Arthroscopic Microfracture for Focal Glenoid Osteochondral Lesions in Young Active-Duty Military Patients: A Minimum 10-Year Follow-Up

Abstract

Background:

Glenoid osteochondral defects (OCDs), while uncommon, are a recognized source of shoulder pain and dysfunction, particularly in young, active individuals. Arthroscopic microfracture (MFx) is a commonly used surgical option. However, long-term outcomes remain poorly defined.

Purpose:

To evaluate long-term clinical and functional outcomes after arthroscopic MFx for focal glenoid OCD in active-duty military patients.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective review was conducted of 31 active-duty military patients (<54 years) who underwent arthroscopic MFx for focal, full-thickness (Outerbridge grade 4) glenoid OCD with concomitant biceps tendinitis, subacromial bursitis, and partial rotator cuff (RC) tears, performed by a single surgeon between January 2010 and June 2015. Descriptive data, trauma history, time from symptom onset to surgical intervention, and magnetic resonance imaging (MRI) findings were recorded. Pre- and postoperative clinical assessments included shoulder range of motion (ROM), visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores. Since minimal clinically important differences for glenoid MFx are not defined, validated thresholds from shoulder arthroplasty literature were used for context. Rates of return to sports, military duty, and revision procedures were assessed at final follow-up.

Results:

The mean follow-up was 138 ±14.85 months (range, 120-182 months). The mean age was 36 years (range, 22-54 months), and 94% (29/31) were men. A history of traumatic injury was recorded in 61% (19/31) of patients. The mean time from symptom onset to surgery was 31 ± 46.6 months. No significant differences in ROM were found postoperatively (P > .05). However, all patient-reported outcomes demonstrated statistically significant improvements: VAS (6.84 ± 1.92 to 2.52 ± 2.41), SANE (46.8 ± 20.1 to 81.1 ± 18), and ASES (51.1 ± 14.1 to 82.7 ±17) (P < .0001 for all). At final follow-up, 68% (21/31) returned to sports and 78% (24/31) resumed unrestricted active military duty. Revision procedures were required in 4 patients (13%): 2 underwent total shoulder arthroplasty, and 2 underwent revision MFx with debridement. MRI detected OCD lesions in only 29% (9/31) of cases.

Conclusion:

Arthroscopic MFx offers durable pain relief and functional improvement for focal glenoid OCD with concomitant biceps tendinitis, subacromial bursitis, or partial RC tears in high-demand military patients. At a minimum 10-year follow-up, outcomes demonstrated sustained clinical benefits, high return to duty, moderate return to sports (RTS), and low revision rates. Limited MRI sensitivity and prolonged time to surgical treatment highlight the importance of early clinical suspicion and timely surgical intervention in this challenging population.

Osteochondral defects (OCDs) of the glenoid are an uncommon but clinically significant source of shoulder pain and dysfunction in young, active individuals.^15,16,27 Although less frequently encountered in the general civilian population, emerging evidence suggests these lesions may occur more commonly among military personnel.^15,16‚35 This increased incidence is likely attributable to the physically demanding nature of military service, which includes repetitive high-load activities that impose substantial stress on the glenohumeral joint.^4,19,21,35 Military patients, therefore, represent a distinct high-risk population that presents unique diagnostic and therapeutic challenges.^{15,16,35,36,50,52}

Although glenoid OCDs in military patients are often associated with other shoulder joint pathologies, such as shoulder instability, labral tears, and rotator cuff (RC) tears, the incidence of focal glenoid OCD remains poorly defined and likely underestimated.^14-16,35,53 This is probably due to the nonspecific clinical presentation and subtle radiographic findings of the injury.^{8,25,28,29,33,48} While magnetic resonance imaging (MRI) is the preferred modality for evaluating intra-articular pathology, its sensitivity for glenoid OCD is variable and highly influenced by magnetic field strength, imaging protocols, and radiologist interpretation.^25,28,33,48 Consequently, glenoid OCD is often identified intraoperatively, resulting in delayed diagnosis and postponed treatment.^15,16,33,35

Management of symptomatic glenoid OCD in young, active patients remains challenging. While shoulder arthroplasty remains the gold standard solution for older individuals with advanced glenohumeral arthritis, it is generally avoided in younger active patients due to concerns over implant longevity and persistent functional limitations.^10,15,22,35 Among active-duty military personnel, these limitations can compromise occupational performance and increase the risk of medical discharge. ²² Consequently, joint-preserving procedures, particularly arthroscopic microfracture (MFx), have become the preferred treatment modality in this patient population.^{1,14,15,16,23,30,35} However, data on focal OCD treated with arthroscopic MFx remain limited.^15,16 While short-term results have been encouraging,^11,49 the long-term outcomes in young, high-demand patients remain poorly defined.

