Shoulder and Elbow
Glenohumeral chondrolysis is a rapidly destructive condition in the shoulder resulting in progressive loss of articular cartilage and early onset degenerative changes. Glenohumeral arthritis is typically grouped by either primary or secondary causes. Unlike primary causes, such as osteoarthritis or inflammatory disease, the term chondrolysis is commonly used to describe rapid onset cartilage dissolution and joint destruction following surgery and is referred to as postarthroscopic glenohumeral chondrolysis (PAGCL). Although the degenerative end result is similar in both osteoarthritis and chondrolysis, PAGCL typically affects younger patients and bears a temporal relationship to an arthroscopic procedure.
Most reported cases of glenohumeral chondrolysis occur following arthroscopic stabilization procedures. Surgical factors include the use of intra-articular pain pumps (IAPP’s), hypotonic irrigation fluid, radiofrequency ablation, proud knots or anchors causing mechanical trauma to cartilage during surgery or possible subclinical infection. It has also been suggested that patient factors such as collagen disorders or a family history of early arthritis may also play a role. Although the pathology of chondrolysis is not completely understood, it is thought that the process is initiated by chemical, mechanical or thermal factors which incite inflammation and degradation of the cartilage matrix, leading to chondrocyte apoptosis, ultimately resulting in increased frictional forces, joint incongruity and accelerated wear.
The diagnosis of PAGCL begins with a thorough clinical history to exclude other causes of cartilage loss which could produce a similar clinical picture. Particular attention should be given to prior trauma, episodes of instability, prior surgery and post-operative pain regimens, specifically the use of IAPP’s. Chondrolysis is most commonly reported in the young population with the average age of 30 years old and typically those with the underlying diagnosis of instability or adhesive capsulitis. Thus, dislocation events and history of motion loss should be noted. A careful medical history should also be taken to identify possible underlying collagen disorders, autoimmune conditions or inflammatory arthropathies.
The most common subjective history in a patient who has developed PAGCL is that of progressive pain and loss of mobility following arthroscopic surgery. Symptoms typically progress rapidly with uncharacteristic pain and stiffness outside the normal postoperative course. Timeline for onset of symptoms is variable with some reports documenting a delay in identification of up to 9 months postoperatively. Hansen et al. described the identification of patients with PAGCL by having all of the following findings: (a) worsening pain at rest and with motion, (b) crepitus, (c) decreasing active motion secondary to pain and (d) glenohumeral joint space narrowing on AP radiographs. Radiographic findings are typical of those seen in other arthritic conditions and include joint-space narrowing, subchondral cysts and periarticular erosions but without typical osteophyte formation seen with osteoarthritis. Findings on magnetic resonance imaging (MRI) include diffuse bipolar articular cartilage loss and marrow edema.
There is no consensus regarding the diagnostic criteria for differentiation of chondrolysis from other pathologic conditions which affect articular cartilage. Standard diagnostic workup begins with standard AP, scapular Y and axillary views of the shoulder to assess for joint space narrowing, alignment and osteophyte formation. A West Point view may also be obtained for improved visualization of the anteroinferior glenoid. MRI is useful to detect cartilage loss before radiographic changes are seen; however, this modality has limitations on the ability to detect full thickness cartilage lesions. The addition of arthrography has not been found to improve the accuracy over standard MRI. Computed tomography (CT) can provide a more detailed examination of the bony architecture but is primarily used for preoperative planning when arthroplasty solutions are considered. Arthroscopy allows for definitive characterization of chondral lesions if the diagnosis remains unclear or if advanced imaging is inconclusive.
PAGCL is a rapidly destructive condition with irreparable changes and prevention is critical. It is important for surgeons to understand and limit modifiable factors. This includes maintaining careful surgical technique to avoid inadvertent injury to articular surfaces, limiting the use of radiofrequency devices which can elevate joint temperature, avoiding proud anchors and knots, always placing them outside the joint surface and in particular avoid the use of intra-articular infusion devices and limit articular placement local anesthetics alone or with epinephrine.
