Abstract
Background:
Osteochondritis dissecans (OCD) affects the shoulder in only 0.6% of patients aged 2 to 19 years with disease most commonly in the humeral head. When the glenoid is affected, it is often in male overhead throwing athletes and treated with fixation via autologous osteochondral plugs following bone marrow aspirate.
Indications:
The primary indication for surgical management of OCD is failure of conservative management, often with imaging showing disruption of the glenoid subchondral plate. This patient is an 18-year-old male pitcher with over 2 years of chronic, deep-seated shoulder pain unresponsive to conservative management.
Technique Description:
We present a primary arthroscopic technique of autologous bone marrow aspirate concentrate graft for management of OCD in an 18-year-old college baseball pitcher. The patient was placed in the left lateral decubitus position with an axillary roll and standard portals were established. A loose fragmented flap with no underlying osseous material was debrided and a 3-cm central area of bony loss was identified. Bone marrow aspirate of 80 mL was taken from the anterior superior iliac crest. The aspirate was mixed with Biocartilage (Arthrex) to fill the defect flush with the surrounding tissue and sealed with fibrin glue. Ports were closed and an abduction sling was applied.
Results:
A recent review article demonstrated that athletes who underwent surgical management of OCD lesions returned to sports an average of 1.2 months sooner than those managed non-operatively, though this difference was not significant. This patient had a full return to play at 9 months. At 1-year follow-up, he made a full recovery and is currently playing professionally without shoulder pain.
Discussion/Conclusion:
Autologous bone marrow aspirate defect filling is a viable treatment of OCD, even in high-level overhead throwing athletes. It allows for arthroscopic treatment with long-term success in the treatment of pain and function.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
This video demonstrates our technique for surgical management of osteochondritis dissecans (OCD) of the glenoid.
Here are our disclosures.
OCD is a focal, idiopathic alteration of subchondral bone that increases risk for instability and disruption to adjacent articular cartilage and may result in osteoarthritis. Patients usually present with non-specific joint pain that is worsened by exercise. Mechanical symptoms may indicate advanced disease.1,2
OCD is frequently associated with trauma or overuse, and most patients are multisport athletes. In a recent epidemiology study, Weiss et al 5 found that approximately 62% of lesions occur in knees, 25% in ankles, and 12% in elbows, with only 0.6% of all OCD injuries occurring in shoulders.
Diagnosis is made with radiograph and magnetic resonance imaging (MRI). For the shoulder, anteroposterior, Grashey, axillary, and scapula Y views should be obtained. MRI may be obtained as needed.
Our patient is an 18-year-old male, division I baseball player who presented with 2 to 3 years of right dominant shoulder pain that failed to dissipate with rest and non-steroidal anti-inflammatory drugs. His pain was exacerbated with throwing activity, but he denied mechanical symptoms and reported no history of trauma.
On physical exam, there was firing of the deltoid in all 3 planes and full passive range of motion was noted. Rotator cuff strength testing was 5+ throughout. Equivocal superior labrum, anterior to posterior (SLAP) testing was reproduced with negative crank and dynamic labral shear testing. There was no apprehension or instability with anterior or posterior load shift testing, and the shoulder exhibited full range of motion.
Osteochondral injury in the posterior glenoid is visualized on the radiograph as seen here, but MRI was obtained for better characterization. Here is a video of the MRI. He was noted to have a disruption of a 5-mm diameter segment of the glenoid subchondral plate with approximately 2 mm of impaction and underlying hyperintense or intermediate-signal intensity cysts with hypointense rims. The overlying cartilage was shown to be intact. Findings were consistent with a chronic osteochondral impaction injury of the posterosuperior quadrant glenoid.
Given the patient's unstable lesion with cartilage delamination, persistent pain refractory to conservative treatment, and skeletal maturity, surgical management was indicated, and we proceeded with debridement of the lesion and filling of the defect with bone marrow aspirate concentrate and extracellular matrix.
The key steps of this procedure include the following: iliac crest aspiration for bone marrow aspirate, drying the lesion, biocartilage preparation and introduction, fibrin glue sealant, and stability assessment.
The patient was placed in the left lateral decubitus position with an axillary roll. All bony prominences were padded, and shoulder insufflation was obtained. The posterior superior viewing portal and anterior mid-glenoid portal were established. The anterior iliac crest was draped separately for bone marrow aspirate harvest.
On diagnostic arthroscopy, the subscapularis and anterior superior labrum were intact. The superior labrum demonstrated no evidence of a SLAP tear. Evaluation of the biceps demonstrated no lip sticking or instability. The rotator cuff, axillary pouch, and complete inferior labrum were nicely intact. The humeral head was pristine without evidence of chondral wear. There were small fragments of loose bodies that were subsequently removed with a shaver suction as well as a grasper.
Upon posterior evaluation, there was a loose fragmented flap that was unstable centrally, such that the probe could be inserted underneath. There was also rubbery central sclerotic chondral tissue that was hypermobile and with a loose area of chondral delamination peripherally at the chondral labral junction as well as posterior labral fissuring without underlying instability.