This study aimed to evaluate the long-term clinical outcomes and completion of military service, with a minimum 10-year follow-up, of active-duty military patients who underwent arthroscopic MFx for focal glenoid OCD. This study hypothesized that this treatment would result in sustained improvement in patient-reported outcome measures (PROMs), high rates of return to preinjury military function, and completion of military service.

Methods

This was a retrospective analysis of all active-duty military patients <54 years who underwent arthroscopic MFx for focal glenoid OCDs between January 2010 and June 2015. All procedures were performed by a single senior surgeon (N.P.) at a single military medical facility. Institutional review board approval was obtained before study initiation, and written informed consent was obtained from all patients after a thorough explanation of the study procedures.

Patient Population

Active-duty military patients aged 22 to 54 years who underwent arthroscopic MFx for a single contained full-thickness glenoid osteochondral defect (Outerbridge grade 4) between January 2010 and June 2015 were eligible for inclusion. Patients were required to have a minimum of 10 years of follow-up and to have complete pre- and postoperative PROMs available at final evaluation.

All included patients had failed a minimum of 3 months of nonoperative management consisting of nonsteroidal anti-inflammatory drugs, supervised physical therapy, home exercise programs, and limited-duty profiling before surgical consideration. Additionally, all patients underwent preoperative evaluation with 1.5-T magnetic resonance arthrography.

All lesions were confirmed intraoperatively via diagnostic arthroscopy and were limited to the glenoid surface. In all cases, MFx was performed along with standardized adjunctive procedures, including biceps tenotomy (for pain relief and to facilitate early rehabilitation), subacromial bursectomy, debridement of small bursal-sided partial-thickness RC tears, labral debridement, acromioclavicular joint resection, acromioplasty, free cartilage removal, and rotator interval release, when indicated.

Patients were excluded if they were >54 years, had prior shoulder surgery, underwent concomitant procedures such as capsulolabral or RC repair, or had focal or concomitant OCDs of the humeral head. Additional exclusion criteria included partial-thickness chondral lesions (Outerbridge grades 1-3) and lesions >4 cm².

Surgical Procedure

All procedures were performed by the senior author (N.P.), using a consistent technique throughout the study period. Patients were positioned in the modified beach-chair position after the induction of general anesthesia and administration of a preoperative interscalene nerve block. A comprehensive examination under anesthesia was conducted to assess the passive range of motion (ROM) and glenohumeral stability in both the anterior and posterior planes. The operative extremity was then secured in a Spider hydraulic arm holder (Smith & Nephew), and the shoulder was prepped and draped in standard sterile fashion.

A diagnostic arthroscopy of the glenohumeral joint was performed through standard posterior and anterior portals. Once the focal glenoid chondral lesion was identified, any concomitant intra-articular pathology was documented and addressed as indicated.

Biceps tenotomy was routinely performed in all patients to address biceps-related symptoms and to facilitate an early postoperative ROM without restriction. After tenotomy, the chondral defect was defined, and unstable cartilage flaps were debrided using a combination of arthroscopic shaver, ring curettes, and arthroscopic biter. Vertical walls were then established circumferentially around the defect using a ring curette to promote defect stability and to contain the marrow clot, which is essential for fibrocartilage formation.^23,24 The calcified cartilage layer was meticulously removed, avoiding penetration into the subchondral bone plate.

MFx was performed using an MFx awl, creating perforations approximately 3 to 4 mm in depth and spaced 3 to 4 mm apart across the base of the lesion. Inflow was temporarily halted to confirm adequate flow of marrow elements into the defect, confirming appropriate stimulation of the subchondral bone bed (Figure 1).

Figure 1.

Intraoperative images of glenoid OCD* and MFx†.

These images demonstrate the surgical management steps for glenoid OCDs. The sequence highlights the progression from lesion identification to therapeutic intervention and the biological response that follows. Intraoperative images of a 30-year-old male patient: (A) Grade 4 anterior glenoid OCD lesion measuring 12 × 20 mm. (B) Debridement and MFx (blue arrows) of the OCD lesion. (C) Blood and stem cell influx (red arrow) from the MFx site.