Non–operative management primarily centers upon managing pain and functional mobility. Although much of the available literature is inconclusive on the effectiveness of non-operative treatment measures, several treatment strategies exist. A formalized physical therapy or home exercise program emphasizing glenohumeral end range of motion and reducing capsular tightness should be instituted early to prevent adhesion formation. Strengthening and resistive exercises should be kept light to prevent joint irritation. Scapulothoracic strengthening is useful to improve scapular control and a balanced rotator cuff program will help prevent asymmetrical motion and reduce glenohumeral forces.
First line pharmacologic therapy is based upon the patient’s medication tolerance and typically begins with oral acetaminophen, non-steroidal anti-inflammatory medications (NSAIDs), or selective cyclooxygenase-2 (COX-2) inhibitors. Glucosamine and chondroitin sulfate, although unproven, is typically safe and may be considered. It is important to remember that serious gastrointestinal complication such as gastric ulceration and bleeding can occur with prolonged use of nonselective NSAIDs. This can be prevented with the adjuvant use of a proton pump inhibitor (PPI); although NSAID medication should be discontinued if gastric irritation is suspected. Opioid medications should be discouraged as they lack anti-inflammatory properties and can produce physical dependence. Intra-articular corticosteroid injections are useful for acute flare-ups; however, the duration of pain relief is variable. Injections should be used sparingly in young patients and in conjunction with pharmacologic therapy and a rehabilitation program. Viscosupplementation with hyaluronic acid derivatives is an alternative to corticosteroid injections, but is costly and there is little evidence to support efficacy.
Indications for Surgery
While failure of non-operative management for chondrolysis is an indication for surgery, the surgeon should recognize the inability of achieve complete pain relief in many patients with chondrolysis. Surgery should be considered a salvage procedure rather than a cure. Post-operative expectations should be discussed at length before surgery. In addition, implant longevity is a concern for young patients in whom an arthroplasty is considered.
Surgical techniques for the management of chondrolysis are not specific or unique to the diagnosis and consist of those typically used for managing capsular contractures, biceps pain and degenerative joint disease. In general, non-arthroplasty procedures consist of palliative measures, such as debridement with or without capsular release, biceps tenotomy or tenodesis. Biologic options such as autogenous chondrocyte implantation, osteochondral allografts and interpositional grafting with lateral meniscal allografts or xenograft membranes are technically feasible; however, the true benefit of these techniques is debatable. Arthroplasty options include hemiarthroplasty, total shoulder arthroplasty, and prosthetic articular resurfacing. Two common techniques are described below but are typical of standard arthroscopic and open shoulder techniques.
Debridement with and without capsular release:
Standard arthroscopic equipment is used. Beach chair or lateral decubitus position can both be utilized per surgeon preference. Begin by establishing a posterior portal for the arthroscope and next create an anterior portal in the rotator interval. The extent of chondral damage, biceps, labrum and rotator cuff are evaluated. The inferior axillary pouch is examined for loose bodies. The joint is thoroughly irrigated to wash away loose chondral debris and the arthroscopic shaver is utilized to debride loose cartilaginous flaps and labral degeneration. Switching the viewing and working portals is necessary to achieve a complete debridement. Biceps lesions should be addressed with either tenotomy or subpectoral tenodesis. A capsular release may then be performed using an electrocautery device or arthroscopic basket. Care should be taken not to damage the deep subscapularis muscle and tendon anteriorly and the infraspinatus tendon posteriorly with the use of the electrocautery during the release of the hypertrophic capsule. The capsule of the rotator interval is debrided with a shaver. The extremity is removed from the arm holder and post-capsular release range of motion is evaluated.
Standard open shoulder surgery equipment with glenoid retractors and the surgeon’s preferred shoulder arthroplasty implant is utilized. Patient placed in the beach chair position. The deltopectoral approach is utilized, incising the skin and subcutaneous tissue to locate the cephalic vein. This vein can be either retracted medially with the pectoralis muscle or lateral with the deltoid muscle exposing the deltopectoral interval. The clavipectoral fascia is incised and the biceps is located in the bicipital groove. The biceps is tenotomized and the arm is placed in external rotation to expose the anterior humeral circumflex artery and veins. These vessels are coagulated and the subscapularis can be either taken directly off or tenotomized 1-2cm medial to its insertion on the lesser tuberosity.
