Abstract
Background:
The treatment of full-thickness cartilage lesions of the humeral head in active-duty servicemembers (ADSMs) who have concomitant full-thickness rotator cuff tears and focal cartilage lesions of the humeral head is uncommon and presents clinical challenges.
Purpose:
To compare the midterm clinical and functional outcomes of ADSMs who underwent isolated arthroscopic rotator cuff repair (ARCR) with those who underwent ARCR and concomitant humeral head microfracture (HHMfx) for focal, full-thickness cartilage lesions of the humeral head.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
This was a retrospective analysis of ADSMs from a single duty-station who underwent ARCR for full-thickness rotator cuff tears between January 2014 and June 2019 with a minimum follow-up of 5 years. Patients who underwent ARCR + HHMfx were compared with those who underwent isolated ARCR based on outcome measures including the visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, and range of motion. Statistical analysis was performed using paired t tests to compare preoperative and postoperative outcomes. Minimal clinically important difference (MCID) was also evaluated, but not Patient Acceptable Symptom State or substantial clinical benefit due to the small sample size.
Results:
A total of 74 patients were eligible for inclusion, with 22 undergoing ARCR + HHMfx and 52 undergoing isolated ARCR. Significant postoperative improvements were observed in all patient-reported outcome measures (P < .0001 for all). Comparisons between the 2 cohorts demonstrated no significant differences in VAS pain scores (0.9 ± 1.6 vs 0.6 ± 1.0, respectively; P = .3045) but significantly improved SANE (90.2 ± 10.7 vs 95.1 ± 6.5; P = .0178) and ASES (91.7 ± 10.9 vs 96.1 ± 5.9; P = .0293) scores in the isolated ARCR group. Among patients in the ARCR + HHMfx group, MCID achievement rates were 90.9% (n = 20) for VAS, 77.3% (n = 17) for SANE, and 95.5% (n = 21) for ASES. All patients within the isolated ARCR group met the MCID thresholds for VAS, SANE, and ASES scores. Range of motion improved, although changes in forward flexion, external rotation, and internal rotation were not statistically significant (P > .05 for all). At the final follow-up, 20 (90.9%) patients in the ARCR + HHMfx group and 48 (92.3%) patients in the ARCR group returned to preinjury work and activity levels (P > .9999). Similarly, 19 (86.4%) patients in the ARCR + HHMfx group and 46 (88.5%) patients in the ARCR group returned to preinjury sports participation (P > .999). One patient (4.6%) in the ARCR + HHMfx group and 2 patients (3.9%) in the ARCR group progressed to total shoulder arthroplasty (TSA). Other complications included stiffness in 1 patient (1.9%) in the ARCR group and retear in 3 patients (5.8%) in the ARCR group.
Conclusion:
ARCR + HHMfx resulted in significant improvements in pain, function, and patient-reported outcomes at midterm follow-up that were comparable to outcomes for isolated ARCR. Although return-to-work and return-to-sport rates were slightly higher with the isolated ARCR group, this did not reach statistical significance, and the 95% TSA-free survival rate suggests that this combined approach appears to be a viable joint-preserving option for select patients with concomitant rotator cuff tears and focal humeral head cartilage lesions. However, study limitations include the retrospective design, small sample size, and heterogeneity introduced by concomitant procedures.