*OCD, osteochondral defect.

† MFx, microfracture.

✗ Glenoid cartilage.

+Subchondral bone.

After intra-articular evaluation and treatment, attention was directed to the subacromial space. Subacromial bursectomy was performed in all patients to treat reactive bursitis, a common finding in military patients with delayed surgical intervention and altered shoulder mechanics. The bursal surface of the RC was assessed, and small partial-thickness tears were debrided as necessary. Acromioplasty was performed in select cases based on intraoperative findings—including subacromial impingement or acromial morphology.

Postoperative Rehabilitation

All patients were discharged on the day of surgery and initiated rehabilitation under a standardized protocol at a single military-based physical therapy facility. The rehabilitation protocol was uniform across patients, regardless of whether focal glenoid MFx or concomitant procedures were performed.

Pendulum exercises, along with active ROM of the elbow, wrist, and fingers, were initiated upon resolution of the regional nerve block. Opioid analgesics were prescribed for a maximum of 10 days postoperatively. During the first 6 weeks, all patients were advised to use a sling (SmartSling, Ossur) for comfort, particularly in the first 2 weeks, with discontinuation permitted as tolerated. Immediate initiation of passive and active-assisted ROM was encouraged to prevent stiffness, especially in forward flexion and external rotation. Patients were instructed to avoid combined horizontal adduction and internal rotation, which places increased shear stress across the glenoid surface. Active shoulder-strengthening, weight-bearing, and axial-loading activities (eg, push-ups, overhead lifting) were restricted for the first 6 weeks. Beginning at 6 weeks, patients progressed to active motion and isometric RC strengthening, followed by light resistance training using bands and pulleys. Isotonic strengthening exercises were introduced at approximately 12 weeks postoperatively. Return to unrestricted activity, including full military duty or athletic participation, was typically permitted between 4 and 5 months postoperatively, based on clinical recovery.

Data Collection

Demographic and clinical data were collected prospectively at routine postoperative follow-up visits, conducted either in person or via telemedicine for patients unable to return to the military base due to reassignment or separation from service. For telemedicine follow-ups, validated PROMs, including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain, were completed electronically. In these cases, ROM assessments were performed by licensed physical therapists at the patient's location using a standardized protocol consistent with that used by the treating surgeon during in-person visits. All demographic, clinical, and surgical data were retrospectively reviewed for completeness and accuracy by an independent research assistant (J.P.S.).

Collected variables included age (years), sex (male/female), surgical laterality (right/left), and arm dominance (dominant/nondominant). Follow-up duration (months) was calculated from the date of surgery to the most recent clinical evaluation.

Military occupational specialties (MOSs) were categorized as combatant (infantry, artillery, military police, firefighter) or supportive (logistics, computer technician, mechanic, food service) to assess physical demand variability. A documented history of traumatic shoulder injury before surgery (yes/no), as well as the time interval from symptom onset to surgical intervention, were recorded based on review of the patients’ medical records. Preoperative MRI reports were reviewed to determine whether glenoid chondral lesions were identified preoperatively (yes/no). Operative reports were analyzed for documentation of intraoperative procedures performed, including glenoid MFx and all concomitant procedures. Lesion size, in square centimeters (cm²), was measured intraoperatively using calibrated arthroscopic probes and recorded from surgical documentation.

Clinical and patient-reported outcomes were assessed both preoperatively and at the final follow-up. Active ROM was measured with a goniometer during in-person visits and with a virtual goniometer during telemedicine visits. ROM values were recorded for forward flexion (FF) and external rotation (ER) (in degrees), and internal rotation (IR) as the highest vertebral level reached with the thumb. Pain severity was assessed using VAS scores, and functional outcomes were assessed using the ASES and SANE scores. Postoperative data included RTS and military duty, discharge from service, and need for revision surgery.

Statistical Analysis

Statistical analyses were performed using SPSS Statistics (Version 25; IBM Corp). Descriptive statistics were used to summarize patient and clinical characteristics. Continuous variables were reported as means and standard deviations, ranges, and 95% CIs, while categorical variables were summarized using frequencies and percentages. The chi-square test of independence was used to evaluate the correlation between OCD size and detection rates on MRI, and a correlation box plot was illustrated using Microsoft Excel 2019 (Microsoft Corp). A paired t test was used to compare preoperative and final follow-up values for continuous clinical outcome measures, including shoulder ROM, VAS for pain, ASES, and SANE scores. The Wilcoxon signed-rank was used to compare categorical variables. For all analyses, P < .05 was considered statistically significant.

