NON-PROSTHETIC SURGICAL OPTIONS
In the absence of reliable evidence, it is the opinion of the work group that non-prosthetic surgical options may or may not provide short-term benefit for patients with glenohumeral joint osteoarthritis

Rationale

Several non-arthroplasty options exist for young patients with glenohumeral joint osteoarthritis. These options include arthroscopic debridement with capsular release, axillary nerve release, humeral osteoplasty, microfracture, osteochondral allograft, and biologic resurfacing with various tissue allografts. All of these options have small case series reports of the clinical outcomes relating the success and or failures of these methods of joint preservation surgery. These options therefore should be used with caution and although not found to cause significant adverse postoperative complications the results are mixed. Skelley et al. reported only minimal temporary pain relief and 42.4% of the cohort went on to total shoulder arthroplasty at an average of 8.8 months following the arthroscopic procedure. Additionally, 60.6% of patients reported they were not satisfied with the outcome. In contrast, Mitchell et al. reported 5 year follow up on what the authors termed the “CAM” (complete arthroscopic management) procedure which included humeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. The authors reported that 26% of patients went on to total shoulder arthroplasty at a mean of 2.6 years (range 6 months-8.2 years). Five-year survivorship was 76.9%. Risk factors associated with failure of this procedure included Walch type B2 or C glenoids (P=0.006), joint space narrowing resulting in <2mm of joint space remain on the true AP radiograph. Additionally, 2 patients required additional surgery one underwent revision capsular release for stiffness at 5.6 months and the other underwent a revision CAM procedure at 7.9 years. There were no reported intraoperative or postoperative complications.

Little has been published on the outcomes, survivorship, or complications associated with microfracture or osteochondral allograft reconstruction.       

Biologic resurfacing of the glenoid has been reported as an option using either lateral meniscus allograft or human acellular dermal tissue matrix. Strauss et al. reported intermediate term follow up of this procedure and found clinical failure rate of 51.2%. The group that lateral meniscus allograft use utilized had a failure rate of 45.2% at mean of 3.4 years, and those with human acellular dermal tissue matrix interposition had a failure rate of 70% at an average of 2.2 years. The cohort had early postoperative improvements in ASES, VAS pain scores, simple shoulder test and range of motion, but these improvements were short lived. Lo et al. reported the results of hemiarthroplasty supplemented with glenoid biologic resurfacing using acellular human dermal allograft and found 81% of patient were satisfied or very satisfied with the results at an average follow up of 60 months. 9.1% of patients went on to revision surgery with conversion to anatomic total shoulder arthroplasty. Additionally, there were 11% who had poor function postoperatively but did not go on to revision surgery. Although this modification of the procedure does involve hemiarthroplasty the results seem to be improved as compared to isolated glenoid interposition.

 

Strength of Evidence (quality of evidence): No reliable evidence

 

Benefits & Harms:

Providing non-arthroplasty surgical options to young patients may be beneficial to this difficult patient population. Risks and benefits of these procedures must be discussed with the patients to determine who would best be suited for these types of joint preserving options.

 

Outcome Importance:

Given the current literature a lot of work remains to determine the efficacy of these joint preserving non-arthroplasty surgical treatment options.

 

Cost Effectiveness/Resource Utilization:

These options are often expensive and time consuming with prolonged recovery, especially the interposition arthroplasty techniques. With the relatively high failure rates and needs for future revision surgery the value of these options still is to be determined.

 

Acceptability:

To be determined.

 

Feasibility:

There are several surgeons performing these operations, but due to poor evidence to the efficacy of this outcomes of these procedures is yet to be determined.

 

Future Research:

Future studies are needed to provide strong high-quality evidence to support the use of these surgical techniques.

 

Additional References:

Millett, P.J., Fritz, E.M., Frangiamore, S.J., Mannava, S. Arthroscopic Management of Glenohumeral Arthritis: A Joint Preservation Approach. J Am Acad Orthop Surg. 2018;26(21):745-752.

Mitchell, J.J., Horan, M.P., Greenspoon, J.A., Menge, T.J., Tahal, D.S., Millett, P.J. Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 5-Year Follow-up. Am J Sports Med. 2016;44(12):3206-3213.

Strauss, E.J., Verma, N.N., Salata, M.J., et. al. The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2014;23(3):409-19.

Lo, E.Y., Flanagin, B.A., Burkhead, W.Z.. Biologic resurfacing arthroplasty with acellular human dermal allograft and platelet-rich plasma (PRP) in young patients with glenohumeral arthritis-average of 60 months of at mid-term follow-up. J Shoulder Elbow Surg. 2016;25(7):e199-207.

Skelley, N.W., Namdari, S., Chamberlain, A.M., Keener, J.D., Galatz, L.M., Yamaguchi, K. Arthroscopic debridement and capsular release for the treatment of shoulder osteoarthritis. Arthroscopy. 2015;31(3):494-500


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