Management of concurrent shoulder pathologies, such as rotator cuff tears and focal, full-thickness cartilage lesions of the humeral head, presents a unique challenge in the shoulder. Both osteochondral defects and rotator cuff tears are being increasingly diagnosed in younger, active patients due to improved diagnostic modalities and increased activity levels, with incidences ranging from 12.5% to 28%.5,6,9,11 Active-duty servicemembers (ADSMs) are particularly susceptible to these concomitant pathologies, given the high-demand nature of their occupational tasks that frequently involve heavy lifting, overhead motions, and combat-readiness requirements. If left untreated, these osteochondral lesions have been shown to contribute to persistent pain, functional limitations, and degenerative changes, complicating postoperative rehabilitation after rotator cuff repair. 12 Microfracture is a described technique to address these focal cartilage defects by way of stimulating marrow-derived cells and promoting fibrocartilage repair. 14 Although microfracture has been extensively studied in the knee,3,7,10,16 literature regarding use of microfracture in the glenohumeral joint remains scarce, especially in the context of managing concurrent pathologies such as rotator cuff tears and osteochondral lesions. Even so, what limited shoulder microfracture studies are available are primarily focused on glenoid-based lesions2,4,15 with minimal data addressing humeral head lesions in the context of concurrent rotator cuff pathology. Given that ADSMs have increased exposure to repetitive high-impact tasks that exacerbate both rotator cuff pathology and cartilage degeneration compared with their civilian counterparts, management of these concomitant injuries remains a relevant topic for ADSMs, where optimal functional recovery and expeditious return to duty are essential for maintaining military readiness.
The purpose of the current study was to evaluate the midterm outcomes of concomitant arthroscopic rotator cuff repair (ARCR) and humeral head microfracture (HHMfx) for focal cartilage lesions in ADSMs. We hypothesized that a combined approach addressing both structural deficits would produce significant improvement in patient-reported outcome measures (PROMs) and mitigate the risk of progressive joint degeneration as measured by progression to arthroplasty within the follow-up time period.
Methods
Study Design and Inclusion Criteria
In this retrospective analysis of prospectively collected data, ADSMs who underwent ARCR between January 2014 and June 2019 at a single institution were eligible for inclusion. Those who were diagnosed with Outerbridge grade IV chondral lesions during diagnostic arthroscopy underwent ARCR and HHMfx, whereas the isolated ARCR group did not have any documented cartilage lesions requiring intervention. All patients had a minimum of 5-year follow-up. Patients who underwent concomitant labral repair at the time of surgery were excluded from the study due to differing postoperative rehabilitation protocols. Patients who underwent concomitant arthroscopic subacromial decompression, biceps tenotomy or tenodesis, arthroscopic acromioclavicular joint resection, arthroscopic rotator interval release, and removal of free cartilage bodies remained eligible for inclusion. Institutional review board approval was obtained before commencing the study (No. 2024-0007), and written informed consent was obtained from all participants.
Surgical Procedure
The senior surgeon's technique remained consistent throughout the study period. After the administration of general anesthesia and a presurgical interscalene block, all patients were placed in a modified beach-chair position, followed by examination under anesthesia. A Spider hydraulic arm holder (Smith & Nephew) was used to stabilize the operative shoulder, and the patient was draped appropriately. A complete diagnostic arthroscopy was performed, and any concomitant intra-articular pathology was addressed at this stage.
For patients undergoing microfracture of focal humeral head chondral lesions, loose cartilage margins surrounding the chondral defect were debrided using an arthroscopic shaver, arthroscopic biter, or ring curette. A ring curette was then used to create vertical walls around the defect, and the calcified cartilage was debrided, taking care to not penetrate the subchondral bone. A microfracture awl was then used to pierce the subchondral bone to a depth of approximately 3 to 4 mm, spacing the holes 3 to 4 mm apart. Arthroscope inflow was temporarily stopped, and the defect was assessed for appropriate bone marrow element infiltration.
A limited subacromial bursectomy was performed to evaluate the bursal surface of the rotator cuff and the greater tuberosity. The edge of the rotator cuff tendon was then prepared. A single-row repair technique was used for small tears (<1 cm), and a double-row repair was used for all medium or large tears (>1 cm).
Postoperative Rehabilitation
All patients attended physical therapy 2 or 3 times per week, and the rehabilitation protocol remained standardized among all patients, regardless of rotator cuff tear size. Patients were immobilized in neutral rotation in a SmartSling (Ossur) for 4 weeks and instructed to begin pendulum shoulder exercises after the resolution of their interscalene block. At 4 weeks postoperatively, immobilization was discontinued, and passive forward flexion exercises were introduced. Active range of motion and a gradual strengthening program were started at 6 weeks postoperatively, with patients allowed to return to unrestricted activity at 6 months.
