Microfracture in the Shoulder
Chondral lesions of the glenohumeral joint, although less common than chondral lesions in other joints such as the knee or ankle, can be a source of shoulder pain in an active population. While the incidence of such defects of the shoulder has been documented as 5% to 17%, these reports do not differentiate which of these defects are the primary symptom generators and meet the indications for treatment. The treatment options for chondral defects of the shoulder remain poorly defined. Often, the diagnosis of a symptomatic shoulder chondral defect is difficult to make secondary to vague nonlocalizing complaints, with history and examination findings similar to other common shoulder conditions. Additionally, imaging studies are poor at detecting chondral injuries until late in the disease process because of the relatively thin cartilage in the shoulder. Often, diagnosis may be delayed until the time of shoulder arthroscopy. While the cause of most cartilage defects in the shoulder is unknown, there has been a reported association with recurrent instability, rotator cuff tears, iatrogenic injury, and capsulorrhaphy techniques.
Once a glenohumeral chondral defect is identified, no consensus exists among orthopaedic surgeons on the most appropriate treatment options. Nonsurgical treatments include physical therapy and steroid injections, while surgical options incorporate palliative, reparative, restorative, and reconstructive techniques such as arthroplasty. While total shoulder arthroplasty remains an excellent treatment option for older patients with diffuse symptomatic cartilage disease, in younger patients, this option is less attractive because of functional limitations and relatively short implant survival time in active patients. Further, arthroplasty may not be the preferred option for focal defects. The clinical outcomes of debridement and reconstructive and restorative techniques have been discussed in the literature; however, there remains a paucity of information regarding reparative surgical treatment for glenohumeral chondral defects, specifically microfracture.
Microfracture has been established as an effective therapeutic solution for full-thickness cartilage defects of the knee because of its low surgical morbidity and technical feasibility as a first-line treatment with good clinical outcomes. As there is minimal vascular supply to the articular cartilage, defects of any origin rarely heal spontaneously and often require surgical intervention secondary to a high prevalence of clinical symptoms and functional disability. In addition to the lack of blood supply, the limited healing capacity of articular cartilage is due to the virtual absence of an undifferentiated cell population that is able to respond to traumatic and/or degenerative injury. While marrow stimulation has been shown to be effective in other joints such as the knee and ankle, we are aware of only one study describing the clinical outcomes of patients who have undergone open microfracture in the shoulder joint and no study reporting the outcomes of arthroscopic microfracture available in the literature. The purpose of this study is to report the short-term clinical outcomes of microfracture for symptomatic articular defects of the glenohumeral joint. The hypothesis was that treatment of articular defects in the glenohumeral joint using microfracture would demonstrate similar short-term clinical outcomes when compared with other joints.