Abstract
Glenoid articular cartilage lesions are a significant cause of persistent shoulder pain, particularly following trauma or previous surgical interventions, such as failed Bankart repairs. Current surgical approaches for addressing cartilage damage in the glenohumeral joint include microfracture, osteochondral autograft transfer, osteochondral allograft transplantation, and autologous chondrocyte implantation. However, the use of bone marrow aspiration concentrate (BMAC), which is rich in mesenchymal stem cells, has emerged as a promising minimally invasive single-step procedure that promotes cartilage regeneration. This study presents an arthroscopic technique for addressing cartilage defects in the glenoid using BMAC after failed Bankart repair in a patient. Although the evidence base for BMAC in glenoid defects is limited, early clinical results suggest effective cartilage healing, few complications, and satisfactory patient outcomes. This technique appears to be safe and offers the benefit of being a single-step process that utilizes autologous bone marrow mesenchymal cells to facilitate cartilage regeneration. Further research is needed to establish the long-term efficacy of this approach for treating glenoid cartilage lesions.
Technique Video
Glenoid articular cartilage lesions are a recognized cause of persistent shoulder pain, particularly following trauma or previous surgical interventions. In 1993, Neviaser was the first to identify the glenolabral articular disruption lesion, describing it as a traumatic injury that leads to a tear in the anterior inferior labrum and a loss of articular cartilage, which results in pain in the front of the shoulder.1 Although more prevalent in load-bearing joints, such as the knee and ankle, glenoid chondral defects can be a source of significant functional limitation and may not always be readily apparent on magnetic resonance imaging (MRI). Their association with conditions such as shoulder instability, repetitive microtrauma, or previous failed surgeries, such as Bankart repair, has been well established.2, 3, 4
Overhead athletes and patients with rotator cuff pathology frequently exhibit glenoid cartilage lesions, with studies reporting incidences ranging from 13% to 57% depending on the associated pathology and patient population.5
Cartilage defects were commonly found in 38% of patients with anterior glenohumeral instability.6 The etiology of these lesions includes trauma, which can be a single event or repetitive microtrauma, postarthroscopic surgery, infections, osteochondritis dissecans, and an association with instability and rotator cuff tears.7
The literature on treatment options and outcomes for full-thickness glenoid articular lesions is notably sparse. Current surgical approaches for addressing cartilage damage in the glenohumeral joint include microfracture, osteochondral autograft transfer,8 osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation.9 These techniques, initially developed for managing chondral lesions in weightbearing joints, have been adapted for shoulder use.
Role of Bone Marrow Aspiration Concentrate
Bone marrow aspiration concentrate (BMAC) is rich in mesenchymal stem cells (MSCs) capable of both direct chondrogenic differentiation and paracrine signaling, which stimulate cartilage repair. Because MSCs comprise only 0.001% to 0.02% of all nucleated cells in unprocessed bone marrow aspirate, commercially available systems use density-gradient centrifugation to enhance their concentration by up to 5-fold, resulting in BMAC, which is then mixed with thrombin solution. This mixture is drawn into a syringe, and another syringe with fibrin sealant is prepared. Both syringes are attached to a 20-gauge application needle using a Y-shaped connector), allowing BMAC and fibrin glue to be delivered simultaneously during application from a scaffold, which helps to retain BMAC within the defect. The use of autologous BMAC offers several advantages, including the following:
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Minimally invasive, single-step procedure
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No donor site morbidity
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Use of the patient’s own MSCs, reducing immunologic risks
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Promotes cartilage regeneration via both differentiation and paracrine mechanisms
Although the evidence base for BMAC in glenoid defects is limited, early clinical results suggest effective cartilage healing, few complications, and satisfactory patient outcomes.
Recognizing the link between focal chondral defects and shoulder instability, we were motivated to document our technique because of the lack of existing literature on an arthroscopic approach for repairing chondral damage of the glenoid during the arthroscopic Latarjet procedure.
Surgical Technique
A video presenting arthroscopic method for addressing glenoid cartilage damage (Video 1).
We present an arthroscopic method for addressing glenoid cartilage damage following unsuccessful Bankart repair. All participants provided informed consent. Preoperative imaging includes standard radiography and MRI to assess the size and position of the cartilage defect and identify any additional related conditions.