Data Collection
Patient demographic characteristics including age, laterality, and sex were collected. Preoperative imaging and operative reports were reviewed to determine procedures performed and concomitant pathology. Tear size was determined using the Southern California Orthopaedic Institute classification system. Patient-reported outcomes, including the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Single Assessment Numeric Evaluation (SANE), and range of motion, were collected both preoperatively and postoperatively at 5-year follow-up for comparison. Return to preinjury level of work, activity, and sport was evaluated. Any complications or revision procedures were documented during the follow-up period.
Statistical Analysis
Statistical analysis was performed using SPSS Statistics, Version 25.0 (IBM). Continuous data were described by a combination of mean, standard deviation, range, and 95% CI. Paired t tests and chi-square versus Fisher exact tests were used to compare the differences between the pre- and postoperative results as well as between the 2 patient cohorts including rates achieving the minimal clinically important difference (MCID). A distribution-based MCID threshold was calculated with the size-based method using the formula MCID = 0.5 (standard deviation). Statistical significance was defined as P < .05.
Results
Between January 2014 and June 2019, a total of 77 patients underwent ARCR. Those with concomitant labral repairs, glenoid osteochondral lesions, and previous surgeries were excluded from further analysis. Two patients were lost to follow-up, leaving a total of 74 patients for final analysis. A total of 22 patients were found to have focal, full-thickness humeral head cartilage lesions at time of diagnostic shoulder arthroscopy, who subsequently underwent HHMfx. The 52 remaining patients did not have any documented cartilage lesions and underwent isolated ARCR (Figure 1).
STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) flow diagram. ARCR, arthroscopic rotator cuff repair; HHMfx, humeral head microfracture; OCD, osteochondral defect.
Patient Demographic Characteristics and Perioperative Findings
The mean patient age at time of surgery was 58.0 ± 9.8 years in the ARCR + HHMfx group and 54.2 ± 14.6 years in the ARCR group (P = .2678). The majority of patients in both groups were men (72.7% vs 63.5%, respectively; P = .4411). The mean follow-up duration was 87.5 ± 19.6 months in the ARCR + HHMfx group and 88.4 ± 10.2 months in the ARCR group.
Cartilage lesions in the humeral head were graded as Outerbridge grade IV, with a mean lesion size of 2.54 ± 2.00 cm2. Rotator cuff tears in the ARCR + HHMfx group and ARCR group were categorized as either small, medium, large, or massive, with no significant difference between the 2 groups in regard to tear size. Concomitant procedures performed included arthroscopic subacromial decompression in all patients (n = 22 vs n = 52, respectively; P≥ .999), biceps tenotomy or tenodesis (n = 17 vs n = 40; P = .9739), arthroscopic rotator interval release (n = 5 vs n = 10; P = .7324), removal of free cartilage bodies (n = 3 vs n = 0), and arthroscopic acromioclavicular joint resection (n = 2 vs n = 7; P = .5990) (Table 1).
Patient Demographic Characteristics, Lesional Characteristics, and Concomitant Procedures a
Values are expressed as mean ± SD or n (%). Boldface indicates statistical significance. ARCR, arthroscopic rotator cuff repair; HHMfx, humeral head microfracture.
Patient-Reported Outcome Measures
Statistically significant improvements were observed in all PROMs comparing preoperative to postoperative values for both groups (Table 2). The VAS score for pain showed an overall 5.5-point decrease for the ARCR + HHMfx group and 7.7-point decrease for the ARCR group. Both the SANE and ASES scores improved markedly with a 34.9- and 36.2-point increase, respectively, for the ARCR + HHMfx group and a 46.5- and 53.3-point increase, respectively, for the ARCR group. However, when comparing the mean differences between the 2 groups’ postoperative values, SANE scores were slightly significantly greater in the ARCR group (P = .0178), and ASES scores were improved as well (P = .0267). No statistically significant difference was found in VAS scores (P = .3045). The majority of patients in the ARCR + HHMfx group (n = 20; 90.9%) demonstrated VAS improvements over the MCID threshold, whereas 77.3% (n = 17) and 95.5% (n = 21) demonstrated improvements over the SANE and ASES thresholds, respectively (Table 3). All patients with isolated ARCR met the MCID thresholds for VAS, SANE, and ASES scores. When comparing MCID achievement rates between the 2 cohorts, we noted a statistically significant difference in VAS (P = .0275) and SANE (P < .001) scores but not ASES scores (P = .1216).
