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Glenoid Microfracture in Active-Duty Military Patients: Minimum 5-Year Follow-Up Demonstrates 75% Survival

Open AccessPublished:October 14, 2022DOI:https://doi.org/10.1016/j.jseint.2022.09.011

      Abstract

      Purpose

      To present mid-term patient reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid.

      Methods

      All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met final inclusion criteria for the study, and all-were active-duty military at time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes.

      Results

      Mean follow-up was 81.45±19.43 months (range 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6±13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons (ASES) score (57.20 vs. 88.27, p < .0001) and Single Assessment Numeric Evaluation (SANE) (45.00 vs. 86.33, p < .0001). Mean pain decreased significantly as measured by the pain VAS (5.40 vs. 1.37, p < .0001). Range of motion in forward elevation, external rotation and internal rotation did not change significantly postoperatively (p = 0.4528, 0.4810 and 0.1919, respectively). Concomitant procedures did not predict changes in pain, ASES, or SANE scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but seven (35%) underwent medical discharge, including the five patients who had experienced treatment failure, plus two additional patients.

      Conclusion

      Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at five-years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

      Keywords

      Active-duty service members experience shoulder pain and dysfunction at rates that far outpace those observed among civilian patients
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      . Despite these risks, there exists a select group of patients who benefit greatly from this procedure and are able to return to sport and activity following microfracture. The utility of this procedure in military patients wishing to remain on active-duty service, however, is unknown.
      The primary purpose of this study is to present mid-term patient reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid. The secondary purpose is to determine if dominant arm involvement affects outcomes. We hypothesize that glenoid microfracture produces substantial improvements in patient reported outcome measures, with a majority of patients able to both remain on active-duty service and avoid secondary surgical procedures. Additionally, we hypothesize that involvement of the dominant extremity portends worse clinical outcomes.

      METHODS

      This study is a retrospective analysis of active-duty military patients under the age of 50 who underwent glenoid microfracture between January 2013 and December 2016. Data were collected upon enrollment in a prospective research database throughout the course of treatment and assessed retrospectively. Institutional review board approval was obtained prior to beginning the study.

      Patient Population

      Inclusion criteria encompassed active-duty military patients over the age of 18 and under the age of 50 who underwent glenoid microfracture for a painful, full-thickness glenoid chondral lesion. All patients were treated at a single institution serving a single military base. All patients had a minimum of five-years follow-up with complete outcomes scores both pre- and postoperatively at last follow-up appointment. Excluded from this study were patients younger than 18 or older than 50, patients with a history of ipsilateral shoulder surgery, patients undergoing either concomitant labral repair or rotator cuff repair, patients with Outerbridge 0 – III injuries, and patients with less than five years follow-up
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      All patients had activity-related pain as their primary chief complaint and noted pain severe enough to interfere with both their military duty requirements and activities of daily living. Prior to being considered for surgery, all patients had failed at least three months of conservative treatment including anti-inflammatory medications, physical therapy, home exercise and limited-duty profiling. All patients underwent preoperative MR-arthrogram, which was reviewed retrospectively by the operating surgeon in conjunction with arthroscopic images and operative reports.
      Patient age, sex, laterality, and military occupation were obtained in addition to outcome measures including the American Shoulder and Elbow Surgeons (ASES) score and the Single Assessment Numeric Evaluation (SANE). Additional outcomes collected included pain as measured by the Pain Visual Analog Scale (VAS), active range of motion in forward elevation, external rotation and internal rotation, complications, and active-duty status
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      Surgical technique