With no underlying osseous material on the underlying surface of that chondral flap, the flap was fragmented and removed. Then the underlying bony bed was debrided to the calcified cartilage and reactive tissue. Bleeding bone was reached with care to avoid creating further cavitary lesion or bony deficiency. During this process, a small central area was noted that had about 3 cm of bony loss. This measured approximately 5 mm in width, and the remainder was flushed with surrounding area of subchondral normal bone leaving just the chondral deficiency.
Approximately 80 mL of bone marrow aspirate were obtained from the anterior superior iliac crest through a stab incision and were processed to generate approximately 5 to 7 mL of bone marrow aspirate with isolated leukocyte-depleted growth factors. Biocartilage was then mixed which was used as the biological substrate to encourage overlying fibrocartilaginous fill of this defect.
We then introduced approximately 3 mL of biocartilage filling to just below and slightly recessed from the surrounding area of cartilage. This was then manipulated into position such that the filling was flush with the surrounding chondral tissue. Once the filling was adequately positioned and demonstrated excellent packing stability, loose fragments were removed. Fibrin glue was then applied to seal the filling into place. After 5 minutes arthroscopic equipment was subsequently removed, distraction was let down, and all portal sites and bone marrow aspirate harvest sites were closed directly. An abduction sling was placed and ice packs were applied at the surgical site.
Reported outcomes are favorable and complications are rare. Donor site morbidity is the most common postoperative complication, but others include infection and injury to neurovascular structures. A recent study by Kolin et al 3 found there to be no significant difference in patient-reported outcomes for patients with OCD that underwent 1 of 3 lesion-specific surgical treatments.
Here are a few pearls to consider for this technique. Lateral decubitus position is preferred to allow dependent positioning of graft material and biologic adjuvant. The lesion is curetted to vertical margins with healthy petechial bleeding of subchondral bone, with or without bone marrow stimulation, to promote graft integration. After evacuation of arthroscopic fluid, a suction tip is applied to sterile cotton-tipped applicators to dry the lesion before graft introduction. Colinear position of the posterior portal should be ensured to allow for ease of graft introduction. Biocartilage is gently introduced via 7+ mm cannula at a level that is flush to slightly recessed below the level of the surrounding cartilage prior to application of fibrin glue. After graft and glue application, a labral elevator or Freer elevator may be utilized to contour graft tissue for a more even fill. If an unshouldered lesion that extends to the periphery of the glenoid is present, labral stabilization may be performed using a suture anchor to ensure maintenance of the grafted material.
Postoperatively, strict immobilization with elbow, wrist, and hand range of motion is maintained for the first 2 weeks. After that, 4 weeks of sling immobilization in the neutral gunslinger position should be maintained. Thereafter, the patient should limit forward flexion and abduction, but allow gentle supported pendulums. Passive range of motion may be allowed with external rotation limited to approximately 40° and internal rotation limited to approximately 30°, all with glenohumeral joint distraction.
Our patient underwent physical therapy 1 to 2 times per week until returning to full range of motion which was approximately 5 to 6 months. During postoperative weeks 0 to 6, forward flexion was restricted to 30° and internal rotation to 30° to 40°. The shoulder was limited to passive range of motion and assisted active range of motion with heat before and ice after physical therapy sessions. During weeks 6 to 12, range of motion was increased to within 20° of the opposite side and the patient advanced strength training as tolerated from isometrics to using bands and eventually light weights 3 times per week. In the months following, he advanced to full range of motion and increased strength training with sports rehab beginning at 3 months. He was cleared to return to throwing around 5 months postoperatively with advancement to throwing from the pitcher's mound around 6 months.
At 6 months postoperatively, our patient had full passive range of motion with the exception of internal rotation in which he had 20° loss from full arc. At 9 and 12 months he had full range of motion.
In general, sporting precautions should be recommended for approximately 6 months. Our patient had a full return to play at 9 months. Pardiwala et al 4 found that the mean time for return to sports in patients with OCD of the glenoid was 6.8 months for operative treatment and 8.0 months for non-operative treatment, though this difference was not found to be statistically significant.
At 6-month postoperative follow-up, the patient's pain was well tolerated with mild discomfort at the biceps and subcoracoid region. At 12-month follow-up, he had experienced continual strength gains and resumption of full activity with no pain at rest, mechanical symptoms, numbness, or tingling. He returned to successful team participation and eventually progressed into a professional baseball career.
Thank you for your time.
Footnotes
Submitted May 1, 2023; accepted August 10, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: N.A.T. received support for education from Arthrex, Smith & Nephew, Medwest Associates, and SouthTech Orthopedics; hospitality payments and honoraria from Encore Medical; a grant from Medical Device Business Services and Arthrex; and hospitality payments from Stryker Corporation. B.R.W. received support for education from SouthTech Orthopedics, Arthrex, and Peerless Surgical; honoraria from Vericel and Musculoskeletal Transplant Foundation; is a paid speaker for Arthrex and Vericel; received consulting fees from FH Orthopedics, Vericel, DePuy Synthes Products, and Medical Device Business Services; and hospitality payments from Piedmont Plus Innovation. 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.