Given that specific thresholds for clinically meaningful improvement after glenoid MFx have not been established, previously validated benchmarks derived from shoulder arthroplasty literature were used to contextualize patient-reported outcome improvements. Thresholds for the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) were applied as follows: MCID – VAS, 1.6 points; SANE, 28.8 points; ASES, 13.6 points; SCB – VAS, 3.2 points; SANE, 50 points; ASES, 20.7 points; PASS – VAS, 1.3 points; SANE, 75.5 points; ASES, 81.9 points)^13,39-41,51

Results

Study Cohort

During the study period, the senior surgeon performed 72 arthroscopic MFx procedures for glenoid OCDs in military patients aged <54 years. Of these, 24 patients underwent concomitant labral repair, 14 underwent RC repair, and 3 were lost to follow-up. After applying the study's exclusion criteria, 31 patients (31 shoulders) met the inclusion criteria and were available for final analysis (Figure 2).

Figure 2.

Flowchart for the inclusion of populations for analysis.

The mean age of the cohort was 36 years (range, 22-54 years), with 29 (94%) male and 2 (6%) female patients. The right shoulder was involved in 15 patients (48%) and the left in 16 (52%). The dominant shoulder was treated in 17 patients (55%), and the nondominant shoulder in 14 (45%). The mean follow-up duration was 138 months (range, 120-182 months).

All patients were active-duty military personnel at the time of surgery. A total of 22 patients (71%) served in combat-related roles, while 9 (29%) held supportive positions. A documented history of shoulder trauma was present in 19 patients (62%), with a mean interval from symptom onset to surgical intervention of 31 ± 46.6 months (Table 1).

Table 1.

Baseline Characteristics and Concomitant Arthroscopic Procedures ^a

		Study Cohort N = 31
Follow-up, months		138 ± 15.01 (120-182)
Age, years		36 ± 9.11 (22–54)
Sex	Male	29 (94)
	Female	2 (6)
Operated shoulder laterality	Right	15 (48)
	Left	16 (52)
Dominant shoulder affected	Dominant	17 (55)
	Nondominant	14 (45)
Traumatic cause		19 (62)
Time to surgery, months		31 ± 46.6 (2-180)
Military occupation
Combatant role	Infantry	14 (46)
	Artillery	5 (16)
	Military police	2 (6)
	Firefighter	1 (3)
	Total	22 (71)
Supportive	Logistics	1 (3)
	Computer technician	2 (6)
	Mechanic	4 (14)
	Food supplier	2 (6)
	Total	9 (29)
Concomitant arthroscopic procedures	Subacromial bursectomy	31 (100)
	Biceps tenotomy	31 (100)
	Debridement of bursal-sided partial-thickness RC tears	10 (32)
	Labral debridement	4 (13)
	ACJ resection	2 (6)
	Acromioplasty	6 (19)
	Removal of loose intra-articular cartilage	4 (13)
	Rotator interval release	2 (6)

^aData are presented as mean ± SD (range) or n (%). ACJ, acromioclavicular joint; RC, rotator cuff.

Radiology Evaluation

Based on MRI reports, OCDs were detected in only 9 (29%) patients, and the mean cartilage lesion size was 1.508 ± 1.482 cm² (range, 0.24-4 cm²). No correlation was found between cartilage defect size and OCD detection on MRI (Figure 3).

Figure 3.

Association between osteochondral defect size and detection on preoperative MRI. MRI, magnetic resonance imaging.

Concomitant Procedures

All patients underwent arthroscopic subacromial bursectomy and biceps tenotomy. Additional procedures included debridement of bursal-sided partial-thickness RC tears in 10 patients, labral debridement in 4 patients, acromioclavicular joint resection in 2 patients, acromioplasty in 6 patients, removal of loose intra-articular cartilage in 4 patients, and rotator interval release in 2 patients.