      Patients were positioned in a modified beach-chair position following administration of general anesthesia and a presurgical interscalene block. A Spider hydraulic arm holder (Smith & Nephew, Andover, MA, USA) was then employed to stabilize the operative shoulder and the patient was draped. Complete diagnostic arthroscopy of the glenohumeral joint was performed and the chondral lesion was identified (Figure 1). Concomitant procedures frequently including arthroscopic biceps tenodesis, arthroscopic-assisted sub-pectoral biceps tenodesis, and arthroscopic acromioclavicular joint resection arthroplasty were performed (Table 1). Following the completion of concomitant intraarticular procedures, the loose cartilage and chondral flaps abutting the defect were débrided with an arthroscopic shaver, ring curette and/or arthroscopic biter. Once the lesion was well-contained, a ring curette was utilized to create vertical walls circumferentially around the defect. We then proceeded to débride the layer of calcified cartilage with a curette, ensuring to not violate the subchondral bone. A microfracture awl was then used to penetrate the subchondral bone to the depth of the awl tip (approximately 3 – 4 mm), with the holes spaced approximately 3 – 4 mm apart (Figure 2). Once complete, arthroscope inflow was terminated in order to ensure that there was appropriate defect fill with bone marrow elements (Figure 3).
      Figure thumbnail gr1
      Figure 1Right shoulder of a 32-year-old male with an 8.0x14.0 mm full-thickness glenoid osteochondral defect, as viewed from the posterior viewing portal.
      Table 1Preoperative/Intraoperative Patient Characteristics
      Total (N = 20)
      Age, years, mean ± SD (range)38.85 ± 9.17 (22-50)
      Follow-Up, months, mean ± SD (range)81.45 ± 19.43 (60-108)
      Male, N (%)19 (95.00%)
      Combat Arms, N (%)
      Defined as patients whose military duties require regular high-demand physical readiness training, manipulation of firearms, moving across uneven terrain and obstacles with heavy loads, hand to hand combat training and other warfighting tasks (i.e. infantry, artillery, military police)
      15 (75.00%)
      Dominant shoulder involvement, N(%)12 (60.00%)
      History of a traumatic event, N(%)10 (50.00%)
      MRI Evidence of chondral injury, N(%)8 (40.00%)
      Time to surgery from symptom onset, months, mean ± SD31.65 ± 51.73
      Surgical time, minutes, mean ± SD64.70 ± 16.46
      Glenoid Lesion Area, cm2, mean ± SD2.17 ± 1.15
      Concomitant Procedures
      ASAD, N(%)20 (100.00%)
      ABT, N(%)6 (30.00%)
      AASPBT, N(%)5 (25.00%)
      ASB, N(%)4 (20.00%)
      Débridement of humeral head OCD, N(%) (average size 1.75 ± 1.5 cm2)4 (20.00%)
      Note: ASAD: arthroscopic subacromial decompression, ABT: arthroscopic biceps tenodesis, AASPBT: arthroscopic-assisted sub-pectoral biceps tenodesis, ASB: arthroscopic subacromial bursectomy, ADHH: arthroscopic débridement of the humeral head
      Defined as patients whose military duties require regular high-demand physical readiness training, manipulation of firearms, moving across uneven terrain and obstacles with heavy loads, hand to hand combat training and other warfighting tasks (i.e. infantry, artillery, military police)
      Figure thumbnail gr2
      Figure 2The same patient from , following lesion preparation and microfracture.
      Figure thumbnail gr3
      Figure 3Inflow from the pump has been shut off, to allow for visualization of lesion fill with bone marrow contents

      Postoperative Rehabilitation

      Patients were discharged home the same day of their procedure. All patients were instructed to begin pendulum shoulder movement once the interscalene nerve block had worn off. Narcotic pain medications were prescribed for up to ten days postoperatively. Patients were given a sling for comfort for the first 2-4 weeks. Passive range of motion was permitted and encouraged immediately after surgery, with rapid progression to active-assist and active range of motion as tolerated. All patients attended physiotherapy at the same military physical therapy group and followed the same protocol, although the treating therapist or therapist aide did vary from patient to patient. Light strengthening was permitted at 6 weeks postoperatively, pending restoration of range of motion, and unrestricted strengthening was permitted at 12 weeks postoperatively. Return to unrestricted activity was allowed at 4 months postoperatively after the patient was cleared by physical therapy and the patient reported subjective readiness to return to full duty. For three months after surgery, patients were placed on a limited duty profile to decrease the occupational physical requirements characteristic of their work and were restricted from participating in the army physical fitness test (APFT) for an additional three months. Treatment failure was defined as continued pain with inability to return to unrestricted active duty.

      Statistical Analysis

      Statistical analysis was conducted using IBM SPSS Statistics, version 25.0 (IBM Corp, Armonk, NY, USA) and GraphPad Prism, version 9.0.0 (GraphPad Software, San Diego, CA, USA). As clinical significance thresholds following glenoid microfracture have not been determined, previously published values for the minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) following shoulder arthroplasty were used. Similarly, previously published values for maximum orthopedic improvement (MOI) for the SANE and ASES following arthroscopic rotator cuff repair were used in lieu of microfracture specific metrics
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      RESULTS

