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Arthroscopic resurfacing of the glenoid with Graft-jacket dermal allograft(Wright medical) and Q-Fix anchors (Smith & Nephew)

    Overview

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    Osteoarthritis of the shoulder in young patients is challenging to treat with no ideal solution. Joint replacement is the end option but the choice of replacement has also generated controversy. Studies in older patients have shown a better result after total shoulder arthroplasty compared with hemiarthroplasty with regard to motion, pain relief, and the need for early revision. However, in these young, active patients glenoid loosening, eccentric wear of the prosthetic glenoid, and the potential need for multiple revision surgeries has led many authors to recommend only humeral head replacement at the initial surgery. Hemiarthroplasty is also not the ideal solution as glenoid erosion and subsequent pain can lead to early revision, which is then more challenging as a consequence of the bone loss.
    Burkhead and colleagues addressed these concerns in their report of a technique of humeral head replacement with biologic resurfacing of the glenoid with a soft-tissue graft. Their results in 6 patients with 2 years’ follow-up showed excellent results in 5 and a good result in 1. A variety of grafts have been used ranging from facia lata to lateral meniscus allograft. Krishnan et al. recently published their results with 2 to 15 years’ follow-up in 36 shoulders in 34 patients treated with biologic glenoid resurfacing in combination with hemiarthroplasty; 31 of 36 achieved satisfactory results.
    In an attempt to avoid replacement all together, and find a less invasive solution, arthroscopic procedures have been undertaken rangeing from debridement to capsular release. However previous studies have shown that techniques involving debridement alone are more likely to result in inferior results with an increasing severity of arthritis.
    Resurfacing of the glenoid using human dermal allograft has been attempted by a number of authors in order to improve upon the results of debridement in isolation. Essentially it is a form of Autologous Matrix Induced Chondrogenesis(AMIC), the glenoid is microfractured and covered with a dermal allograft with the aim of achieveing a fibro-cartilagenous repair that will improve pain and function.

    Author : Professor Martyn Snow FRCS (TR & Orth).
    Institution :The Royal Orthopaedic Hospital Birmingham, UK.

    Indications

    INDICATIONS
    Early to moderate osteoarthritis of the glenohumeral joint or global chondral defect effecting the glenoid.
    SYMPTOMS & EXAMINATION
    Patients present with the typical pain and restriction in movement seen with osteoarthritis of the shoulder. The pain is commonly present at night resulting in disturbed sleep. The loss of range of motion effects patients abilities to undertake activities above shoulder height and tasks that require external and internal rotation.
    Examination confirms the classical loss of external rotation. The presence of associated ACJ tenderness needs to be documented. Assessment of the biceps and rotator cuff is difficult due to the pain from the glenohumeral joint and so imaging is more heavily relied on in these cases.
    IMAGING
    AP and Axillary X-ray of the shoulder can confirm the loss of joint space and the presence of osteophytes. The congruency of the glenohumeral joint can also be assessed.
    An MRI of the shoulder should be undertaken to confirm the presence of osteoarthritis and associated lesions of the biceps or rotator cuff. The bony architecture should be documented to determine if there is posterior glenoid erosion. The shape and congruity of the shoulder joint should be noted as this may effect a patients suitability for the surgery (see contrindications)
    ALTERNATIVE OPERATIVE TREATMENT
    Capsular release of the glenohumeral joint: This can be undertaken in combination with a debridement and biceps tenotomy/tenodesis. The younger the patient the more likely one is to consider the addition of a re-surfacing procedure.
    Hemiarthroplasty: Hemiarthroplasty is also not the ideal solution as glenoid erosion and subsequent pain can lead to early revision, which is then more challenging as a consequence of the bone loss.
    Total Shoulder replacement: Studies in older patients have shown a better result after total shoulder arthroplasty compared with hemiarthroplasty with regard to motion, pain relief, and the need for early revision. However, in these young, active patients glenoid loosening, eccentric wear of the prosthetic glenoid, and the potential need for multiple revision surgeries has led many authors to recommend only humeral head replacement at the initial surgery.
    NON-OPERATIVE MANAGEMENT
    Steroid injection
    Physiotherapy
    Analgesia
    Activity modification
    CONTRAINDICATIONS
    Severe osteoarthritis – with loss of glenohumeral joint congruity (once the shape of the humeral head has flattened and the glenohumeral joint is no longer congruent) this operation is no longer indicated. The biomechanics would not allow the dermal patch to integrate on the glenoid itself.
    Elderly : This is an operation that should only be considered in younger individuals, in order to delay the need for joint replacement.
    Rotator cuff tears: The rotator cuff must be intact

    Setup

    The patient is placed in the beach chair position and draped in the usual fashion for a shoulder arthroscopy, the arm is positioned in a spider arm positioner. This operation can also be performed in the lateral decubitus position if preferred.

