Shoulder Cartilage Surgery

Shoulder Joint Cartilage and Focal Damage

The humeral head and glenoid surfaces that make up the shoulder joint (glenohumeral joint) are covered with a smooth, white, durable, and flexible tissue called hyaline cartilage. During joint movement, this cartilage prevents the bones from rubbing against each other, allowing pain-free motion, and absorbs loads.

Focal Cartilage Damage vs. Widespread Osteoarthritis (Omarthrosis): The condition discussed in this article differs from shoulder osteoarthritis (omarthrosis), in which cartilage is worn away broadly over a large area of the joint. What is addressed here are full-thickness or near-full-thickness focal cartilage defects occurring in a specific region of the joint (on the humeral head or the glenoid) where the surrounding cartilage is relatively intact.

The Goal of Shoulder Cartilage Surgery: The main objectives of these surgical methods are:

• To repair, regenerate, or restore the damaged cartilage surface.
• To reduce pain and mechanical symptoms such as catching and locking.
• To improve shoulder function (range of motion, strength).
• To prevent or delay the progression of cartilage damage into widespread shoulder osteoarthritis.

Why Does Cartilage Damage Occur in the Shoulder? Risk Factors

Focal cartilage damage in the shoulder joint generally occurs for the following reasons:

• Trauma (Especially Shoulder Dislocations): This is one of the most common causes. During a shoulder dislocation, the humeral head can strike the edge of the glenoid. This impact can cause damage to the cartilage and underlying bone on the humeral head (typically a Hill-Sachs lesion in the posterosuperior region) or at the edge of the glenoid (a bony defect, especially in the anteroinferior region, along with a Bankart lesion). Direct blows or fractures can also lead to cartilage damage.
• Repetitive Microtrauma / Overuse: Although less pronounced than in the knee, repetitive and demanding shoulder movements, particularly in throwing sports, can cause cartilage wear and localized damage over time.
• Osteochondritis Dissecans (OCD): A rarer condition in which the blood supply to a portion of the bone beneath the cartilage in the shoulder (usually the humeral head) is disrupted, causing it to separate.
• Avascular Necrosis (AVN): When the blood supply to the humeral head is disrupted for various reasons (corticosteroid use, alcohol, certain diseases), the bone tissue dies and collapses, and the cartilage covering it is damaged as well.
• Chronic Instability: Recurrent shoulder dislocations or looseness (instability) can lead to abnormal friction on the joint surfaces and cartilage wear over time.

What Are the Symptoms of Shoulder Cartilage Damage?

The symptoms of shoulder cartilage damage can often be vague and may be confused with other shoulder problems (such as labral tears, rotator cuff problems, or impingement syndrome). Possible symptoms include:

• Deep Shoulder Pain: Pain felt inside the shoulder that generally increases with activity.
• Mechanical Symptoms: A sensation of clicking, catching, locking, or grinding (crepitus) during shoulder movement. These symptoms are important findings suggestive of focal cartilage damage.
• Restricted Motion: Limitation in shoulder movement due to pain or a mechanical block.
• A Feeling of Insecurity: Rarely, a sensation of the shoulder giving way or instability.
• Localized Pain: Pain that occurs with certain movements (e.g., moving the arm into a specific position) depending on the location of the damage.

How Is Shoulder Cartilage Damage Diagnosed?

A careful evaluation is required to diagnose focal cartilage damage:

• Detailed History: A history of prior shoulder dislocation, the mechanism of injury, when and how symptoms (pain, catching, etc.) began, and which movements aggravate the complaints are noted.
• Physical Examination: The shoulder’s range of motion, muscle strength, and stability are assessed. Special maneuvers may be attempted to elicit catching or clicking, although findings may not be specific. Tender points are identified.
• Imaging Methods:
  
  • X-ray: Generally insufficient to demonstrate isolated cartilage damage. However, it is taken to rule out or detect bony problems (fracture, Hill-Sachs lesion, glenoid bone loss, OCD, advanced osteoarthritis).
  • Computed Tomography (CT): Particularly useful for evaluating the size and shape of bony defects (Hill-Sachs, glenoid bone loss).
  • Magnetic Resonance (MR) Imaging or MR Arthrography (MRA): The most important imaging method for diagnosing cartilage damage. It directly shows the condition of the cartilage, the location, size, and depth of the damage, and the underlying bone structure. It also reveals accompanying soft-tissue injuries such as labral or rotator cuff tears. MR arthrography (MRI performed after injecting contrast material into the joint) is more sensitive than standard MRI for detecting small or suspected cartilage and labral lesions.
• Diagnostic Arthroscopy: When imaging methods are insufficient or a definitive diagnosis cannot be reached, or in patients already scheduled for surgery, direct examination of the shoulder joint with a camera (arthroscopy) provides a definitive diagnosis and allows treatment in the same session.

