there was uncertainty regarding causation as described here: Chondrolysis causation?. Additional posts on this important entity can be found in these posts: Chondrolysis causation and Chondrolysis of the shoulder and 'pain pumps'.

These author report an innovative approach to these defects; it remains to be seen whether this type of humeral head replacement

is more conservative than replacement with a prosthesis.