Clinical and Patient Reported Outcomes

Although postoperative improvements in shoulder ROM were observed across all planes, these changes did not reach statistical significance: FF improved from 152.6°± 15.2° to 157.7°± 5.1° (P = .051), ER from 63.9°± 13.5° to 67.3°± 5.1° (P = .19), and IR from T10.7 ± 2.9 to T9.9 ± 1.9 (P = .23). In contrast, statistically significant improvements were observed in all PROMs after surgery. VAS for pain scores decreased from 6.8 ± 1.9 to 2.5 ± 2.4 (P < .0001), SANE scores improved from 46.8 ± 20.1 to 81.1 ± 17.97 (P < .0001), and ASES scores increased from 51.1 ± 14.1 to 82.7 ± 17.1 (P < .0001) (Table 2).

Table 2.

Comparison of Pre- and Postoperative Clinical and Patients Reported Outcomes ^a

Category	Pre	Post	P
VAS for pain	6.84 ± 1.92	2.52 ± 2.41	.0001
SANE score	46.77 ± 20.11	81.13 ± 17.97	.0001
ASES score	51.06 ± 14.13	82.74 ± 17.05	.0001
FF, deg	152.58 ± 15.16	157.74 ± 5.14	.0515
ER, deg	63.87 ± 13.52	67.26 ± 5.14	.1973
IR, vertebral level	T 10.65 ± 2.89	T 9.90 ± 1.87	.2350

^aData are presented as mean ± SD. Bold P values indicate statistically significant difference between groups (P <.05). ASES, American Shoulder and Elbow Surgeons; ER, external rotation; FF, forward flexion; IR, internal rotation; Post, postoperative; Preop, preoperative; VAS, visual analog scale; SANE, Single Assessment Numeric Evaluation.

The majority of patients achieved the MCID for VAS, SANE, and ASES scores, as well as the SCB for VAS and ASES scores, and the PASS for SANE and ASES scores. In contrast, a smaller proportion of patients met the SCB threshold for SANE scores (35%) and the PASS threshold for VAS (38%) scores (Table 3).

Table 3.

Patients Meeting the MCID, SCB, and PASS for the VAS, SANE, ASES ^a

PROMs	MCID	SCB	PASS
VAS for pain	23 (87)	21 (68)	12 (38)
SANE score	18 (58)	11 (35)	24 (77)
ASES score	27 (87)	23 (74)	18 (58)

^aData are presented as n (%). ASES, American Shoulder and Elbow Surgeons; MCID, minimal clinically important difference; PASS, patient acceptable symptom state; PROMs, patient-reported outcome measures; SANE, Single Assessment Numeric Evaluation; SCB, substantial clinical benefit; VAS, visual analog score.

Revisions and RTS and Military Active Duty

Over the course of the study, 4 patients (13%) underwent revision surgery. Two patients required conversion to anatomic total shoulder arthroplasty at 6 and 8 years after the index procedure, while 2 other patients underwent repeat arthroscopic glenoid MFx and debridement at 4 and 6 years postoperatively. At final follow-up, 21 patients (68%) returned to their preinjury level of sports participation, and 24 patients (78%) resumed unrestricted active-duty military service. Seven patients (22%) were medically discharged from service, including 3 of the 4 patients (75%) who underwent revision surgery. There was no statistically significant difference in medical discharge rates based on military occupational specialty, with 5 of 22 (22%) combatant personnel and 2 of 9 (22%) supportive personnel discharged (P = 1.03) (Table 4).

Table 4.

Revision, RTS, Activity, and Discharge From Service ^a

		RTS	Return to Military Duty	Discharge From Military
Revisions, n = 4	TSA, n = 2	0/2 (0)	0/2 (0)	2/2 (100)
	MFx + debridement, n = 2	1/2 (50)	1/2 (50)	1/2 (50)
Combatant duty, n = 22		16/22 (73)	17/22 (78)	5/22 (22)
Supportive duty, n = 9		5/9 (56)	7/9 (78)	2/9 (22)
Total		21/31 (68)	24/31 (78)	7/31 (22)

^aData are presented as mean ± SD or n (%). MFx, microfracture; RTS, return to sports; TSA, total shoulder arthroplasty.

Discussion

The principal findings of this study demonstrate that arthroscopic MFx for focal grade 4 glenoid OCD with concomitant biceps tendinitis, subacromial bursitis, or partial RC tears may offer meaningful and sustained clinical improvement at a minimum 10-year follow-up, supporting its role as a viable long-term option for symptom relief and functional restoration in young, high-demand patients. Patients experienced clinically meaningful improvements in VAS, SANE, and ASES scores, with most exceeding established MCID, SCB, and PASS thresholds. Exceptions included a smaller proportion achieving the SCB threshold for SANE scores (35%) and the PASS threshold for VAS scores (38%). A majority (78%) returned to unrestricted active-duty military service, and 68% resumed preinjury athletic activity. The revision rate was relatively low (13%), with only 2 patients requiring conversion to shoulder arthroplasty. Notably, the MRI detection rate of glenoid OCDs was low (29%), underscoring the need for high clinical suspicion in this population.