    Operation – 1

    The arm is placed in neutral rotation and slight forward flexion. The arm is generally kept in this position throughout the operation. The arm positioner will allow for greater lateral traction to be applied in the beach chair position.

    An initial standard, posterior portal is created 2cm below and medial to the poster-lateral corner of the acromion.

    A diagnostic arthroscopy is carried out. At this stage the chondral surfaces are assessed along with the rotator cuff and biceps.
    A-Humeral head
    B-Long head of biceps
    C-Subscapularis

    A standard anterior portal is then created through the rotator interval and an Arthrocare 90 is inserted through a 8.5mm clear view cannula (smith and nephew). Clear cannulas are useful in this surgery in order to ensure good suture management.

    A biceps tenotomy or tenodesis is commonly carried out, in order to reduce the potential of a pain generator continuing to cause symptoms, despite glenoid resurfacing. In this case, following discussion with the patient, a biceps tenotomy was performed.

    A standard capsular release is performed using an arthrocare 90, first releasing the middle gleno-humeral ligament, then the inferior gleno-humeral ligament down to approximately 6 o’clock. The rotator interval is then completely cleared and the coracoid process skeletonised. It is often difficult to fully release the coraco-humeral ligament whilst visualising through the rotator interval, this may need to be completed when in the subacromial space.

    M – MGHL
    H – Humeral Head
    G – Glenoid

    The arthrocare is then placed through the posterior portal and a posterior capsular release is then performed.

    G – Glenoid
    P – Posterior Capsule

    An anterior superior arthroscopic portal is then created whilst viewing from the posterior portal. The location is just off the anterolateral corner of the acromion.
    A needle is inserted just anterior to the supraspinatus within the rotator interval, a knife is then used to cut the rotate interval in this position before a second 8.5mm cannula is inserted.
    A-Humeral head
    B- Supraspinatous
    C-Anterior cannula

    A 3rd 8.5mm cannula is then inserted through the posterior portal.

    The arthroscope is then placed within the anter0-superior cannula and the joint surfaces, including the glenoid are fully assessed. At this point the absence of glenoid erosion can be confirmed and the integrity of the labrum can be assessed as this will have a potential bearing on supplementary fixation. In the absence of good labral tissue further anchors maybe required.
    L – Labrum
    H- Humeral head
    G – Glenoid

    A 90⁰ Arthrocare wand is initially used to remove any remaining cartilage from the glenoid, however, the labrum is retained in order to secure the graft at a later stage.

    G – Glenoid
    L – Labrum
    H- Humeral head

    The glenoid surface is then debrided with a 4.5mm arthroscopic burr until the sclerotic bone has been removed. Caution should be used in order not to remove too much bone so that cancellous bone is exposed, as this could compromise the potential longevity of future polyethylene glenoid insertion at a later date. Some authors do recommend eccentric burring in order to correct any posterior glenoid erosion as seen with a Walshe B2 glenoid, however, personally I feel that this technique is not successful once such erosion has developed.

    Viewing through posterior portal a microfracture awl can then be used in order to create multiple microfracture holes throughout the glenoid. These should be approximately 3-5mm apart. Recent evidence would suggest that nano-fracture is more effective in accessing vascular channels and therefore, it is preferential to drill the glenoid with a 1-2mm drill, which should be inserted to a depth of approximately 8-9mm.
    The curved drill guide to the 2.9mm bioraptor instability anchor (Smith and Nephew) is a good option in this scenario and can help achieve perpendicular holes to the glenoid. However, there are commercially available nanofracture kits available.

    The antero-superior portal usually provides the best angle to the glenoid but the anterior and posterior portals should be used as required.

    A GraftJacket max force extreme is the dermal allograft used in this procedure. It comes in a dehydrated state and needs to be soaked for 10 minutes in normal saline prior to use. It is advisable not to soak the graft too long prior to use, as the graft will continue to re-hydrate whilst being shuttled into the joint. The majority of the cases described in the literature have been undertaken using this graft.

    The posterior anchor is inserted at 3 O’clock 1-2mm on the face of the glenoid. The 12 O’clock anchor is usually inserted through the antero-superior portal or can be inserted through an accessory Nevassier portal.
    A-Humeral head
    B-Six o’clock Q-fix anchor
    C-Glenoid with micro-fracture holes
    D-9 o’clock anchor being inserted through posterior portal.