Patient Reported Outcome Measures a
Preoperative and postoperative data are presented as mean ± SD. Boldface indicates statistical significance. ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Surgeons standardized assessment score; HHMfx, humeral head microfracture; SANE, Single Assessment Numeric Evaluation; VAS, visual analog scale pain score.
Distribution-Based MCID Thresholds a
The 0.5 SD method (MCID = 0.5 × [SD of Δ score]) was used to calculate the distribution-based MCID threshold. Boldface indicates statistical significance. ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Surgeons standardized assessment score; HHMfx, humeral head microfracture; MCID, minimal clinically important difference; SANE, Single Assessment Numeric Evaluation; VAS, visual analog scale pain score.
Range of Motion
There was no statistically significant difference between preoperative or postoperative forward flexion, external rotation, or internal rotation for both groups (Table 4).
Range of Motion a
Preoperative and postoperative data are presented as mean ± SD. ARCR, arthroscopic rotator cuff repair; HHMfx, humeral head microfracture.
Survivorship and Return to Activity
By the end of follow-up, 1 patient (4.6%) in the ARCR + HHMfx group progressed to total shoulder arthroplasty (TSA) 5 years postoperatively at age 57 and 2 patients (3.9%) in the ARCR group at 10 months and 23 months postoperatively. One patient experienced retear but declined TSA. Among the remaining patients in the ARCR + HHMfx group, 20 of 22 (90.9%) patients successfully returned to their preinjury level of work and activity, whereas 19 of 22 patients (86.4%) resumed their preinjury level of sports activity, demonstrating a high rate of functional recovery. No significant differences were found compared with the ARCR group, with 48 of 52 patients (92.31%) returning to preinjury level of work and activity and 46 of 52 patients (88.46%) returning to preinjury level of sport activity (P > .9999 for both). No major complications such as infections or nerve injuries were reported during the follow-up period except for 1 patient in the ARCR group (1.9%) who developed stiffness and 3 patients in the ARCR group (5.8%) who experienced retear.
Discussion
In patients with concomitant rotator cuff tears and focal, full-thickness humeral head cartilage lesions, ARCR with HHMfx produced clinically and statistically significant improvements in PROMs at the midterm follow-up with outcomes comparable to isolated ARCR. Although return to preinjury level of work and sports activity was slightly higher in the ARCR group, the vast majority of patients in both groups achieved preinjury functional levels with low rates of progression to arthroplasty. Our findings offer a promising treatment strategy for humeral head cartilage lesions in the setting of rotator cuff tear.
Currently, a paucity of data is available regarding the combined treatment of concomitant humeral head osteochondral defects and rotator cuff tears. A recent study by Dey Hazra et al 1 examined isolated HHMfx in 17 patients at a mean follow-up of 9.4 years. The investigators reported a survival rate of 80% with significant improvements in patient-reported outcomes; however, their study excluded 8 patients who had concomitant rotator cuff repairs. This highlights the rarity of this combined pathology and the challenge in identifying a sufficient number of patients for analysis. Thus, our cohort of 22 patients represents a substantial contribution to the literature regarding this specific clinical presentation. The superior survival rate in our study (95.4% vs 80%) may also reflect the importance of addressing rotator cuff pathology when present compared with treating cartilage lesions in isolation.
Our results align with and extend previous investigations involving isolated glenohumeral microfracture. Frank et al 2 demonstrated 88% return to preoperative activity level at midterm follow-up of 27.8 months as well as improvements in VAS scores. However, their study did not include patients with concomitant rotator cuff pathology. In a long-term evaluation for isolated microfracture, Wang et al 15 reported a 76.6% survival rate with sustained improvements in VAS and ASES scores at 10-year follow-up, which aligned with the findings of our study.