OCDs of the glenohumeral joint are typically identified in older patients with chronic RC pathology.^10,26 However, emerging evidence suggests an increased incidence of glenoid OCDs in younger, active individuals, particularly among male military personnel with glenohumeral instability or RC injury.^{14,23,31,34,35,43,49} This is likely due to increased exposure to repetitive microtrauma, high-impact activities (eg, pushups and bench pressing), and a greater incidence of shoulder trauma and instability events encountered in military service members.^14,15,31,35 In accordance with previous reports, 94% of the study cohort were highly active military male patients.

Despite these reports, focal glenoid OCD is a rare, under-recognized pathology.^27,47,49,53 When present, it can cause persistent shoulder pain, functional limitations, difficulty returning to duty or sport, and may increase the risk of early-onset glenohumeral osteoarthritis.^{10,14,18,35,38,49} Given these potential consequences, timely diagnosis and treatment are critical, but remain challenging.^8,10,23 The diagnostic difficulty stems largely from the nonspecific nature of symptoms, subtle clinical presentation, and the lack of definitive findings on physical examination.^8,27,38,47 Although shoulder trauma commonly precedes symptom onset, this is not consistently reported.^9,49 Accordingly, in this cohort, 61% reported acute shoulder trauma prior to symptom onset. However, the remaining patients did not recall a specific inciting event. In these cases, chronic repetitive microtrauma from high-demand military activities likely altered shoulder biomechanics, progressively leading to glenoid OCD and subsequent cartilage degeneration.^2,27,29

Several studies have demonstrated favorable short- to mid-term outcomes after MFx for glenohumeral cartilage lesions. Frank et al ¹¹ reported 80% success and 18% complication rates at 27.8 months follow-up, while Millett et al ²³ observed significant VAS and ASES improvements with a reoperation rate of 19% at 47 months. Longer-term data from Wang et al ⁴⁹ showed a 76.6% survivorship rate at 9.6 years, although 33.3% experienced failure, with a mean time to failure of 3.7 years postoperatively.

Unlike prior studies including bipolar lesions,^11,23,49 this study examines a homogeneous cohort of 31 active-duty military patients with focal glenoid OCDs, representing one of the largest series with ≥10-year follow-up (range, 120-180 months) after arthroscopic MFx. At final follow-up, most patients demonstrated significant improvements in VAS, ASES, and SANE scores, with the majority surpassing MCID, SCB, and PASS thresholds (Table 3). The revision rate was 13%, lower than previously reported, with only 2 patients (6%) converting to arthroplasty. Both patients who required arthroplasty were older than the mean age of the cohort (48 and 54 years at the time of injury), and 1 also had a large OCD measuring 4 cm². These findings may help inform clinical decision-making, as older patients with large glenoid OCDs may experience less favorable outcomes after MFx. Additionally, 68% returned to preinjury sports levels and 78% returned to active duty, a higher rate than previously reported for MFx with concomitant labral (58%) or RC (71.4%) repairs.^14-16 Return to duty and discharge rates were similar across roles, with only 22% of both combatant (5/22) and support personnel (2/9) medically discharged, highlighting the long-term durability of arthroscopic MFx in high-demand patients.

Imaging-based diagnosis of glenoid OCDs also remains a significant challenge.^{8,25,28,29,33} While MRI is the preferred modality for evaluating articular cartilage pathology, its sensitivity for detecting glenoid OCDs varies widely (31% to 75%) due to thin glenohumeral cartilage (1-1.8 mm), overlapping anatomy, and similar signal intensities of cartilage, bone, and labrum.^{8,25,28,33,37,48,53} Diagnostic accuracy also depends on magnet strength, imaging protocol, MR arthrography use, and radiologist expertise.^{5,12,17,20,48} Prior studies have demonstrated improved performance with 3.0-T MRI versus 1.5-T systems,^5,20 and higher sensitivity with MR arthrography, particularly when using 3-dimensional volumetric sequences.^12,17 Reader interpretation further limits sensitivity, with only moderate agreement reported for small or low-grade defects. ⁴⁸ Notably, while there was a trend toward larger lesions being more likely to be detected on MRI in this cohort, the association was not statistically significant, and no correlation was found between OCD lesion size and MRI detection rates, with even larger defects occasionally overlooked on imaging. Despite using 1.5-T MR arthrography in this cohort, preoperative OCD detection was low (29%), contributing to delayed surgical intervention (mean 31 ± 46.6 months). This delay may have been further compounded by military-specific factors such as frequent relocations, limited access to orthopedic care, and duty-related underreporting of symptoms.^3,15,32,44