Patient Setup and Positioning
The patient is placed in a beach-chair position (Fig 1) under general anesthesia and an interscalene block in the beach-chair position. A traction force of 5 kg is applied to the forearm, maintaining the arm at a 60° elevation, with 10° of shoulder abduction and in a neutral rotation. The right shoulder is prepared using 7.5% povidone-iodine and covered with sterile drapes. Similarly, the area from the right iliac crest to the inguinal region is prepared for bone marrow aspiration.
Fig 1.
Patient placed in the beach-chair position.
Diagnostic arthroscopy is initiated using the posterior portal. An arthroscopic Latarjet procedure is performed using 2 cortical buttons (Smith & Nephew. Andover, MA), one placed anteriorly and the other posteriorly. Attention is then directed toward addressing the cartilage defect located anteriorly in the glenoid (Fig 2A). The bed of the defect, identified as an Outerbridge grade 4 cartilage defect, is debrided with a curette (Fig 2B). The cartilage defect is microfractured (Fig 2C), and bone marrow is aspirated percutaneously from the right iliac crest by inserting the trocar of the bone marrow aspiration kit (Arthrex. Naples, FL) approximately 3 finger breadths proximal to the anterior superior iliac spine (Fig 3A). A total of 60 mL of bone marrow aspirate is collected and processed using an Angel Concentrated Platelet Rich Plasma System (Arthrex) (Fig 3B). The prepared cartilage defect area is dried and maintained in a dry field to ensure adequate joint distension. Carbon dioxide insufflation is performed at a pressure of 15 mm Hg and a flow rate of 2 L/min, a method that has been previously shown to be safe in knee arthroscopy. The final BMAC concentrate is mixed with human thrombin (Baxter, Vienna, Austria) (Fig 3C) and applied along with sealer protein concentrate (Baxter), which together form fibrin glue to cover the cartilage defect (Fig 3D). No additional washing is performed, allowing the scaffold with the marrow concentrate to form a compact plug (Fig 4).
Fig 2.
Arthroscopic visualization from the suprabicipital portal in the right shoulder with a patient in the beach-chair position shows glenoid catilage defect (A), defect meticulously debrided with a curette (B), and microfracturing of the defect done to ensure BMAC retention and maximize cell activity for regeneration (C). (BMAC, bone marrow aspirate concentrate; G, glenoid; GC, glenoid cartilage; MF, microfractured defect area.)
Fig 3.
(A) Bone marrow aspiration from 3 finger breadths above the anterosuperior iliac spine. (B) Total of 60 mL bone marrow aspirated and processed in the Arthrex system. (C) Bone marrow aspirate is mixed with thrombin solution. (D) The mixture is drawn into the syringe. Another syringe with sealant protein is prepared, and both syringes are attached to a 20-gauge application needle using a Y-shaped connector.
Fig 4.
(A) Bone marrow aspirate concentrate (BMAC) implantation onto the cartilage defect. (B) Arthroscopic visualization from the suprabicipital portal in the right shoulder with the patient in a beach-chair position, showing formation of BMAC fibrin glue on the cartilage defect of the glenoid.
Rehabilitation
The shoulder is initially immobilized postoperatively. Early motion of the elbow and hand begins on day 1; passive shoulder exercises commence on day 10. Full passive range of motion is achieved by 6 weeks, with progression to strengthening thereafter. Return to daily activity is permitted at 6 weeks, with a gradual resumption of sports activities after 6 months. The addition of cartilage repair does not require deviation from standard rehabilitation following the Latarjet and remplissage procedures.
Discussion
Chondral lesions of the glenoid are frequently missed during preoperative imaging and may present as persistent pain following stabilization. Accurate diagnosis using advanced imaging techniques, such as MRI, is crucial for selecting the most appropriate treatment approach, including surgical interventions.
Optimal management aims to restore the glenoid articular surface and geometry, minimize the exposed articular defect, re-establish stability, and preserve long-term function.10 The choice of joint-preserving treatment for younger and more active individuals remains a topic of discussion.
Among the available techniques, BMAC stands out as a safe, autologous, and single-step intervention that promotes hyaline-like cartilage repair in small case series and animal models. Table 2 summarizes the therapeutic approaches for glenohumeral joint articular cartilage lesions in young individuals.