Previous studies have highlighted that the presence of concomitant cartilage lesions and rotator cuff tears can negatively affect ARCR outcomes.9,11,12 This is reflected in our findings that isolated patients with ARCR had significantly higher ASES and SANE scores compared with patients who underwent ARCR + HHMfx. Hill et al 5 evaluated 24 patients undergoing ARCR and microfracture (glenoid, humeral head, or both) at a minimum of 1-year follow-up. The investigators found postoperative improvements in VAS, ASES, Simple Shoulder Test, and SANE scores; however, only 52% of patients achieved the MCID for all collected patient-reported outcomes. In contrast, our study demonstrated that >90% of patients met MCID for pain (VAS) scores and ASES (90.9% and 95.5%, respectively), and 77.3% met the MCID threshold for SANE scores, suggesting excellent clinical outcomes.
Further supporting the combination of rotator cuff repair and cartilage restoration, Green et al 4 investigated young, high-demand patients, specifically active-duty military personnel younger than 50 years, who underwent both rotator cuff repair and glenoid microfracture. Their study demonstrated favorable outcomes, with significant improvements in pain and function; 71% of patients returned to active-duty military service at 6-year follow-up. Notably, the investigators also observed a low rate of revision surgery, mirroring the outcomes of our study. These findings reinforce the efficacy of this combined approach in younger, active populations. 4
A key distinction between the present study and prior investigations is the location of the cartilage lesion being treated. Although prior studies primarily examined microfracture outcomes for glenoid defects, our study evaluates microfracture in specifically humeral head lesions. It is postulated that humeral head lesions may have a greater capacity for load distribution and healing due to anatomic differences in articular cartilage and subchondral bone thickness. In addition to greater compressive stiffness at high strain levels, the glenoid's structural properties may contribute to higher contact pressures during shoulder articulation and thus experience greater shearing forces. 8 As the concave stabilizing structure of the glenohumeral joint, glenoid cartilage lesions can directly affect joint congruency and stability, potentially leading to poorer outcomes when treated with microfracture. 13 Conversely, humeral head lesions located on the convex articular surface may allow for improved healing due to reduced shearing forces and better subchondral bone access to marrow-derived cells for fibrocartilage formation. 8
Limitations
Although these findings are promising, several limitations must be considered. The retrospective nature of this study introduces potential biases in patient selection and data collection, given that the decision to perform microfracture was based on intraoperative findings and surgeon judgment. The small sample size of 22 patients in the ARCR + HHMfx group additionally limits statistical power in detecting differences between the 2 groups. However, given the rarity of these concomitant pathologies as demonstrated by previous studies with only 8 patients identified, 1 this study represents a meaningful contribution to this limited literature. The inclusion of patients who underwent concomitant arthroscopic procedures also introduces heterogeneity to our study that limits attribution of outcomes specifically to microfracture. Although our study followed patients for a mean of 7.3 years, the assessment of long-term cartilage regeneration or joint degeneration would provide a more complete picture of the durability of microfracture in the shoulder joint. Furthermore, the homogeneity of our active-duty military cohort limits the generalizability of these results to younger, more active populations or to those with different activity demands and rehabilitation resources.
Conclusion
The combination of ARCR and microfracture in ADSM for the treatment of concomitant rotator cuff tears and focal, full-thickness humeral head cartilage lesions yielded favorable midterm outcomes comparable to ARCR alone. Both groups demonstrated significant improvements in pain, function, and return to activity. Our study also highlights the low risk of this treatment strategy, with a failure rate of only 4.6%. Our findings support the viability of this approach as a joint-preserving strategy for patients with concomitant rotator cuff tears and humeral head cartilage lesions. However, the study's retrospective nature, heterogeneity of concomitant procedures, and relatively small sample size warrant further investigation. Future prospective studies, ideally randomized controlled trials, with larger and more diverse patient cohorts, long-term follow-up, and assessments of cartilage repair durability, are needed to further refine patient selection criteria and optimize outcomes for this combined treatment approach.
Footnotes
Final revision submitted December 21, 2025; accepted February 27, 2026.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