      During the study period the senior surgeon performed microfracture on 46 patients with grade IV glenoid lesions. Twenty patients underwent concomitant labral repair for anterior, posterior or combined instability, three patients underwent concomitant rotator cuff repair and three patients could not be reached for follow-up, leaving a total of 20 patients with a mean follow-up of 81.45±19.43 months available for analysis (Table 1, Figure 4). A majority of patients were male and in a combat arms military occupation specialty (MOS), with an average age of 38.85 years. The average size of the glenoid defect was 2.17±1.15 cm2. Concomitant procedures performed can be seen in Table 1.
      Five patients progressed to failure at time of final follow-up and therefore were excluded from outcome score and arm-dominance subgroup analysis. In the remaining patients, there were significant improvements in all patient-reported outcome measures (PROMs) at final follow-up. At minimum five-years follow-up, mean pain as measured by the pain VAS decreased, while shoulder function, as measured by the SANE and ASES, increased (p-value < 0.0001, respectively). There was no significant change in range of motion (Table 2). A majority of patients met the MCID and achieved the PASS as measured by the Pain VAS, SANE and ASES scores (Table 3). Furthermore, a majority of patients achieved SCB as determined by Pain VAS and ASES scores. In the patients who achieved survival, MOI was reached by 66.67% of patients as determined by the SANE and 53.33% as determined by the ASES score. Although patients who underwent surgery on their nondominant shoulder had lower pain and higher outcome scores at final follow-up, these differences did not vary significantly (Table 4).
      Table 2Comparison of Pre-operative and Post-operative Outcome Measures for Patients Who Did Not Fail Treatment (n = 15)
      OutcomePreoperative, mean (95% C.I)Postoperative, mean (95% C.I)DifferenceP value
      VAS5.40 (4.74, 6.06)1.37 (0.48, 2.25)-4.17 (-3.43, -4.90)<0.0001
      SANE45.00 (36.23, 53.77)86.33 (80.48, 92.19)41.33 (30.24, 52.42)<0.0001
      ASES57.20 (52.83, 61.57)88.27 (82.35, 94.18)31.07 (24.39, 37.74)<0.0001
      Forward Elevation156.00 (153.62, 158.38)156.33 (153.90, 158.77)0.33 (-0.82, 1.49)0.3225
      External Rotation66.33 (63.90, 68.77)67.33 (64.83, 69.84)1.00 (-1.74, 3.74)0.4486
      Internal RotationT10.67 (9.51, 11.82)T9.80 (8.78, 10.82)T0.87 (-0.48, 2.22)0.1919
      Table 3Achievement of Clinical Significance
      Pain VAS
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      • Timmons M.K.
      The Effect of Repeated Shoulder Motion on Scapular Dyskinesis in Army ROTC Cadets.
      SANE
      • Arciero R.A.
      • Wheeler J.H.
      • Ryan J.B.
      • McBride J.T.
      Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations.
      ASES
      • Arner J.W.
      • Elrick B.P.
      • Nolte P.C.
      • Haber D.B.
      • Horan M.P.
      • Millett P.J.
      Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up.
      Clinical Outcome MeasureN(%)ThresholdN(%)ThresholdN(%)Threshold
      Minimum Clinically Important Difference (MCID)14 (93.33)1.610 (66.67)28.814 (93.33)13.6
      Substantial Clinical Benefit (SCB)11 (73.33)3.23 (20)50.29 (60)31.5
      Patient Acceptable Symptomatic State (PASS)11 (73.33)1.513/15 (86.67)75.513 (86.67)76.0
      Maximum Orthopaedic Improvement (MOI)N/AN/A10 (66.67)>75%8 (53.33)>69.5%
      Table 4Comparison of Final Outcome Scores Between Shoulder Dominance
      Dominant (n = 9)Non-Dominant (n = 6)P value
      VAS, mean (95% CI)2.75 (1.70, 3.801.38 (-0.05, 2.81)0.1389
      SANE, mean (95% CI)77.50 (69.73, 85.27)83.13 (69.28, 96.98)0.4635
      ASES, mean (95% CI)79.17 (71.44, 86.90)86.75 (79.42)0.2850
      Forward Elevation, mean (95% CI)155.67 (152.89, 158.45)154.38 (150.94, 157.82)0.3225
      External Rotation, mean (95% CI)65.00 (60.48, 69.52)67.50 (63.79, 71.21)0.4486
      Internal Rotation, mean (95% CI)T10.58 (9.46, 11.70)T9 (7.72, 10.28)0.0888
      All patients underwent concomitant arthroscopic subacromial decompression (ASAD). Concomitant procedures included arthroscopic biceps tenodesis (ABT), arthroscopic-assisted sub-pectoral biceps tenodesis (AASPBT), arthroscopic subacromial bursectomy (ASB), and arthroscopic débridement of the humeral head (ADHH). As a whole, concomitant procedures were not significantly related to net changes in Pain VAS, SANE, and ASES scores as well as forward flexion (FF), external rotation (ER), and internal rotation (IR) measurements (VAS: R2 = 0.2454, F(4,10) = 0.8130, p = 0.5449; SANE: R2 = 0.1287, F(4,10) = 0.3693, p = 0.8253; ASES: R2 = 0.1245, F(4,10) = 0.3555, p = 0.8346; FF: R2 = 0.3152, F(4,10) = 1.151, p = 0.3880; ER: R2 = 0.04396, F(4,10) = 0.1149, p = 0.9743; IR: R2 = 0.1718, F(4,10) = 0.5185, p = 0.7244). Similarly, concomitant procedures were not significantly related to final Pain VAS, SANE, and ASES scores or ER and IR measurements (VAS: R2 = 0.4104, F(4,10) = 1.740, p = 0.2174; SANE: R2 = 0.4810, F(4,10) = 2.317, p = 0.1282; ASES: R2 = 0.4565, F(4,10) = 2.100, p = 0.1557; ER: R2 = 0.2661, F(4,10) = 0.9064, p = 0.4962; IR: R2 = 0.1718, F(4,10) = 0.5185, p = 0.7244). The overall regression for FF was statistically significant (R2 = 0.8902, F(4,10) = 20.27, p <.001) with presence of ABT and ADHH predicting significantly lower FF (ABT: β = -6.560, CI = -9.096 – -4.025, p = .0002; ADHH: β = -4.769, CI = -7.715 – -1.824, p = .0048).
      There were no instance of postoperative infection or nerve injury. Survivorship was 100% at one-year postoperative, 85% at three-years postoperative and 75% at five-years postoperative follow-up (Table 5). Average time to treatment failure was 45.6±13.15 months postoperative. All five (25%) patients who failed went on to undergo additional surgery: four underwent comprehensive arthroscopic management (CAM) and one underwent an anatomic total shoulder arthroplasty
      • Millett P.J.
      • Horan M.P.
      • Pennock A.T.
      • Rios D.
      Comprehensive Arthroscopic Management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis.
      . At most recent follow-up, 13/20 (65%) of patients remained on active-duty with no limitations or permanent profile required to substantiate continuous occupational limitations. Of the seven who could not remain on active duty, five experienced treatment failure, and two had persistent activity-limiting pain inconsistent with continued active-duty service.
      Table 5Preoperative Patient Characteristics for Patients Who Experienced Treatment Failure
      Total (N = 5)
      Age, years, mean ± SD (range)42.40 ± 5.77 (34-50)
      Male, N (%)4 (80.00%)
      Combat Arms, N (%)
      Defined as patients whose military duties require regular high-demand physical readiness training, manipulation of firearms, moving across uneven terrain and obstacles with heavy loads, hand to hand combat training and other warfighting tasks (i.e. infantry, artillery, military police)
      4 (80.00%)
      Dominant shoulder involvement, N(%)3 (60.00%)
      History of a traumatic event, N(%)2 (40.00%)
      MRI Evidence of chondral injury, N(%)1 (20.00%)
      Time to surgery from symptom onset, months, mean ± SD35.40 ± 67.49
      Surgical time, minutes, mean ± SD73.60 ± 26.34
      Glenoid Lesion Area, cm2, mean± SD2.52 ± 1.50
      Concomitant Procedures
      ASAD, N(%)5 (100.00%)
      ABT, N(%)1 (20.00%)
      AASPBT, N(%)3 (60.00%)
      Débridement of humeral head OCD, N(%) (average size 1.00 cm2)1 (20.00%)
      Note: ASAD: arthroscopic subacromial decompression, ABT: arthroscopic biceps tenodesis, AASPBT: arthroscopic-assisted sub-pectoral biceps tenodesis
      Defined as patients whose military duties require regular high-demand physical readiness training, manipulation of firearms, moving across uneven terrain and obstacles with heavy loads, hand to hand combat training and other warfighting tasks (i.e. infantry, artillery, military police)