Currently, shoulder arthroscopy remains the gold standard for diagnosing glenohumeral cartilage lesions, offering direct visualization and superior diagnostic accuracy compared with MRI.^18,45,48 Given the multifactorial causes of diagnostic delay, a high suspicion for glenoid OCD is essential, especially in high-demand groups like active-duty male military personnel.^8,14,35,38 Early diagnostic arthroscopy may be warranted in select cases to confirm diagnosis and enable timely treatment, potentially reducing long-term complications.

Management of glenohumeral OCDs remains variable, with no established consensus.^6,10,38,49 Nonoperative treatment is reserved for patients with mild symptoms or limited surgical candidancy.^8,10,11,38 Surgical options include arthroscopic debridement and joint-preserving techniques such as MFx, osteochondral grafting, autologous chondrocyte implantation, and shoulder arthroplasty.^{7,9,10,22,24,34,46} Arthroscopic debridement may offer short-term pain relief, but functional improvement is limited, with conversion to arthroplasty reported in 26% to 42% of cases within 9 to 31 months, with up to 60% of patients with grade 4 chondral changes reporting dissatisfaction.^25,42 While total shoulder arthroplasty is effective in older patients with advanced arthritis, outcomes are suboptimal in younger active individuals due to limited implant longevity and high functional demands, with 10-year implant survival as low as 61% in patients <50 years and high rates of persistent dysfunction and medical discharge among military personnel.^22,46 Given these limitations, joint-preserving procedures are preferred in younger, high-demand populations, with MFx being the most commonly performed.^6,10,30 In a systematic review of 14 studies (100 shoulders) treated for focal glenohumeral cartilage defects, Fiegen et al ¹⁰ reported that MFx was used in 62% of cases. Similarly, this study shows that MFx may serve as a valuable alternative to arthroplasty in younger, high-demand populations.

Limitations

This study has several important limitations. First, its retrospective design and relatively small sample size introduce potential selection and reporting bias. Second, the predominantly male active-duty military cohort may limit generalizability to civilian or female populations with lower physical demands. Third, the MCID, SCB, and PASS thresholds were extrapolated from previously arthroplasty literature, as procedure-specific values for focal glenoid MFx have not been established. Nonetheless, these values align with previous glenohumeral MFx studies and offer a reasonable framework for assessing clinical relevance. Fourth, follow-up imaging was not routinely performed, limiting assessment of fibrocartilage regeneration or osteoarthritis progression. Another limitation of this study is the presence of concomitant procedures, including mainly subacromial bursectomy and biceps tenotomy, which may have influenced postoperative outcomes and limited the ability to attribute results solely to the MFx procedure. However, these additional procedures are commonly performed in conjunction with glenoid MFx in routine clinical practice, and their inclusion reflects the real-world surgical environment in which these patients are typically treated. Lastly, all procedures were performed by a single, fellowship-trained shoulder and elbow surgeon with substantial experience in arthroscopic techniques, which may limit the generalizability of the results to surgeons with differing training backgrounds or surgical approaches. Despite these limitations, this study represents one of the largest cohorts to date with a minimum 10-year follow-up after arthroscopic MFx for focal glenoid OCDs and offers valuable long-term data supporting the durability and safety of this joint-preserving approach in young, high-demand patients.

Conclusion

Arthroscopic MFx offers durable pain relief and functional improvement for focal glenoid OCDs with concomitant biceps tendinitis, subacromial bursitis, or partial RC tears in high-demand military patients. At minimum 10-year follow-up, outcomes demonstrated sustained clinical benefits, high return-to-duty, moderate return-to-sport, and low revision rates. Limited MRI sensitivity and prolonged time to surgical treatment highlight the importance of early clinical suspicion and timely surgical intervention in this challenging population.