A lesser tuberosity osteotomy (LTO) could also be performed. With a retractor under the humeral head, the capsule is incised off the humeral neck and the humerus is gently externally rotated to expose the humeral head. Depending on the technique of the preferred arthroplasty, the humeral head is measured and cut, and the humeral metaphysis is reamed and broached to the correct size. The glenoid is addressed next if a total shoulder arthroplasty is performed. With the subscapularis tractioned laterally, the axillary nerve is identified deep to the conjoint and superficial to the subscapularis muscle and protected while resecting the anterior and inferior capsule. Glenoid retractors are placed and the glenoid is resurfaced per the technique specific to the shoulder arthroplasty system selected. Holes are drilled in the bicipital groove for transosseous placement of sutures to repair the subscapularis tendon or LTO. The definitive humeral component is cemented or impacted in place and the subscapularis/LTO is repaired.
Pearls and Pitfalls of Technique
During arthroscopic debridement, the viewing and working portals should be switched to achieve a complete debridement and ensure the entire joint is evaluated for loose bodies, including the subcoracoid pouch.
The biceps should not be ignored as a pain generator and should be managed with tenotomy or tenodesis if found to be inflamed or degenerative.
During shoulder arthroplasty, identifying the axillary nerve and protecting it allows for a safe, extensive capsular release, thereby improving glenoid exposure.
Intraarticular cultures should be considered and cultured for 10-14 days to ensure chondrolysis is not a manifestation of Propionibacterium acnes infection, especially in cases when no intraarticular pain pump was utilized.
Since complete pain relief is not always achieved, even with arthroplasty, appropriate patient expectations should be established before surgery.
Even in patients with glenohumeral degenerative changes, a capsular release and aggressive manipulation could cause an unrecognized dislocation. Place the camera back in the joint or obtain an x-ray in the PACU to avoid this complication
Failure to specifically request to keep p. acnes cultures for minimum of 2 weeks could result in a false negative test.
While not technically a complication, persist pain and poor function can persist after arthroscopy and arthroplasty. Otherwise, complications of arthroscopic debridement/capsular release or arthroplasty for chondrolysis are similar to those procedures done for adhesive capsulitis and glenohumeral arthritis respectively.
After arthroscopic debridement, patients remain in a sling for 7-10 days. The sling is then discontinued and active and passive range of motion is performed with a therapist to maintain range of motion.
After arthroplasty, patients remain in a sling for a total of 6 weeks. After 1 week, Codman’s exercises and passive range of motion is begun while limiting external rotation to 30 degrees to protect the subscapularis repair. At 6 weeks, the sling is discontinued and active assist and active range of motion is begun. Strengthening starts after 12 weeks.
Outcomes/Evidence in the Literature
Hasan, SS, Fleckenstein, CM. "Glenohumeral chondrolysis: part I--clinical presentation and predictors of disease progression". Arthroscopy. vol. 29. 2013. pp. 1135-1141.(PAGHC is a rapidly destructive process that most often affects young patients. Almost all cases in this series were associated with intraarticular pain pumps. Those without pain pumps had prominent intraarticular anchors or tacks.)
Hasan, SS, Fleckenstein, CM. "Glenohumeral chondrolysis: part II--results of treatment". Arthroscopy. vol. 29. 2013. pp. 1142-1148.(PAGHC responds poorly to arthroscopic procedures and often requires an arthroplasty within a few years. Arthroplasty results in improved motion but often incomplete pain relief.)
Matsen, FA, Papadonikolakis, A. "Published evidence demonstrating the causation of glenohumeral chondrolysis by postoperative infusion of local anesthetic via a pain pump". J Bone Joint Surg Am. vol. 95. 2013. pp. 1126-1134.(Chondrolysis cannot be reverse, only prevented. Vast majority of cases can be prevented by avoiding intraarticular pain pump infusions.)
