Diagnostics and Treatment Early Shoulder

New research sheds light on treatment strategies for this challenging condition By Matthew Busam, MD, and Brian J. Cole, MD, MBA

rthopaedic surgeons have long sought offer the same prognosis to a teenager who markedly. Fortunately, active research means to allow patients with painful presents with debilitating shoulder arthritis programs at Rush University Medical Center Oconditions to maintain active life- resulting from a variety of causes. (Rush) has allowed basic science and animal styles. , a painful and sometimes research to be quickly translated into thera- debilitating condition associated with advanc- Traditionally, young, active patients with peutic alternatives for young patients with ing age and many times signaling the end of glenohumeral (shoulder) arthritis are not potentially devastating problems. youthful activities, is viewed as an inevi- considered good candidates for . table aspect of the aging process. But Heavy laborers are offered shoulder arthro- Active Research arthroplasty, especially in the hip, knee, and desis, and those wishing to return to sports shoulder, has allowed generations of patients or overhead activities often are left with no In addition to finding novel therapies, to regain function and minimize pain. optimal surgical solution.1 The number of active research has brought insight into very young people — teenagers and those in the pathogenesis of early joint destruction. Ongoing research into component design their 20s — with advanced shoulder arthritis Osteoarthritis is a multifactorial process that and surgical technique has improved func- has been very low until recently when the includes metabolic and mechanical path- tional outcomes as well as the longevity of number of these patients referred to the ways that ultimately lead to the common implants, allowing faster recovery. However, Restoration Center at Midwest endpoint of articular cartilage breakdown, despite tremendous advances in the last Orthopaedics at Rush (MOR) has increased pain, and dysfunction. several decades, arthritic conditions in younger patients continue to challenge orthopaedic surgeons.

When a 70-year-old patient presents with a painful arthritic shoulder, surgeons can reliably predict that a total shoulder arthro- plasty will reduce pain and improve function and that the results will likely last the rest of the patient’s life without the need for revi- Radiographs at initial presentation of a 20-year-old male following a shoulder stabilization procedure demonstrate complete joint destruction. sion . Unfortunately, surgeons can’t

8 Orthopaedic Excellence Diagnostics and Treatment

Because forces across the shoulder are of patients were presented by Charles Beck, Notably, there is no evidence to date that the generally less than the hip or knee, shoul- MD, and colleagues from Salt Lake City, use of local anesthetics in joint injections or der arthritis is less likely to be appreciated Utah, in a paper entitled “Post-arthroscopic in the form of postoperative pain manage- radiographically and clinically. Patients often Shoulder Chondrolysis with Associated ment for other , including the shoulder Early Shoulder present with significant joint destruction Intra-articular Pain Pump Catheter Use.” when rotator cuff repair has been performed, but note an ongoing loss of motion and Twelve shoulders in 10 patients who under- is associated with any negative effects. went arthroscopic shoulder stabilization developed chondrolysis. All of the patients Treatment Options Arthritis had been treated with an intra-articular pain pump postoperatively.3 Though determining the causes of early, rapid cartilage loss in the glenohumeral joint Shoulder surgeons at MOR have seen several may help surgeons prevent future cases, young patients with similar findings, namely rapid chondrolysis following intra-articular pain pump use, and have set out to deter- Case Study This intraoperative photo shows severe humeral mine whether a connection existed between A 20-year-old Pacific Ten Conference college head chondrolysis. the anesthetic and cartilage degeneration. baseball player dislocated his nondominant shoulder diving into a base. He underwent function over the course of many years. If Andreas Gomoll, MD, Bernard R. Bach Jr., arthroscopic shoulder stabilization without a teenager presents with a short duration MD, and Brian Cole, MD, from the Section of the use of thermal techniques. Postoperatively of symptoms but advanced radiographic Sports Medicine at MOR, along with Richard he was treated with an intra-articular pain changes and marked functional deficits, Kang, a Rush medical student, and James pump for 24 hours. His postoperative course degenerative arthritis would not be the Williams, PhD, from Rush’s Department was complicated by severely restricted range of most common cause. Our research has set of Anatomy, developed a rabbit model to motion and continued pain developing within out to determine the potential causes of this mimic the use of intra-articular pain pumps. one year postoperatively. devastating problem. They then demonstrated that delivering Six months later, he underwent an arthroscopic During the last decade, thermal capsular evaluation with planned capsular release to shrinkage or the use of radiofrequency improve his motion. Arthroscopy revealed energy or heat was initially hailed as a complete destruction of both the humeral simple arthroscopic treatment for patients head and glenoid articular surfaces. He was with glenohumeral instability. Over the last subsequently referred to Midwest Orthopaedics several years, however, surgeons around at Rush for evaluation and treatment. the country began reporting complications Upon presentation, his range of motion was related to thermal capsular shrinkage proce- severely restricted, and he had significant pain. dures. For this and many other reasons, the This intraoperative photo taken after humeral Because of the patient’s young age and desire procedure is largely abandoned for contem- head resection shows the degenerative change on to remain physically active, Brian Cole, MD, porary arthroscopic stabilization procedures the glenoid. and his team at Rush University Medical Center using sutures.2 elected to proceed with biologic glenohumeral local anesthetic in a closed system such as arthroplasty (joint transplantation) consisting To limit the need for narcotic pain medicine, the glenohumeral joint led to significant many surgeons advocate the use of pumps chondrotoxicity. While not definitive, this of a humeral head allograft replacement and placed in the shoulder to deliver measured basic science work cautions against using a resurfacing of the glenoid with a lateral amounts of local anesthetic over the course intra-articular pain pumps in a closed, small meniscus allograft. of 24 hours or longer. The patient typically volume joint over longer time periods and in Subsequent to this, the patient developed removes these pumps at home. higher volumes and points to a possible cause profound reduction in pain, improvements in of rapid cartilage breakdown in young patients motion, and has begun the initial phases of At the 2006 annual meeting of the American who have undergone shoulder surgery com- return to competitive collegiate-level baseball. Academy of Orthopaedic Surgeons, a series bined with pain pump use.4

