A Surgical Technique & Case Report Resurfacing of Isolated Articular Cartilage Defects in the Glenohumeral echniques Joint With Microfracture: A Surgical T & Technique & Case Report Mark A. Slabaugh, MD, Rachel M. Frank, BS, and Brian J. Cole, MD, MBA Abstract to traumatic or degenerative injury.8 With regard Isolated, full-thickness chondral lesions of the gle- to the knee, several surgical techniques are being nohumeral joint remain significant problems for ath- used to address these issues, including simple lavage echnologies letes, workers, and the elderly. Microfracture has and débridement, abrasion, drilling, osteochondral been established as an effective therapeutic solution T autografts, osteochondral allografts, autogenous cell for such cartilage defects of the knee, because of 1,2,4,9,10 its low surgical morbidity and ease as a first-line transplantation, and microfracture. Recently, treatment with good clinical outcomes. Although the arthroscopic microfracture technique has also the indications for microfracture and the surgical been used in attempts to correct chondral lesions in techniques are similar for cartilage injuries of the other joints that are arthroscopically accessible. For shoulder and knee joints, the literature includes no example, microfracture is now a common procedure rthopedic reviews of the use of microfracture in the humeral used to treat the articular cartilage abnormalities of O head or glenoid surface. Overall, microfracture is the ankle and elbow.11,12 Articular cartilage injuries of a minimally invasive, technically simple surgical procedure that provides an excellent option for patients with isolated full-thickness chondral defects. “...microfracture is a minimally In this article, we describe the subtleties of micro- fracture in the glenohumeral joint and outline the invasive and a technically clinical course of a typical patient. Protectedsimple surgical procedure that provides an excellent icrofracture has been established as an effective therapeutic solution for full- first-line treatment option thickness cartilage defects of the knee because of its low surgical morbidity for patients with isolated full- M 17 and ease as a first-line treatment with good clinical thickness chondral defects. ’’ outcomes. As there is minimal vascular supply to the articular cartilage, defects of any etiology sel- the glenohumeral joint are now increasingly recog- dom heal spontaneously and often require surgical nized and treated. intervention secondary to a high prevalence of clini- The goal with microfracture is to encourage chon- cal symptoms and functional disability.1-7 Another dral resurfacing by gaining access to the underlying reason articular cartilage has a limited capacity to marrow and creating an environment that is ready for heal on its own—besides there being minimal blood tissue regeneration through use of the body’s natural supply—is that there is a virtual absence of an undif- vascular response to injury.4,7,9,13 The basic science ferentiated cell population that is able to respond behind the microfracture technique has been thor- oughly examined.3,13,14 Blood with marrow elements MAJ Slabaugh, USAF, MC, is Assistant Professor of Surgery, enters a prepared chondral lesion and organizes into Lackland Air Force Base, Texas. a fibrous clot that consists of mesenchymal stem cells, Ms. Frank is a medical student, and Dr. Cole is Professor, Departments of Orthopedics & Anatomy and Cell Biology, Division growth factors, fibrin, and platelets. Cells within the of Sports Medicine, and Section Head, Cartilage Restoration clot undergo metaplasia to initially form granulation Center at Rush, Rush University Medical Center, Chicago, Illinois. tissue.15,16 Within the first postoperative week, the gran- ulation tissue undergoes fibrosis and then hyaliniza- Address correspondence to: Mark A. Slabaugh, MD, Maj USAF, tion and chondrification to ultimately become fibro- Copyright2200 Bergquist Dr, Suite 1, Lackland AFB, TX 78236 (tel, 210-497- 2263; e-mail, [email protected]). cartilage over the course of 6 to 12 months if proper rehabilitation and surgical technique are implemented. Am J Orthop. 2010;39(7):326-332. Copyright Quadrant HealthCom This resulting fibrocartilagenous tissue ultimately Inc. 2010. All rights reserved. repairs what once was a full-thickness chondral defect. 