      DISCUSSION

      Glenoid microfracture offers a potentially attractive treatment option for symptomatic Grade IV chondral lesions not responding to PT in a young, active-duty military population as it enables patients to remain on unrestricted active-duty. The primary conclusion of our study is that outcomes and survivorship following microfracture in military patients is consistent with published reports of this procedure in civilian patients; that is, a majority of patients who did not fail treatment experienced statistically and clinically significant improvements in PROMs, decreases in pain and high rates of return to unrestricted active-duty military service
      • Frank R.M.
      • Van Thiel G.S.
      • Slabaugh M.A.
      • Romeo A.A.
      • Cole B.J.
      • Verma N.N.
      Clinical outcomes after microfracture of the glenohumeral joint.
      ,
      • Millett P.J.
      • Huffard B.H.
      • Horan M.P.
      • Hawkins R.J.
      • Steadman J.R.
      Outcomes of full-thickness articular cartilage injuries of the shoulder treated with microfracture.
      ,
      • Wang K.C.
      • Frank R.M.
      • Cotter E.J.
      • Davey A.
      • Meyer M.A.
      • Hannon C.P.
      • et al.
      Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.
      . In addition, it does not appear that dominant arm involvement is associated with worse PROMs. In line with civilian patient survivorship data, however, five (25%) patients experienced treatment failure at mean 45.6±13.15 months postoperatively
      • Wang K.C.
      • Frank R.M.
      • Cotter E.J.
      • Davey A.
      • Meyer M.A.
      • Hannon C.P.
      • et al.
      Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.
      .
      While the exact incidence of glenohumeral chondral lesions is unknown, they are not uncommon findings during diagnostic arthroscopy, with a variety of etiologies implicated in the pathogenesis of these lesions
      • Frank R.M.
      • Van Thiel G.S.
      • Slabaugh M.A.
      • Romeo A.A.
      • Cole B.J.
      • Verma N.N.
      Clinical outcomes after microfracture of the glenohumeral joint.
      ,
      • Millett P.J.
      • Huffard B.H.
      • Horan M.P.
      • Hawkins R.J.
      • Steadman J.R.
      Outcomes of full-thickness articular cartilage injuries of the shoulder treated with microfracture.
      ,
      • Snow M.
      • Funk L.
      Microfracture of chondral lesions of the glenohumeral joint.
      . Although classically associated as sequalae of concomitant glenohumeral pathology, i.e. instability or rotator cuff injury, glenohumeral chondral lesions can also occur secondary to trauma or systemic illness
      • Denard P.J.
      • Wirth M.A.
      • Orfaly R.M.
      Management of glenohumeral arthritis in the young adult.
      ,
      • Duchman K.R.
      • Hettrich C.M.
      • Glass N.A.
      • Westermann R.W.
      • Group M.S.
      • Wolf B.R.
      • et al.
      The Incidence of Glenohumeral Bone and Cartilage Lesions at the Time of Anterior Shoulder Stabilization Surgery: A Comparison of Patients Undergoing Primary and Revision Surgery.
      ,
      • Gross C.E.
      • Chalmers P.N.
      • Chahal J.
      • Van Thiel G.
      • Bach Jr., B.R.
      • Cole B.J.
      • et al.
      Operative treatment of chondral defects in the glenohumeral joint.
      ,
      • McCarthy M.M.
      • McCarty E.
      Treatment of Articular Cartilage Injuries in the Glenohumeral Joint.
      ,
      • Seidl A.J.
      • Kraeutler M.J.
      Management of Articular Cartilage Defects in the Glenohumeral Joint.
      . Management of full-thickness glenohumeral cartilage lesions in young, active patients represents a challenging clinical scenario, as these injuries lack inherent regenerative capability and, if symptomatic, often necessitate surgical intervention
      • Cohen N.P.
      • Foster R.J.
      • Mow V.C.
      Composition and dynamics of articular cartilage: structure, function, and maintaining healthy state.
      . The optimal surgical treatment, however, for these young patients is poorly defined. Arthroplasty remains a suboptimal treatment option, both due to the increased risk for early revision in young patients in addition to the strict postoperative lifting restrictions that are typically incongruent with many active patients’ goals and expectations
      • Dillon M.T.
      • Inacio M.C.
      • Burke M.F.
      • Navarro R.A.
      • Yian E.H.
      Shoulder arthroplasty in patients 59 years of age and younger.
      ,
      • Kusnezov N.
      • Dunn J.C.
      • Parada S.A.
      • Kilcoyne K.
      • Waterman B.R.
      Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population.
      ,
      • Magnussen R.A.
      • Mallon W.J.
      • Willems W.J.
      • Moorman 3rd, C.T.
      Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons.
      . Whereas osteochondral transplantation or chondrocyte implantation has gained acceptance in other joints, outcomes data for these procedures, especially with respect to glenoid lesions, is limited
      • Denard P.J.
      • Wirth M.A.
      • Orfaly R.M.
      Management of glenohumeral arthritis in the young adult.
      ,
      • McCarthy M.M.
      • McCarty E.
      Treatment of Articular Cartilage Injuries in the Glenohumeral Joint.
      ,
      • Seidl A.J.
      • Kraeutler M.J.
      Management of Articular Cartilage Defects in the Glenohumeral Joint.