Table 1.
Different Steps of the Operation
| 1 | Patient placed in a beach-chair position under general anesthesia and an interscalene block |
| 2 | Diagnostic arthroscopy performed |
| 3 | Arthroscopic Latarjet and remplissage performed |
| 4 | Anterior glenoid defect visualized |
| 5 | Defect bed debrided with curette and microfracturing of defect done |
| 6 | Bone marrow aspiration: percutaneous aspiration from the right iliac crest, trocar inserted 3 finger breadths above the anterosuperior iliac spine |
| 7 | 60 mL bone marrow aspirate processed using the Arthrex Angel Concentrated Platelet Rich Plasma System |
| 8 | Defect area dried, joint maintained in a dry field with CO2 insufflation (15 mm Hg, 2 L/min) |
| 9 | BMAC concentrate mixed with human thrombin |
| 10 | BMAC and fibrin glue delivered simultaneously during application to form a scaffold |
BMAC, bone marrow aspirate concentrate.
Table 2.
Therapeutic Approaches for Glenohumeral Joint Articular Cartilage Lesions in Young Individuals
| Category | Procedure | Indications | Advantages | Limitations |
|---|---|---|---|---|
| Arthroscopic surgery | Debridement and lavage | Small, superficial, or frayed lesions | Minimally invasive, short recovery | Not restorative; symptom control only |
| Microfracture | Small (<2-4 cm2), full-thickness unipolar defects | Stimulates fibrocartilage repair | Fibrocartilage inferior to hyaline; unpredictable durability | |
| Cartilage restoration | Osteochondral autograft transfer | Small unipolar lesions in young patients | Transplants native hyaline cartilage | Donor site morbidity, technically challenging |
| Osteochondral allograft transplantation | Larger unipolar/bipolar lesions; failed prior surgery | Replaces bone and cartilage; no donor site morbidity | Graft availability, risk of nonintegration | |
| Autologous chondrocyte implantation | Larger full-thickness lesions (mostly investigational in shoulder) | Regeneration with hyaline-like tissue | Two-stage procedure, limited shoulder data | |
| Biologic resurfacing | Fascia lata autograft, dermal allograft, scaffold | Bipolar lesions with preserved joint space (young patients) | Joint-preserving, delays arthroplasty | Variable outcomes, long-term durability uncertain |
Millet et al.11 examined 25 shoulders that received microfracture treatment for articular cartilage injuries. They observed a notable improvement in 81% of the shoulders (25/31), with the most significant progress seen in smaller lesions, whereas bipolar lesions had poorer outcomes. A drawback of this method is the formation of fibrocartilage instead of hyaline cartilage. Fibrocartilage is less advantageous than hyaline cartilage in terms of joint surface mechanics.
In their systematic review, Prigmore et al.12 explored the application of OCA transplantation for addressing traumatic impaction fractures, recurrent instability, and degenerative joint disease in the shoulder. The review encompassed 17 studies with a total of 83 shoulders, indicating an overall success rate of 82% and generally positive outcomes, especially for isolated osteochondral injuries. These results imply that OCA is a promising biological treatment option for complex shoulder conditions, although the evidence is largely derived from case reports and series. The main drawbacks are the availability of grafts and the risk of integration.
According to Riff et al.,13 OCA is a feasible option for young individuals with isolated chondral damage in the humerus, although the presence of bipolar disease in the shoulder leads to higher failure rates and poorer outcomes.
Pham et al.14 documented a case involving a 14-year-old adolescent with osteochondritis dissecans in the humeral head, which was successfully treated using an arthroscopic osteochondral autograft transfer from the knee, resulting in a satisfactory outcome. The main drawback of this treatment is donor site morbidity.
Buchmann et al.15 documented the treatment of 3 full-thickness cartilage defects in the humerus (each measuring 6.0 cm2) and 1 full-thickness cartilage defect in the glenoid (2.0 cm2) using autologous chondrocyte implantation. Postsurgery, the average visual analog scale score was 0.3 of 10, the mean Constant score was 83.3 ± 9.9, and the average American Shoulder and Elbow Surgeons index was 95.3 ± 8.1, indicating satisfactory shoulder function. MRI results showed adequate coverage of the defects, with evidence of fibrocartilaginous repair tissue.