Shoulder Cartilage Surgery Options

Various methods, based on principles similar to those used in the knee, are available for the surgical treatment of focal cartilage damage in the shoulder. However, because the anatomy and biomechanics of the shoulder joint differ, application techniques and success rates may vary compared with the knee. Prof. Dr. Murat Bozkurt selects the most appropriate method based on the characteristics of the patient and the damage:

1. Arthroscopic Debridement / Chondroplasty (Cleaning/Shaving): This procedure involves removing loose fragments detached from damaged cartilage and smoothing rough, frayed cartilage edges with special instruments. It provides only temporary relief and does not repair the cartilage. It is generally performed for small, superficial damage or as an adjunct during another procedure.
2. Bone Marrow Stimulation Techniques (Microfracture / Nanofracture): Small holes are made in the bone beneath the damaged cartilage so that stem cells and blood from the bone marrow form a repair tissue (fibrocartilage) at the site. In the shoulder, particularly on the glenoid (socket) side, results are less predictable than in the knee. It can generally be attempted in younger patients and for small (< 2 cm²) defects.
3. Osteochondral Autograft Transplantation (Mosaicplasty / OAT): This involves transplanting cartilage-bone cylinders taken from non-weight-bearing areas of the patient’s own knee or shoulder joint into the damaged area. Its application in the shoulder is technically more demanding than in the knee. It is generally suitable for small-to-medium-sized defects on the humeral head (“ball”). Donor-site morbidity and the limited number of available grafts are disadvantages.
4. Osteochondral Allograft Transplantation: This involves transplanting appropriately sized fresh or frozen cadaveric cartilage-bone grafts, obtained from a tissue bank, into the damaged area. It is a good option, particularly for large (> 2-3 cm²) defects on the humeral head or glenoid. Disadvantages include the availability of a suitable graft, cost, and a very low but present risk of disease transmission/rejection. It is technically demanding.
5. Autologous Chondrocyte Implantation / Transplantation (ACI / MACI): This is a two-stage method (cartilage biopsy plus laboratory cell expansion, followed by transplantation in a second surgery). It has the potential to form hyaline-like cartilage in large defects. It is applied less frequently in the shoulder than in the knee, is technically challenging, is costly, and requires a very long rehabilitation process. It is generally reserved for large defects on the humeral head.
6. Other Techniques: Methods such as repairs using newly developed synthetic or biological scaffolds, and biological adjunct therapies (PRP, stem cell applications — evidence is still limited), are also in the research and development stage.

Choice of Surgery, Risks, Benefits, and the Long Recovery Process

The choice of shoulder cartilage surgery technique depends on many factors: the size, location (humeral head or glenoid), and depth of the damage; the patient’s age and activity expectations; other accompanying shoulder problems (instability, rotator cuff tear, etc.); and the surgeon’s experience in this area. Treating defects on the glenoid (socket) side is generally more challenging than treating humeral head defects, and outcomes are less predictable.

• Benefits: The goals of successful surgery are reduced pain, relief of mechanical symptoms such as catching, improved shoulder function, and potentially slowing the progression of shoulder osteoarthritis.
• Risks: General risks present in any surgery (infection, bleeding, nerve damage, anesthesia risks, shoulder stiffness/frozen shoulder) apply. Risks specific to cartilage surgery include failure of the repair or graft (nonunion, deterioration/loss of the cartilage), pain at the donor site in mosaicplasty, persistence or recurrence of symptoms, and the possible need for further surgery in the future.
• Recovery Process: Rehabilitation after shoulder cartilage surgery is very important, takes a long time, and requires significant restrictions. Patient patience and compliance are essential for success.
  
  • Arm Sling Use: To protect the repaired or transplanted cartilage, an arm sling is generally needed for 4 to 6 weeks or longer after surgery.
  • Movement and Activity Restrictions: For weeks, or even months, after surgery, shoulder movements and loading of the arm (lifting, pushing, pulling weight) are restricted. These restrictions vary depending on the procedure performed and the location of the damage.
  • Progressive Physical Therapy: Rehabilitation proceeds very slowly and under controlled conditions. It begins with passive movements, progressing over time to active movements and, after several months, to strengthening exercises. The goal is both to regain motion and to avoid damaging the repaired area.
  • Return to Sports: Return to normal daily activities may take several months. Return to contact sports, throwing sports, or heavy labor generally requires a very long period of 9 to 18 months and may not always be fully possible.

Shoulder Cartilage Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Focal cartilage damage in the shoulder joint is a specialized condition whose diagnosis and treatment require the experience of an orthopedic surgeon specialized in this area. In Ankara, Prof. Dr. Murat Bozkurt offers modern diagnostic and treatment options to patients experiencing shoulder cartilage problems.

Prof. Dr. Bozkurt’s approach:

• Precise Diagnostic Process: He accurately determines the size and location of cartilage damage and any accompanying pathology using advanced imaging methods such as MR arthrography and, when necessary, arthroscopic evaluation.
• Personalized Treatment Plan: He determines the most suitable surgical technique (debridement, microfracture, OAT, allograft, etc.) or conservative treatment option based on the patient’s age, activity level, expectations, and the characteristics of the damage. He is well aware of the technical challenges of shoulder cartilage surgery.
• Meticulous Surgical Technique: He performs the chosen surgical method using the most up-to-date techniques, drawing on his experience in shoulder arthroscopy and open surgery.
• Importance of Rehabilitation: He knows that success after shoulder cartilage surgery depends largely on rehabilitation, and he closely monitors his patients through this challenging process, providing them with proper guidance.

Focal cartilage damage in the shoulder joint is a challenging condition that can lead to pain and loss of function. While modern surgical techniques offer promising solutions, accurate diagnosis, selection of the appropriate surgical method, and, in particular, a long and patient rehabilitation process are critical to a successful outcome. In Ankara you can turn to Prof. Dr. Murat Bozkurt’s expertise for your shoulder cartilage problems.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.