      . As a result, the minimally invasive approach and straightforward technique characteristic of microfracture distinguish it as an attractive potential treatment for glenohumeral chondral lesions
      • Steadman J.R.
      • Rodkey W.G.
      • Rodrigo J.J.
      Microfracture: surgical technique and rehabilitation to treat chondral defects.
      . While short-term outcomes following glenohumeral microfracture were promising, longer-term outcome studies report a 21.4% conversion rate to arthroplasty and a clinical failure rate of 33% to 42%
      • Frank R.M.
      • Van Thiel G.S.
      • Slabaugh M.A.
      • Romeo A.A.
      • Cole B.J.
      • Verma N.N.
      Clinical outcomes after microfracture of the glenohumeral joint.
      ,
      • Millett P.J.
      • Huffard B.H.
      • Horan M.P.
      • Hawkins R.J.
      • Steadman J.R.
      Outcomes of full-thickness articular cartilage injuries of the shoulder treated with microfracture.
      ,
      • Salata M.J.
      • Kercher J.S.
      • Bajaj S.
      • Verma N.N.
      • Cole B.J.
      ,
      • Snow M.
      • Funk L.
      Microfracture of chondral lesions of the glenohumeral joint.
      ,
      • Wang K.C.
      • Frank R.M.
      • Cotter E.J.
      • Davey A.
      • Meyer M.A.
      • Hannon C.P.
      • et al.
      Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.
      .
      The active-duty patient represents a challenging demographic to treat. These often young, high-demand patients place incredible load on their shoulders and experience shoulder injury at a rate that far outpaces the civilian population
      • Enad J.G.
      • Kurtz C.A.
      Isolated and combined Type II SLAP repairs in a military population.
      ,
      • Kampa R.J.
      • Clasper J.
      Incidence of SLAP lesions in a military population.
      ,
      • Owens B.D.
      • Duffey M.L.
      • Nelson B.J.
      • DeBerardino T.M.
      • Taylor D.C.
      • Mountcastle S.B.
      The incidence and characteristics of shoulder instability at the United States Military Academy.
      ,
      • Walsworth M.K.
      • Doukas W.C.
      • Murphy K.P.
      • Bimson W.
      • Mielcarek B.J.
      • Michener L.A.
      Descriptive analysis of patients undergoing shoulder surgery at a tertiary care military medical center.
      . While limited duty and protective profiles are possible for some service men and women, patients in combat arms specialties are often unable or unwilling to accept duty limitations, as full use of their shoulder is required for their warfighting tasks and physical readiness training. Additionally, maintaining active-duty status is especially important for patients who may be nearing retirement and hoping to avoid premature medical separation. During our study period, we encountered 46 patients with full-thickness (Outerbridge IV) glenoid cartilage lesions
      • Outerbridge R.E.
      The etiology of chondromalacia patellae.
      . While 50% of these patients had concomitant glenohumeral instability or a full-thickness rotator cuff tear, the other 50% had no subjective or objective evidence consistent with the presence of these pathologies
      • Duchman K.R.
      • Hettrich C.M.
      • Glass N.A.
      • Westermann R.W.
      • Group M.S.
      • Wolf B.R.
      • et al.
      The Incidence of Glenohumeral Bone and Cartilage Lesions at the Time of Anterior Shoulder Stabilization Surgery: A Comparison of Patients Undergoing Primary and Revision Surgery.
      ,
      • Hsu H.C.
      • Luo Z.P.
      • Stone J.J.
      • Huang T.H.
      • An K.N.
      Correlation between rotator cuff tear and glenohumeral degeneration.
      . Furthermore, of the 20 patients with no evidence of instability or rotator cuff injury, only half could recall a specific inciting traumatic event which preceded the development of their pain. As a result, 50% of our patients with symptomatic, full-thickness glenoid chondral lesions had no evidence of instability, rotator cuff injury, or trauma. Given an incidental incidence of approximately 5-15% on diagnostic arthroscopy, it follows that this population appears to be at a markedly increased risk for either the development or the symptomatic progression of glenoid chondral injury
      • Cameron M.L.
      • Kocher M.S.
      • Briggs K.K.
      • Horan M.P.
      • Hawkins R.J.
      The prevalence of glenohumeral osteoarthrosis in unstable shoulders.
      ,
      • Gartsman G.M.
      • Taverna E.
      The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears.
      ,
      • Mook W.R.
      • Petri M.
      • Greenspoon J.A.
      • Millett P.J.
      The Comprehensive Arthroscopic Management Procedure for Treatment of Glenohumeral Osteoarthritis.
      .
      Although this increased incidence of glenoid chondral lesions among active-duty service members is likely multifactorial, we believe that there are a few critical factors that may explain its presence. First, active-duty service men and women place exceptionally high demand on their shoulders, be it through daily physical training or as a result of jobs which frequently involve lifting, carrying, pushing, pulling and, in the case of warfighters, shooting
      • Cameron K.L.
      • Owens B.D.
      The burden and management of sports-related musculoskeletal injuries and conditions within the US military.
      ,
      • Hauret K.G.
      • Jones B.H.
      • Bullock S.H.
      • Canham-Chervak M.
      • Canada S.
      Musculoskeletal injuries description of an under-recognized injury problem among military personnel.