    The arthroscope is placed in the antero-superior portal. The glenoid then needs to be measured in order for the dermal allograft to be cut to the appropriate size. The easiest way in which this is performed is using a spectrum suture hook (Conmed), which has been preloaded with No. 1 PDS. A grasper is placed in the anterior portal and the spectrum in the posterior portal. The grasper, grasps the end of the PDS and moves to the superior aspect of the glenoid whilst the spectrum in placed at the inferior edge of the glenoid. Once happy that the PDS accurately represented the length of the gelonoid the PDS is fixed in position with a clip or a thumb as it enters the handle so that the PDS length is fixed as the spectrum is removed from the shoulder.

    The length of the PDS suture is then measured on the back table using a ruler and the measurement recorded.

    The width of the glenoid is then measured in a similar manner.

    The Graft Jacket is then cut to size based on the measurement obtained.

    The graft will be inserted porous side down on the glenoid in order to maximise potential bone marrow infiltration. Thus the measurements are done on the dermal (non-porous) side of the graft.

    The corners of the graft are then removed in order to match the shape of the glenoid. The orientation of the graftjacket can be drawn onto the allograft to ensure appropriate insertion. The proposed anchor holes can also be estimated.

    In this case I inserted four 1.8mm all suture Q-Fix anchors (Smith and Nephew) into the glenoid, in order to fix the dermal allograft. The anchors are inserted in a standard fashion at approximately 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock. The anterior portal can be used to insert the 9 0’clock and 6 o’clock anchors (left shoulder).

    The 9 o’clock anchor inserted in a similar fashion as when undertaking an anterior stabilisation. The anchor is inserted 1-2mm on the face of the glenoid.

    The posterior portal can be used to insert the 3 o’clock and the 6 o’clock anchors dependent on the local anatomy.

    Operation – 2

    View from the anter-superior portal with all 4 anchors inserted.

    The graft is shuttled into the joint using the suture from each of the anchors.
    The arthroscope is placed in the posterior portal. The first step is to retrieve one limb of each suture anchor through the anter0-superior cannula. The suture limbs should be retrieved in such a fashion, that the orientation of the anchors on the glenoid matches the orientation of the sutures in the cannula.

    As each suture is retrieved it is passed through dermal allograft using a mayo needle in its appropriate position based on previous markings.

    A mulberry knot (multiple simple knots tied on top of each other to create a very large knot) is then tied in each of the sutures passed through the patch and this will provide the necessary resistance, in order to shuttle the graft into the glenohumeral joint.

    The antero-superior cannula should be imagined to be split into 4 quadrants, with the 12 o’clock anchor in the 12 o’clock position in the cannula, the 6 o’clock anchor in the 6 o’clock position, the 9 o’clock anchor in the 9 o’clock position and the 3 o’clock anchor in the 3 o’clock position. An assistant is necessary at this stage in order to maintain the distribution of the sutures within the cannula appropriately.

    Final position of the sutures in the cannula, with the 4 suture limbs in the 4 imaginary quadrants of the cannula, matching their positions on the glenoid.

    The assistant maintains this orientation on the outside. The suture orientation can be checked prior to graft passage by simply running a suture retriever over the suture from the anchor to the graft. This will determine if there is any tangling of the sutures that needs to be corrected prior to passage.

    At this point, the second limb within each anchor needs to be managed. The 12 o’clock, 3 o’clock and 6 o’clock suture limb should be passed out the posterior portal with the 9 o’clock suture limb being passed out the anterior portal. The graft is then pulled into the shoulder, by pulling on the three sutures limbs in the posterior cannula. A retriever can assist passage by pushing the graft into the joint. The graft should be pulled in primarily by the 6 O’clock suture with the other suture used to unfold the graft. It is important to maintain tension on all sutures as the graft is pulled into the joint. Failing to do thins increases the chance of suture tangling.

    Arthroscopic picture with the graft in-situ. The mulberry knots from each of the anchors can then be retrieved sequentially using a suture retriever. The Arthroscope is placed in the antero-superior portal for this step. The 9 O’clock anchor is initially tied through the anterior cannula, the mulberry knot from the anchor is retrieved with a suture retriever. The other limb of the suture 9 O’clock anchor is also retrieved out the anterior cannula, the mulberry knot is cut off the suture and a standard sliding knot tied with the knot placed away from the glenoid. The 6 O’clock anchor is then tied via the anterior cannula in a similar fashion followed by the 12 O’clock anchor.
    A-Humeral head
    B-mulberry knot in suture from 9 O’clock anchor
    C-Dermal allograft

    Finally the 3 O’clock anchor is tied through the posterior portal.

