This week’s Orthopaedic Crossfire® debate was part of the 17th Annual Current Concepts in Joint Replacement® (CCJR), Spring meeting, which took place in Las Vegas this past May. This week’s topic is “Moderate OA in Patients <50: Best Treated with Arthroscopic Debridement.” For the proposition is Anthony A. Romeo, M.D., Rush University Medical Center, Chicago, Illinois. Opposing is John W. Sperling, M.D., Mayo Clinic, Rochester, Minnesota. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.
Moderator Thornhill: He won’t toot his own horn, but Seth Greenwald has done more over the last 25 years to advance the education of arthroplasty and it’s things like CCJR that really are going to give us our ongoing education.
Dr. Romeo: My charge is to talk to you about arthroscopic management with respect to moderate arthritis in patients around 50 years old.
When we look in arthroscopically, we see a loss of articular cartilage on both sides. The labrums are destroyed in many cases. And the question is: “Is there anything that we can do arthroscopically to manage this?”
Consider a young individual in his 40s who had a stabilization surgery and now has a destroyed joint. Is there anything that we can do for this arthroscopically? Probably not.
We see arthritic conditions in younger, active patients quite frequently and they are oftentimes challenging in terms of what to do. They can be post-surgical or post-traumatic. It could be a form of OCD [osteochondritis dissecans] or avascular necrosis. We had a big wave of chondrolysis sometime ago. Then, of course, early osteoarthritis and focal chondral defects.
The question is: “We know that total shoulder arthroplasty at time zero is a great operation for pain relief and for improvement in function, but is that really the right answer for these young individuals?”
When you do shoulder arthroplasty in these young individuals, about two-thirds of them will last up to 10 years, but that means one-third at 10 years are having revision surgery. When you’re doing these in their 30s and 40s, do you really want to be doing a revision surgery? It’s not so much the bone, it’s the soft tissue revision that really becomes the issue.
We’ve also learned that the more anatomic that we make our humeral components, the better off our patients are. And again, this reflects not so much the bone issue, but really the soft tissue issue that we have to deal with.
When we have chondral injuries to the humerus, we can have an algorithmic approach. If it’s incidental at the time of surgery, we do an arthroscopic debridement for palliative reasons. If it’s a bipolar lesion, we know that ahead of time, then we may have to do some reconstructive procedure. If it’s not bipolar, they’re smaller lesions, then we have treatments like microfracture or putting in plugs. If they’re larger lesions there are some restorative and even reconstructive procedures that have been good for us.
Arthroscopic debridement is typically the first treatment. It’s usually found at the time of the surgery for other reasons. It’s incidental, it’s superficial and the reality is that the humeral articulating cartilage is only about 2mm, in the central portion and it dissipates going peripherally. So it’s not really as effective as we would like it to be in the shoulder area.
So we perform a debridement and then what? Do we just leave it alone? Or are there other things that may be of some value? If there’s a significant stiffness, I will do a capsular release, either selectively or completely to get the range of motion back in these individuals.
This is palliative treatment. We’re trying to alleviate pain. Our best success comes from low demand patients and small focal lesions. Not patients over 65.
Regarding microfracture, We looked at this very early on and we found in a small group of patients who had reasonable early results, 18, 3 of them then failed, and 13 patients at 28 months were able to still continue at 92% satisfaction. Peter Millet, out in Vail, had another series of 31 patients, again mixed diagnoses as these frequently are. And a mean follow-up close to 4 years, 6 failures in that group, the pain was alleviated and ASES [American Shoulder and Elbow Surgeons] scores were good.
The positive factors, which are fairly consistent in the work that’s been done, are small lesions of the humerus and the negative are bipolar lesions or when the humeral head is subluxed posteriorly.
We did a systematic review of the literature a few years ago. We found that positive predictive factors were unipolar and isolated humeral defects less than 2cm. Peter Millet, who’s talked about the CAM procedure, actually does the capsular release like we do, the debridement, the removal of loose bodies, and then he goes after the inferior spur on many of these patients, decompressing the axillary nerve, which is not for the faint of heart. You have to have a separate portal for retractors, usually have to have at least two posterior portals and maybe even three to retract the nerve due to release and we’re still figuring out whether this works outside of Vail.
So keep this algorithm in mind when you’re thinking about how to manage these individuals. There are a variety of treatment options other than just arthroscopic debridement, such as osteochondral allograft. And we keep watching out for this chondrolysis because we know that this is a bad actor in terms of the overall treatment.
Again, some of the final thoughts. Young patients are different. Consider and discuss all alternatives. Arthroscopic surgery may give them a few years of benefit. Counsel patients on outcomes. We’re not really sure if it affects the future of arthroplasty in them, but it doesn’t seem to have a negative affect at this time.
Dr. Sperling: I’ll be talking on the opposite view point from arthroscopic treatment of arthritis in the young adult. In my mind arthroscopy is not the preferred treatment for these young patients and we’ll discuss some of the outcomes of arthroplasty.
In my practice, if I see a patient less than 50 years old, I would say that over 90% of the time its arthroscopy related. Its instability surgery, SLAP [superior labrum, anterior to posterior] repairs that have gone wrong, and we have had different waves of these.
We’ve had thermal. We’ve had pain pump. In my practice I see a number of patients who have anchors misplaced. So we’ve created a lot of this arthritis ourselves. The treatments for these patients are challenging.