Fortier et al.16 conducted a comparative study on the outcomes of treatment using BMAC versus microfracture alone in an equine model of osteoarthritis. The findings indicated that BMAC resulted in significantly superior outcomes both macroscopically and histologically after 3 months. Additionally, the combination of BMAC with microfracturing led to an increased production of type 2 collagen and glycosaminoglycans in the repaired tissue.
In a recent case report, Nair et al.17 described the efficacy of arthroscopic BMAC application in treating cartilage defects of the humeral head and validated its technical feasibility and satisfactory clinicoradiological outcomes when used in conjunction with Latarjet, capsulolabral repair, and remplissage arthroscopically.
In the knee, BMAC has shown effectiveness in treating chondral lesions, with reports indicating an improvement in the visual analog score from 5.4 to 0.5 and the International Knee Documentation Committee Subjective Knee Form score from 39.2 to 82.2. Notably, follow-up MRI results showed excellent defect filling in 81% of patients younger than 45 years and 70% of those older than 45 years.18 Similarly, in cases of talar chondral lesions, MRI indicated that 77.3% of defects were completely filled, and there was a significant enhancement in the Foot and Ankle Outcome Score.19
To date, research on the application of BMAC for glenoid cartilage lesions has been limited. Nevertheless, the few available studies have shown encouraging outcomes, indicating effective cartilage repair and overall improvement without an increase in adverse effects compared with other cartilage repair methods.
This technique appears to be safe, offering the benefit of being a single-step process that utilizes autologous bone marrow mesenchymal cells to aid cartilage regeneration (Tables 3, 4).
Table 3.
Advantages and Disadvantages
| Advantages |
| One-step procedure |
| More than cost-effective than ACI |
| Fully arthroscopic procedure |
| Promotes hyaline-like cartilage repair |
| Disadvantages |
| No long-term follow-up |
| Limited high-level evidence |
ACI, autologous chondrocyte implantation.
Table 4.
Pears and Pitfallsof Our Technique
| Pearls |
| Single-step repair |
| Autologous source |
| Density gradient centrifugation: increases yield of mesenchymal stem cells, boosting chondrogenic potential of BMAC |
| Meticulous defect preparation ensures BMAC retention and maximizes cell activity for regeneration |
| Pitfalls |
| Technically challenging |
| Fluid dilution and washout |
| Limited long-term data |
BMAC, bone marrow aspirate concentrate.
Disclosures
All authors (A.V.N., J.T., P.S.K., K.V., A.R., S.R., P.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
During the preparation of this work, the authors used Wondershare Filmora 14 version in order to edit and narrate the video.
Supplementary Data
With the patient in the beach-chair position, diagnostic arthroscopy is performed, followed by arthroscopic Latarjet by using cortical buttons, one on the glenoid and the other on the coracoid placed anteriorly onto the glenoid. Attention is drawn to the glenoid defect. The viewing portal changes to the suprabicipital portal. The cartilage defect is curetted, and microfracturing is performed. Bone marrow is aspirated from the iliac crest 3 finger breadths above the anterosuperior iliac spine. Bone marrow aspirate is processed in the Arthrex system, and bone marrow aspirate concentrate (BMAC) is prepared. The bone marrow concentrate is mixed with thrombin. After keeping the field dry, prepared BMAC and protein sealant are implanted onto the cartilage defect with a Y-shaped applicator, together forming a fibrin glue that covers the cartilage defect.
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Associated Data
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Supplementary Materials
With the patient in the beach-chair position, diagnostic arthroscopy is performed, followed by arthroscopic Latarjet by using cortical buttons, one on the glenoid and the other on the coracoid placed anteriorly onto the glenoid. Attention is drawn to the glenoid defect. The viewing portal changes to the suprabicipital portal. The cartilage defect is curetted, and microfracturing is performed. Bone marrow is aspirated from the iliac crest 3 finger breadths above the anterosuperior iliac spine. Bone marrow aspirate is processed in the Arthrex system, and bone marrow aspirate concentrate (BMAC) is prepared. The bone marrow concentrate is mixed with thrombin. After keeping the field dry, prepared BMAC and protein sealant are implanted onto the cartilage defect with a Y-shaped applicator, together forming a fibrin glue that covers the cartilage defect.