      ,
      • Lovalekar M.
      • Hauret K.
      • Roy T.
      • Taylor K.
      • Blacker S.D.
      • Newman P.
      • et al.
      Musculoskeletal injuries in military personnel-Descriptive epidemiology, risk factor identification, and prevention.
      . Second, it is well-described that active-duty military patients often experience a substantial delay between symptom onset and eventual appropriate treatment
      • Parnes N.
      • Dunn J.C.
      • Czajkowski H.
      • DeFranco M.J.
      • Green C.K.
      • Scanaliato J.P.
      Biceps Tenodesis as an Attractive Alternative to Superior Labral Anterior-Posterior (SLAP) Repair for Type II SLAP Lesions in Active-Duty Military Patients Younger Than 35 Years.
      ,
      • Scanaliato J.P.
      • Dunn J.C.
      • Fares A.B.
      • Czajkowski H.
      • Parnes N.
      Outcomes of 270 degrees Labral Repair for Combined Shoulder Instability in Active-Duty Military Patients: A Retrospective Study.
      ,
      • Scanaliato J.P.
      • Dunn J.C.
      • Fitzpatrick K.V.
      • Czajkowski H.
      • Parnes N.
      Double-Pulley Remplissage in Active-Duty Military Population with Off-Track Anterior Shoulder Instability Results in Improved Outcomes and Low Recurrence at Minimum Four-Year Follow-Up.
      ,
      • Walsworth M.K.
      • Doukas W.C.
      • Murphy K.P.
      • Bimson W.
      • Mielcarek B.J.
      • Michener L.A.
      Descriptive analysis of patients undergoing shoulder surgery at a tertiary care military medical center.
      . This, coupled with continued physical readiness training and bi-annual physical fitness tests, greatly increases the risk of injury progression. Finally, it is unknown what effect sub-clinical instability or scapular dyskinesia, pathologies frequently encountered in active-duty patients, has on the pathogenesis of chondral injury
      • Andres J.
      • Painter P.J.
      • McIlvain G.
      • Timmons M.K.
      The Effect of Repeated Shoulder Motion on Scapular Dyskinesis in Army ROTC Cadets.
      ,
      • Wolfe J.A.
      • Christensen D.L.
      • Mauntel T.C.
      • Owens B.D.
      • LeClere L.E.
      • Dickens J.F.
      A History of Shoulder Instability in the Military: Where We Have Been and What We Have Learned.
      . Subsequently, active-duty patients’ predisposition to developing concomitant pathologies may implicate or exacerbate the development of glenoid chondral lesions.
      Our findings are comparable to much of the published literature on microfracture for glenohumeral cartilage lesions in civilian patients. In their cohort of 16 patients (17 shoulders) with average 10-year follow-up, Wang et al reported an overall success rate of 66.7%, comparable to our maintenance of active-duty rate of 65%
      • Wang K.C.
      • Frank R.M.
      • Cotter E.J.
      • Davey A.
      • Meyer M.A.
      • Hannon C.P.
      • et al.
      Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.
      . These results are promising, especially when considering that, on average, our patients had larger lesions. Of patients who did not fail treatment, the improvements in PROMs are consistent with previously published values
      • Frank R.M.
      • Van Thiel G.S.
      • Slabaugh M.A.
      • Romeo A.A.
      • Cole B.J.
      • Verma N.N.
      Clinical outcomes after microfracture of the glenohumeral joint.
      ,
      • Millett P.J.
      • Huffard B.H.
      • Horan M.P.
      • Hawkins R.J.
      • Steadman J.R.
      Outcomes of full-thickness articular cartilage injuries of the shoulder treated with microfracture.
      ,
      • Wang K.C.
      • Frank R.M.
      • Cotter E.J.
      • Davey A.
      • Meyer M.A.
      • Hannon C.P.
      • et al.
      Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.
      .
      Determination of the clinical significance of these outcomes, however, is obfuscated by a paucity of data on these metrics following glenoid microfracture. Given that distribution-based methods for determining MCID, SCB and PASS carry not only a risk of underapproximation of the true value but also lack concrete ties to patient satisfaction, we elected to use the previously published values for these metrics following shoulder arthroplasty
      • Beck E.C.
      • Gowd A.K.
      • Liu J.N.
      • Waterman B.R.
      • Nicholson K.F.
      • Forsythe B.
      • et al.
      How Is Maximum Outcome Improvement Defined in Patients Undergoing Shoulder Arthroscopy for Rotator Cuff Repair? A 1-Year Follow-Up Study.
      ,
      • Gowd A.K.
      • Charles M.D.
      • Liu J.N.
      • Lalehzarian S.P.
      • Cabarcas B.C.
      • Manderle B.J.
      • et al.
      Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.
      ,
      • Katz N.P.
      • Paillard F.C.
      • Ekman E.
      Determining the clinical importance of treatment benefits for interventions for painful orthopedic conditions.
      ,
      • Simovitch R.
      • Flurin P.H.
      • Wright T.
      • Zuckerman J.D.
      • Roche C.P.
      Quantifying success after total shoulder arthroplasty: the minimal clinically important difference.
      ,
      • Simovitch R.
      • Flurin P.H.
      • Wright T.
      • Zuckerman J.D.
      • Roche C.P.
      Quantifying success after total shoulder arthroplasty: the substantial clinical benefit.