    Arthroscopic picture showing the graft following tying of the posterior anchor. Further sutures can then be passed through the graft and the labrum using a suture hook, in order to improve the stability of the patch on the glenoid and stabilise loose flaps.
    A-Humeral head
    B-Dermal allograft
    C-3’Oclock suture

    The most common hooks used for this procedure are 60⁰ left and right. The graft is usually entered first and then the labrum. Care must be taken not to disrupt the anchor fixation during this process. A retriever can be used to help stabilise the graft during this process.

    The PDS suture is used to shuttle a No.2 orthocord (Depuy Mitek) through the graft and labrum. It is then tied on the labrum. Usually an additional 3 or 4 sutures are required to fully stabilise the graft.

    Final fixation with the additional labral suture fixation.
    A-Humeral head
    B-Dermal allograft
    C-Additional orthocord suture through graft and labrum
    D-Labrum
    E-3 O’Clock anchor

    Finally if any small dog-ears remain they can be smoothed over using the Arthrocare 90.

    The portals are then closed with interrupted sutures and dressings are applied.

    Post Operative

    The patient is placed in a poly sling for 6 weeks. Passive movements are allowed during this period, from 6 weeks active assisted is commenced and progressed to active as pain allows. Gentle strengthening exercises are commence from 3 months.

    Recommended Reading

    Savoie et al reported on 20 consecutive patients aged 15 to 58 years (mean, 32 years) with severe glenohumeral arthritis who underwent arthroscopic resurfacing of the glenoid with a biologic patch (Restore; DePuy Orthopaedics, Warsaw, IN) at 3-6 years. At last follow-up, 15 patients (75%) remained satisfied. Five patients had proceeded to have surface replacement arthroplasty, but four of five said that they would undergo the arthroscopic procedure again. Active and passive range of motion improved in flexion (80° to 150°), abduction (60° to 120°), external rotation with the arm at the side (10° to 30°), external rotation in abduction (30° to 70°), and internal rotation (10° to 50°). Each rating scale used showed statistically significant (P 􏰁 .05) improvement from preoperatively to postoperatively: VAS, from 8 to 2; ASES, from 22 (out of 100) to 78; UCLA, from 15 (out of 35) to 29; Rowe, from 55 (out of 100) to 81; and Constant-Murley, from 26 to 79. Six of eight parameters on the SF-12 also showed statistically significant improvements.
    Debeer and Burkhart combined their series and reported on 43 arthroscopic dermal allograft resurfacings that were evaluated at a median of 53 months.
    The visual analog scale pain score (0-10) improved from a median of 7 to 2 representing pain relief similar to total shoulder arthroplasty in young patients. Improvements in the median ASES score from 47 to 76, active forward elevation and active external rotation were noted. No complications were noted.
    In 10 shoulders (23% [95% CI, 12%-39%]), revision to a prosthetic arthroplasty was performed at a mean of 45 months (range, 9-71 months) after the index operation. Hem- iarthroplasty was performed in 3 shoulders, anatomic total shoulder arthroplasty in 4, and reverse total shoulder arthroplasty in 3. A older age at the time of surgery and lower pre-operative ASES score correlated with need for earlier revision. Suggesting this procedure is better suited to higher functioning patients in their 40’s and 50’s.

    1. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthro- plasty and Neer total shoulder arthroplasty in patients fifty years old or less. J Bone Joint Surg Am 1998;80:464-473.
    2. Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthro- plasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am 2000;82:26-34.
    3. Smith KL, Matsen FA. Total shoulder arthroplasty versus hemiarthroplasty. Orthop Clin North Am 1998;29:491-506. 4. Edwards TB, Kadakia NR, Boulahia A, et al. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: Results of a multicenter study. J Shoulder Elbow Surg 2003;12:207-213.
    5. Bryant D, Litchfield R, Sandow GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthro- plasty in patients with osteoarthritis of the shoulder. A sys- tematic review and meta-analysis. J Bone Joint Surg Am 2005;87:1947-1956.
    6.Millett PJ, Horan MP, Pennock AT, Rios D. Comprehen- sive arthroscopic management (CAM) procedure: Clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoar- thritis. Arthroscopy 2013;29:440-448.
    7.Hartzler R, Melapi S, de Beer J.F, Burkhart S.S. Arthroscopic Joint Preservation in Severe Glenohumeral Arthritis Using Interpositional Human Dermal Allograft.Arthroscopy 33:11 (November), 2017:1920-1925
    8.Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: midterm results. Savoie FH 3rd, Brislin KJ, Argo D. Arthroscopy. 2009 Aug;25(8):864-71.

    Reference

    • orthoracle.com

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