Orthopaedic Excellence 9 Diagnostics and Treatment

the challenge of how to treat patients who collaborations between shoulder surgeons at from the University of Chicago and completed already have the condition remains. Osteo- MOR, including Dr. Cole, Greg Nicholson, a sports medicine fellowship at the University chondral allografts have been used with MD, and Anthony Romeo, MD. of Pittsburgh. He has been named one of the success in the knee for many years. Recent “Best Doctors in America” by Castle Connely reports from Rush5 and other institutions6 While the problem of glenohumeral arthritis each year since 2004 and as a “Top Doctor” in confirm improved functional outcomes in the young person remains a therapeutic the Chicago metropolitan area each year since and biologic incorporation. Biologic joint challenge, researchers from MOR, in con- 2003. In 2006, he was featured as “Chicago’s replacement allows patients to regain an junction with Rush, have used basic science Top Doctor” and placed on the cover of active lifestyle with less concern about Chicago Magazine. Dr Cole is the Head Team implant failure associated with artificial joint Physician for the Chicago replacement. Basic science research at Rush, Bulls and Co-team Physician for the Chicago including measuring the effect of impaction White Sox. on cell viability within the graft, is helping to further refine the techniques.7 References 1. Krishman SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral In a young, active person’s shoulder, hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: Two to Fifteen-year outcomes. J Bone Joint loosening or outright failure of the glenoid This intraoperative photo shows the implanted Surg Am 2007;89:727-34. component placed at the time of shoulder humeral head. The lateral meniscus has been implanted but is not visualized. 2. Petty DH, Jazrawi LM, Estrada LS, Andrews JR. Glenohumeral replacement is of paramount concern. Many chondrolysis after shoulder arthroscopy, case reports and review of patients who have undergone total shoulder and animal models to help understand the the literature. Am J Sports Med 2004;32:509-15. replacement are restricted from heavy or pathogenesis and shed light on treatment 3. Hansen BP, Beck CL, Townsley RW. Post-arthroscopic shoulder repetitive shoulder activities to reduce the strategies that will hopefully allow patients chondrolysis with associated intraarticular pain pump catheter use. likelihood of implant failure. Hemiarthro- to regain and maintain active lifestyles. In: Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Translational research involving animal Illinois; March 22-26, 2006. models, as well as biomechanical studies 4. Gomoll AH, Kang RW, Williams JM, Bach BR, Jr., Cole BJ. and prospectively collected clinical research, Chondrolysis after continuous intra-articular bupivacaine infusion: has allowed rapid incorporation of new ideas an experimental model investigating chondrotoxicity in the rabbit into clinical practice, potentially improving shoulder. Arthroscopy 2006;22:813-9. patients’ lives significantly. 5. McCulloch PC, Kang RW, Sobhy MH, Hayden JK, Cole BJ. Prospective evaluation of prolonged fresh osteochondral allograft tranplantation of the femoral condyle: minimum 2-year follow-up. Am J Sports This intraoperative photo shows the lateral Matthew Busam, MD, a Med 2007;35:411-20. meniscus allograft prior to implantation (left), medical graduate of Vanderbilt the resected native humeral head (center), and 6. Williams RJ, III., Ranawat AS, Potter HG, Carter T, Warren RF. Fresh the allograft humeral head prior to preparation for University, completed an ortho- stored allografts for the treatment of osteochondral defects of the implantation (right). paedic surgery residency at knee. J bone joint surg Am 2007(89):718-26. plasty is one option, but results have been Vanderbilt University Medical 7. Kang RW, Kressner T, Pacione CA, et al. Surgical impaction damages inferior to total because Center in Nashville, Tennessee. osteochondral grafts: a controlled laboratory study of the biologic the arthritic glenoid remains.8 He will complete a fellow- effects of repeated and varying loads on osteochondral grafts. In: Orthopaedic Research Society; 2007; San Diego, CA; 2007. p. ship in sports medicine at Rush University Paper 0675. Biologic resurfacing of the glenoid has been Medical Center in Chicago and join the Sports 8. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley reported with success in the setting of metal- Medicine Department at the Cincinnati Sports A. A comparison of pain, strength, range of motion, and functional lic humeral head replacement.1,9 Further basic Medicine and Orthopaedic Center in Cincin- outcomes after hemiarthroplasty and total shoulder arthroplasty in research from the lab at Rush showed that nati, Ohio, in August 2007. patients with osteoarthritis of the shoulder. A systematic review and use of lateral meniscus as a biologic glenoid meta-analysis. J Bone Joint Surg Am 2005 87:1947-56. resurfacing mechanism decreases contact Brian J. Cole, MD, MBA, 9. Burkhead WZ, Jr., Hutton KS. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg pressure across the joint and centrally spares is a Professor in the Depart- 1995;4:263-70. glenoid contact, thereby potentially leading ment of Orthopaedics at Rush 10. Creighton RA, Cole BJ, Nicholson GP, Romeo AA, Lorenz EP. Effect of to decreased progression of glenoid wear University Medical Center in lateral mensicus allograft on shoulder articular contact areas and while improving function and reducing Chicago. Dr. Cole received his pressures. J Shoulder Elbow Surg 2006. pain.10 This research has been the subject of medical and master’s degrees

10 Orthopaedic Excellence