      . Similarly, we chose to utilize previously published MOI thresholds following arthroscopic rotator cuff repair for the SANE and ASES. Promisingly, a majority of patients had improvements in PROMs which exceeded the MCID and reached the PASS as determined by the Pain VAS, SANE and ASES. Two-thirds of patients achieved MOI on the SANE, while only 53.33% of patients did so on the ASES. Achievement of SCB was not as ubiquitous: while 73.33% and 60% of patients surpassed this threshold on the Pain VAS and ASES, respectively, only 20% of patients did so on the SANE. SCB as measured by the SANE following shoulder arthroplasty (50.2), however, is far higher than that following rotator cuff repair (29.8) or biceps tenodesis (5.8)
      • Cvetanovich G.L.
      • Gowd A.K.
      • Liu J.N.
      • Nwachukwu B.U.
      • Cabarcas B.C.
      • Cole B.J.
      • et al.
      Establishing clinically significant outcome after arthroscopic rotator cuff repair.
      ,
      • Gowd A.K.
      • Charles M.D.
      • Liu J.N.
      • Lalehzarian S.P.
      • Cabarcas B.C.
      • Manderle B.J.
      • et al.
      Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.
      ,
      • Puzzitiello R.N.
      • Gowd A.K.
      • Liu J.N.
      • Agarwalla A.
      • Verma N.N.
      • Forsythe B.
      Establishing minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after biceps tenodesis.
      . Given that 86.7% of our patients who did not experience treatment failure remained on unrestricted active-duty, we postulate that identification of appropriate clinical significance metrics will further increase achievement of these thresholds in our cohort.
      In much of the published literature on microfracture, the presence of concomitant procedures introduces the possibility that a portion of the observed benefit is secondary to additional procedures
      • Frank R.M.
      • Van Thiel G.S.
      • Slabaugh M.A.
      • Romeo A.A.
      • Cole B.J.
      • Verma N.N.
      Clinical outcomes after microfracture of the glenohumeral joint.
      ,
      • Snow M.
      • Funk L.
      Microfracture of chondral lesions of the glenohumeral joint.
      ,
      • Wang K.C.
      • Frank R.M.
      • Cotter E.J.
      • Davey A.
      • Meyer M.A.
      • Hannon C.P.
      • et al.
      Long-term Clinical Outcomes After Microfracture of the Glenohumeral Joint: Average 10-Year Follow-up.
      . Our analysis demonstrates no significant differences between relevant concomitant procedures and both final outcome scores as well as net changes in outcome scores. The only model achieving statistical significance involved the relationship between ABT and ADHH on final FF measurement; however, the discrepancy in FF rates were estimated at only 6.56 and 4.77 degrees less for each procedure, respectively. With only minor FF disparities of less than seven degrees in FF associated with two procedures in the setting of similar outcome scores and other ROM measurements, these differences are unlikely to be clinically significant. Given the young, active military patient population unique to this study and frequently prolonged time to treatment, the treating surgeon elected to perform ASAD for all patients eligible for inclusion. Subsequently, future research involving patients with and without ASAD is needed to isolate the effects of ASAD on glenoid microfracture outcomes.
      Although a majority of our patients were able to remain on active-duty and avoid the need for further surgery, five (25%) of patients required a secondary surgical procedure. While one patient was treated with an anatomic total shoulder arthroplasty, four patients were reluctant to undergo the same. As a result, these four patients were treated with a comprehensive arthroscopic management (CAM) procedure
      • Millett P.J.
      • Horan M.P.
      • Pennock A.T.
      • Rios D.
      Comprehensive Arthroscopic Management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis.
      ,
      • Mook W.R.
      • Petri M.
      • Greenspoon J.A.
      • Millett P.J.
      The Comprehensive Arthroscopic Management Procedure for Treatment of Glenohumeral Osteoarthritis.
      . Described originally by Millett et al, the CAM procedure involves the combination of glenohumeral chondroplasty, loose body removal, humeral head osteoplasty and osteophyte resection, thorough capsular release, axillary neurolysis, subacromial decompression and biceps tenodesis
      • Parnes N.
      • Perrine J.
      • DeFranco M.J.
      Outcomes of Simultaneous Arthroscopic Rotator Cuff Repair and Inferior Labral Repair Among Active Patients Younger Than 40 Years.
      . An attractive alternative to shoulder arthroplasty, CAM has a reported 10-year survivorship of 63.2%
      • Arner J.W.
      • Elrick B.P.
      • Nolte P.C.
      • Haber D.B.
      • Horan M.P.
      • Millett P.J.
      Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up.
      . Risk factors for early conversion to shoulder arthroplasty following CAM include humeral head collapse and marked joint space narrowing and/or incongruity
      • Arner J.W.
      • Elrick B.P.
      • Nolte P.C.
      • Haber D.B.
      • Horan M.P.
      • Millett P.J.
      Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Minimum 10-Year Follow-up.
      ,
      • Millett P.J.
      • Horan M.P.
      • Pennock A.T.
      • Rios D.
      Comprehensive Arthroscopic Management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis.
      . Promisingly, none of the four patients in our cohort who underwent CAM required additional surgical procedures.

