Biological Resurfacing of the Glenoid

Mike Walton, 2014

The management of arthritis in the young poses a very difficult problem for patients and surgeons. Unfortunately, we know that even in the best hands joint replacements will wear out given enough time. In the young patient this poses a significant challenge, as they may need several replacements during their lifetime.

This is a problem for all joint replacement surgeons but shoulder replacements have a series of unique aspects. With all joints there are two sides, usually a ball and a socket of some sort. In the shoulder the upper part of the humerus (arm bone) forms the ball and the glenoid (part of the shoulder blade or scapula) the socket. The glenoid is a very small socket. The shoulder is also completely dependant on muscles with very little inherent bony stability. This means that if the muscles fail then the shoulder can become unstable. An unstable joint can wear more quickly. Both of these factors mean that replacing the glenoid has been a very difficult challenge to achieve good fixation and longevity.

The two principal options available to surgeons in shoulder replacement have therefore been to perform a total shoulder replacement. This gives better pain relief but may have a higher chance of glenoid loosening over time. Or to just replace the humeral side of the joint acknowledging that the results may be less predictable in terms of pain relief but there is no glenoid to worry about - A difficult choice especially in the young with high demands, expectations and level of function.

A potential solution to this was the proposed BIOLOGICAL RESURFACING of the GLENOID. This involves using a natural biological substance to cover the glenoid instead of a joint replacement. This would be the ideal scenario of achieving good pain relief but without the problems of glenoid implant failure.

The concept dates back over 100 years however it was Burkhead and Hutton (1995) who popularised the technique. They initially used either anterior capsule or fascia lata graft. They reported excellent initial results with good pain relief and increased ROM at 2 years. Their mid-term 7 years results were equally as encouraging with good/excellent results in 86% of shoulders. Other units also demonstrated good results, with Lee et al showing 83% satisfaction at 2-10 years using an anterior capsule graft. Other forms of graft were also tried including Achilles tendon and lateral meniscus allografts. The benefits of the different grafts were theoretically bulkier materiel that would have long life and tissue that had better load bearing characteristics respectively. De Beer described an arthroscopic technique, using commercially available dermal tissue (GraftJacket). 23/32 patients had excellent or satisfactory results. This study also found that the graft appeared to incorporate into the host glenoid into “tissue similar to fibrocartillage” on MRI.

Over the last few years, unfortunately, longer-term studies have started to show that the initial promising results may not be sustainable. Strauss et al reported their series of 41 patients. 31 had had lateral meniscal allograft and 10 GraftJacket with a resurfacing hemiarthroplasty. They found that the GraftJacket group had a clinical failure rate of 70% at 2.3 years and the lateral menisicus group 45% at 3.4 years. JJP Warner from Harvard found that 11/13 of his patients had persistent pain. There was loss of joint space in 100% and 10/13 required revision surgery to a total shoulder replacement. This paper highlighted that the results were significantly inferior to his results with either hemiarthroplasty or total shoulder replacement. Hammond et al compared a case-controlled group of patients having resurfacing hemiarthroplasty alone against a similar group having hemiarthroplasty and biological glenoid resurfacing. They found that the outcome measures in the hemi alone group were better both in pain relief and functional improvement. There was however a high revision to total shoulder replacement rate in both groups (6/23 hemis at 3.8 years and 12/21 hemi + biological resurfacing at 3.6 years).

Shoulder replacement in the young is a difficult problem and one that we have not yet found the solution to. Biological resurfacing of the glenoid promised a novel option however the results do not seem to better than current shoulder replacements and may have a higher rate of complications.

1. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. Burkhead WZ Jr, Hutton KS. J Shoulder Elbow Surg. 1995 Jul-Aug;4(4):263-70.
2. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. J Bone Joint Surg Am. 2007 Apr;89(4):727-34
3. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. Lee KT, Bell S, Salmon J. J Shoulder Elbow Surg. 2009 Nov-Dec;18(6):915-9
4. 
Arthroscopic debridement and biological resurfacing of the glenoid in glenohumeral arthritis. de Beer JF, Bhatia DN, van Rooyen KS, Du Toit DF. Knee Surg Sports Traumatol Arthrosc. 2010 Dec;18(12):1767-73
5. The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. Strauss EJ, Verma NN, Salata MJ, McGill KC, Klifto C, Nicholson GP, Cole BJ, Romeo AA. J Shoulder Elbow Surg. 2014 Mar;23(3):409-19.
6. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ. J Bone Joint Surg Am. 2009 Feb;91(2):419-24
7. Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years. Hammond LC, Lin EC, Harwood DP, Juhan TW, Gochanour E, Klosterman EL, Cole BJ, Nicholson GP, Verma NN, Romeo AA. J Shoulder Elbow Surg. 2013 Oct;22(10):1345-51.