For example, a 19-year-old college student who did landscaping work during the summer. He had a posterior labrum repair, had continued pain in his shoulder. You get the CT scan you can see he’s started to develop significant arthritis in his shoulder. He’s already failed one arthroscopy debridement for this and has continued pain.
Or a patient who had a bony Bankart lesion. Surgery was done. Arthroscopy was done. There were no pain pumps used in this. There was no thermal used in this. This patient had a reaction to the anchors themselves. And this younger patient developed arthritis. So the large surgery, SLAP surgery and labral surgery is contributing to this problem.
Actually people who undergo shoulder arthroplasty have the youngest average age. There’s numerous reports out there on hip and knee. There’s less information in regard to the shoulder as to how to manage this.
Recently we saw a 20-year-old patient who’d undergone a SLAP repair, anchors replaced in the joint, had end-stage arthritis. This patient had severe bone-against-bone arthritis and, in my mind, it’s challenging to think of how any non-arthroplasty procedure is going to help this patient with bipolar disease in their shoulder.
So how do these patients do? If you decide to do an arthroplasty…a study from Tom Wright’s group was encouraging. He noted in their research that there was no downward trend in results with longer follow-up.
We did a study with almost 17-year average follow-up of young people undergoing shoulder arthroplasty with a significant number of these patients having long-term radiographic follow-up as well. We saw significant and consistent improvement in pain with both total shoulder and hemiarthroplasty as well as improvement in active abduction and external rotation. The revisions primarily were on the hemiarthroplasty side. Again, for continued pain due to the fact that the glenoid was not addressed.
If you look at the total shoulder, it’s interesting. The number of people who underwent revision for component loosening is pretty low in our 17-year follow up study. Only three patients underwent revision for component loosening. If you look at the survival, it is much better with arthroplasty.
A total shoulder in a patient less than 50 has a 97% chance of survival at ten years. So the arthroplasty procedures can help these young people with shoulder arthritis.
Why did they fail? They failed because of hemiarthroplasties that were done that did not address the associated glenoid arthritis and glenoid cartilage loss, and at ten years the survival is actually better for total shoulder than hemiarthroplasty.
So in the end this is a very challenging problem. When I see these patients, I think it’s important to understand what their occupational and recreational demands are. I think understanding their expectations and goals is critical and you really do need to tailor the procedure to the individual patient.
Moderator Thornhill: This is great because we really have both sides of the issue pretty much alpha to omega. Tony, help me out a little bit. It seems to me when I listen to you give a very nice talk, that you’re not just talking about arthroscoping the shoulder. You’re talking about operating on the shoulder through an arthroscope. How much of this do you think is lavage and how much do you think is manipulation of the local tissue?
Dr. Romeo: I think the challenge for us is to try to lump all of these together as one type of diagnosis – you have a broader spectrum where both joints, both sides of the joint have bipolar disease. There are anchors in the joint. These are not ideal areas for arthroscopic management. The arthroscopic management is when there is concentric arthritis of the glenohumeral joint and there’s stiffness of the shoulder; there are loose bodies or mechanical symptoms and maybe even an osteophyte. That’s where arthroscopic surgery can have a role.
Moderator Thornhill: John, I think one of the things that Tony is saying is that in really young people, third failure, you’re data or better, what do you do? Let’s say you have a 24-year-old person who comes in and has some of the disease that you showed. You do a total shoulder on them? And if so, what do you allow them to do afterwards?
Dr. Sperling: That’s a great question. I think it’s a discussion with them based on their desire for pain relief balanced with their desire to be active. That’s the discussion I have. We go through the full spectrum that Tony described. What I tell them is that with the total shoulder arthroplasty, they have a 90% chance of pain relief; more consistent pain relief and more complete pain relief. But I give them a 25 pound weight restriction with that arm for the rest of their life.
The hemiarthroplasty is 75-80% chance of pain relief, and eventually I’ll let them go back and lift whatever they want.
I leave the decision up to the patient. Now the 25 pound weight limit comes from thin air frankly. It’s like in hip and knee patients, letting people play doubles tennis and not singles tennis.
Moderator Thornhill: Do you every do a hemiarthroplasty to leave them a little bit of pain to remind them not to lift more than they should? (Chuckles from audience.)
Dr. Sperling: Great question. I think there are some people who, again, want to be extremely active that have to understand that their chance of coming back and saying, “Thank you very much, I’m no better” is about 20% with a hemiarthroplasty.
Moderator Thornhill: This is all real interesting stuff. Tom Minas looked at people who have microfracture and then have ACI [autologous chondrocyte implantation], they don’t do as well. Do you think you are burning some bridges by doing this?
Dr. Romeo: Again, it really comes back to the indications and I think that there are many times when the arthroscopic surgery can be valuable in this younger patient group. There could be a focal defect, so the anchors were put in the wrong spot, but it might be in one specific area. Instead of replacing the entire joint go in and clean out that area, manage the focal articular cartilage defect. We don’t just automatically go shoulder arthroplasty. We think through the algorithm. We’ve had very good results with a capsular release and debridement, at least in the short-term. And these give these individuals an opportunity to preserve their shoulder. We have not seen that it’s been a consequence when we later have to do shoulder arthroplasty because we’re not disturbing the soft tissue envelope.
Moderator Thornhill: In summary, what we’re really saying is that osteoarthritis is a continuing disease and you’ve got one side talking about non-arthroplasty solutions, which I think is laudable. I thank you both for a very good discussion.
Please visit www.CCJR.com to register for the 2017 CCJR Spring Meeting, – May 21 – 24 in Las Vegas.