326 The American Journal of Orthopedics® M. A. Slabaugh et al Overall, microfracture is a minimally invasive and a labral, biceps, or rotator cuff pathology. Often, intra- technically simple surgical procedure that provides an articular chondral defects are incidental findings in excellent first-line treatment option for patients with the setting of these more common or prevalent isolated full-thickness chondral defects.17 diagnoses and should be considered as such without In this article, we explain how to use the microfrac- primary treatment of the articular cartilage disease. ture surgical technique in the glenohumeral joint and In addition, cartilage lesions caused by the sequelae provide a case report on a patient who underwent of single or multiple dislocations also should be care- microfracture treatment. The authors have obtained fully assessed because of the likelihood that symptoms the patient’s written informed consent for print and are secondary to instability and not cartilage degen- electronic publication of the case report. eration. However, cartilage lesions that remain after labral fixation should be considered for microfracture. INDICATIONS The indications for surgical intervention for a focal SURGICAL TECHNIQUE cartilage defect are more difficult in the glenohumeral Microfracture of the glenohumeral joint is a simple joint than in the knee. Secondary to the shoulder surgical technique and is nearly identical to micro- having a large arc of motion and being a relatively fracture of the knee joint.8,19,20 As mentioned, the ideal “Posterior glenoid lesions are more difficult to access from the anterior portal, and a posterior 7-o’clock portal (right shoulder) is useful to access this portion of the glenoid.” load-sparing joint, patients seem to tolerate isolated chondral defect in the shoulder is an isolated full- cartilage defects in the glenohumeral joint better than thickness lesion without reciprocal cartilage damage in other joints. Symptoms can be difficult to identify opposite the defect. Depending on surgeon prefer- clinically, which can result in this defect’s being con- ence, the patient is placed in either the beach-chair or fused with other intra-articular pathology. There is a lateral decubitus position. Anesthesia can be general, symptomatic, isolated high-grade chondral lesion of Protectedregional, or a combination of both. The patient is the glenoid or humeral surface without a significant draped in the usual fashion. The first portal created opposing cartilage abnormality. Typically, patients is the posterior portal, which is typically placed complain of symptoms such as swelling, locking, the 1 to 1.5 cm medial and 2 to 2.5 cm distal to the lateral sensation of catching, and activity-related pain deep edge of the posterolateral acromion and is the same inside the shoulder. standard portal used for all shoulder arthroscopy.21 Symptoms that indicate other concurrent shoulder The anterior portal placement is crucial to the pathology, such as those generated from the acro- success of the microfracture technique in the shoul- mioclavicular joint, biceps tendon, labrum, or rotator der, as it is largely used as the working portal. If cuff, need to be excluded. Other indications that have the chondral defect is isolated to the anterosuperior been typically considered in the knee are difficult to glenoid, the anterior portal should be placed more extrapolate to the shoulder, such as defect size, age laterally just inferior to the biceps tendon. This under 45, body mass index under 30, and preopera- allows a more direct approach to the defect, ensuring tive symptoms lasting longer than 12 months.18 a perpendicular trajectory to perform the microfrac- ture. If the glenoid defect is located more inferiorly, CONTRAINDICATIONS a lower portal just above the subscapularis can be There are several contraindications for microfrac- used, still staying lateral to optimize the trajectory. ture as a surgical option in the glenohumeral joint. Posterior glenoid lesions are more difficult to access Absolute contraindications include patients with from the anterior portal, and a posterior 7-o’clock generalized degenerative joint changes, nonisolated portal (right shoulder) is useful to access this por- chondral lesions (focal defects with a bipolar recipro- tion of the glenoid. In the case of a posterior defect, cal corresponding defect), and high-grade ligament the lateral decubitus position affords easier access to laxity. In addition, patients with tumors or infection this location. Humeral lesions are often more easily of the glenohumeral joint, inflammatory arthropa- accessed with a more medial portal just below the Copyrightthy, or systemic cartilage disease are not considered biceps. Most lesions on the humerus are reached good candidates for microfracture.18 A size limit is not through the anterior portal facilitated by internal known, given the paucity of literature on chondral and external rotation of the arm. Far posterior defects in the shoulder. Relative contraindications defects of the humeral head are reached more easily include patients with concomitant injuries, such as through posterior portals.