      Limitations

      Although our results at mid-term follow-up are promising, there are limitations to this study. Multiple concomitant procedures were performed, which has the potential to obfuscate the results of the microfracture procedure. The cohort is overwhelming male and fully comprised of active-duty soldiers who can go on restricted duty during rehabilitation, so the generalizability of our findings to non-military patients may be limited. All procedures were performed by a single shoulder-elbow fellowship trained surgeon, which may limit the generalizability of these findings while also maintaining reliability regarding operative intervention. The clinical significance measures (PASS, SCB, MCID) are not yet fully defined for shoulder stabilization procedures, so the values for shoulder arthroplasty and/or rotator cuff repair were used as a stand-in
      • Beck E.C.
      • Gowd A.K.
      • Liu J.N.
      • Waterman B.R.
      • Nicholson K.F.
      • Forsythe B.
      • et al.
      How Is Maximum Outcome Improvement Defined in Patients Undergoing Shoulder Arthroscopy for Rotator Cuff Repair? A 1-Year Follow-Up Study.
      ,
      • Gowd A.K.
      • Charles M.D.
      • Liu J.N.
      • Lalehzarian S.P.
      • Cabarcas B.C.
      • Manderle B.J.
      • et al.
      Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.
      ,
      • Simovitch R.
      • Flurin P.H.
      • Wright T.
      • Zuckerman J.D.
      • Roche C.P.
      Quantifying success after total shoulder arthroplasty: the minimal clinically important difference.
      ,
      • Simovitch R.
      • Flurin P.H.
      • Wright T.
      • Zuckerman J.D.
      • Roche C.P.
      Quantifying success after total shoulder arthroplasty: the substantial clinical benefit.
      . Finally, the results are a retrospective review of prospectively collected data, thereby introducing the risk for selection bias inherent to a case series.

      Conclusion

      Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at five-years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

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