Yeh, PC, Kharrazi, FD. "Postarthroscopic glenohumeral chondrolysis". J Am Acad Orthop Surg. vol. 20. 2012. pp. 102-112.(Onset of PAGHC presents as deep unexplained pain occurring months after arthroscopy. Specific pathophysiologic process is likely multifactorial, but prominent nonabsorbable glenoid anchors, thermal devices, and intraarticular pain pumps should be avoided.)
Wiater, BP, Neradilek, MB, Polissar, NL, Matsen, FA. "Risk factors for chondrolysis of the glenohumeral joint: a study of three hundred and seventy-five shoulder arthroscopic procedures in the practice of an individual community surgeon". J Bone Joint Surg Am. vol. 93. 2011. pp. 615-625.(Retrospective review implicates cases in which Marcaine or lidocaine was injected in the glenohumeral joint.)
Ryu, JH, Savoie, FH. "Postarthroscopic glenohumeral chondrolysis of the shoulder". Sports Med Arthrosc. vol. 18. 2010. pp. 181-187.(The complex hemostasis of articular cartilage can be sensitive to mechanical, thermal, and chemical interventions, possibly leading to chondrolysis.)
Elser, F, Braun, S, Dewing, CB, Millett, PJ. "Glenohumeral joint preservation: current options for managing articular cartilage lesions in young, active patients". Arthroscopy. vol. 26. 2010. pp. 685-696.(While studies have shown local anesthetics to be cytotoxic to cartilage, for years they have been used as single injections without resulting in chondrolysis. PAGHC is likely due to the time- and dose-affect of these local anesthetics.)
Scheffel, PT, Clinton, J, Lynch, JR, Warme, WJ, Bertelsen, AL, Matsen, FA. "Glenohumeral chondrolysis: a systematic review of 100 cases from the English language literature". J Shoulder Elbow Surg. vol. 19. 2010. pp. 944-949.(Postoperative infusions of local anesthetic and radiofrequency capsulorrhaphy should be avoided.)
Anderson, SL, Buchko, JZ, Taillon, MR, Ernst, MA. "Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: a report of 18 cases". Arthroscopy. vol. 26. 2010. pp. 451-461.(While a causal relationship cannot be established, the authors caution against intraarticular pain pumps.)
Rapley, JH, Beavis, RC, Barber, FA. "Glenohumeral chondrolysis after shoulder arthroscopy associated with continuous bupivacaine infusion". Arthroscopy. vol. 25. 2009. pp. 1367-1373.(No patients in this series developed PAGHC with a subacromial infusion device. Onset of symptoms and radiographic evidence of PAGHC occurs within 12 months of surgery.)
Glenohumeral Chondrolysis is a damaging condition leading to substantial impairments in the young population and the number of reported cases is on the rise. PAGCL is incompletely understood but well known risk factors have been recognized. Insult to articular surfaces from traumatic events such as recurrent dislocations possibly incites susceptibility; however, strong links to the chondrotoxic effects of intra-articularly administered local anesthetics with or without the addition of epinephrine have been established.
The cascade of articular injury and joint destruction is irreversible and prevention is the key component to reducing the occurrence of this devastating condition. This consists of understanding the side effects of intra-articular administered anesthetics, careful adherence to surgical technique, avoiding prominent suture knots and anchors and limiting the use of thermal devices. Once the diagnosis has been established, treatment centers upon the patients subjective complaints and functional abilities.
Optimal treatment algorithms continue to evolve. Due to the young age at occurrence, palliative type arthroscopic measures should be attempted first-line if non-operative measures fail. Although total shoulder arthroplasty remains the gold standard for global articular cartilage loss, young age at presentation and the high physical demand of this patient population makes this option less practical. Non–arthroplasty solutions may be reasonable for those with chondrolysis at a young age, however, long term outcome data from these procedures is limited.
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