DOI:10.2214/AJR.05.1477
AJR 2007; 188:1094-1098
© American Roentgen Ray Society
Chondrolysis of the Glenohumeral Joint After Arthroscopy: Findings on Radiography and Low-Field-Strength MRI
Timothy G. Sanders1,2,
Michael B. Zlatkin1,3,
Narayan Babu Paruchuri1,3 and
Robert W. Higgins4
1 National Musculoskeletal Imaging, 1930 N Commerce Pkwy., Suite 5, Weston, FL
33326.
2 Uniformed Services University of the Health Sciences, Bethesda, MD.
3 Department of Radiology, University of Miami, Jackson Memorial Hospital,
Miami, FL.
4 Amarillo Sports Medicine and Orthopedic Center, Amarillo, TX.
Received August 22, 2005;
accepted after revision October 10, 2005.
Address correspondence to T. G. Sanders
(radmantgs{at}cs.com).
Abstract
OBJECTIVE. The purpose of this report is to describe the clinical
and imaging findings of chondrolysis of the glenohumeral joint.
CONCLUSION. In the appropriate clinical setting, both radiographs
and MR images of the shoulder can be used to establish the diagnosis of
chondrolysis of the glenohumeral joint.
Keywords: injury • MRI • musculoskeletal system • shoulder • sports medicine
Introduction
Rapid-onset chondrolysis is a condition in which widespread
chondrocyte death occurs within a joint over a relatively short time. The hip
and the knee have been reported to be affected most often. The condition
usually follows exposure of the articular cartilage to a substance that is
toxic to chondrocytes and causes extensive chondrocyte death. In the knee and
hip, exposure to chlorhexidine and methylmethacrylate has been shown to lead
to rapid and diffuse chondrocyte death
[1-4].
There have been several case reports of rapid-onset chondrolysis of the
shoulder after arthroscopy. Although the cause is uncertain, this complication
appears to occur most commonly in young patients who have undergone shoulder
reconstructive procedures to manage shoulder instability
[5-7].
Glenohumeral chondrolysis is devastating and difficult to manage because it
typically occurs in young athletes. Extensive loss of articular cartilage
progresses to severe osteoarthritis of the shoulder, which causes loss of
range of motion and pain with any movement of the involved joint. Treatment is
initially supportive, but arthroplasty eventually may be necessary.
We present four cases of rapid-onset chondrolysis of the glenohumeral joint
after arthroscopy. Each of the four patients, like five patients described in
other reports, was young (14-32 years old) and had undergone arthroscopic
surgery for shoulder instability. These four patients all did well during
surgery and during the initial postoperative recovery period. There were no
reported variations from the standard of care during the arthroscopic
procedures. Three months after surgery, one patient began to report limitation
of overhead activity and decreased internal rotation. By six months after
surgery, two patients began to report decreased range of motion. The fourth
patient was lost to follow-up until 2 years after arthroscopy, but when he
sought treatment, he had been experiencing pain and decreased range of motion
for many months. The common clinical presentation among these four patients
was pain out of proportion to that expected in the normal postoperative period
and progressive loss of the normal range of motion of the shoulder.
Materials and Methods
The cases of four patients in whom rapid-onset chondrolysis of the
glenohumeral joint developed after shoulder arthroscopy were retrospectively
evaluated (Table 1).
Preoperative and postoperative clinical notes and surgical procedure notes
were reviewed in each case. All four patients had undergone preoperative MRI
of the shoulder, and two patients had undergone preoperative shoulder
radiography. After onset of symptoms in the postoperative period, all four
patients underwent repeated shoulder radiography, and two patients also
underwent follow-up MRI. Each of the imaging studies was reviewed in consensus
by two musculoskeletal radiologists.
Preoperative MRI examinations showed a fibrous Bankart lesion in patients 1
and 4. Minimal nonspecific cystic changes in the greater tuberosity of the
humeral head were found in patient 3, but the findings were otherwise
unremarkable. Preoperative MRI of patient 2, a collegiate baseball catcher,
revealed findings consistent with the diagnosis of posterior superior glenoid
impingement with a superior labral anteroposterior tear that extended into the
posterior inferior labrum, minimal partial-thickness undersurface tear of the
infraspinatus tendon, and cystic changes within the posterior lateral aspect
of the humeral head. In all four patients, preoperative MRI showed normal
articular cartilage of the glenohumeral joint with no chondral thinning or
surface irregularity and no changes in signal intensity in the subchondral
bone marrow. Preoperative radiographs of the shoulders of patients 3 and 4
showed no significant abnormality of the glenohumeral joint. Specifically, the
radiographs of both patients showed a normal glenohumeral joint space with no
narrowing or cortical irregularity and no subchondral radiolucency or
sclerosis. The standard radiographs obtained for each patient in the
preoperative and postoperative periods included anteroposterior views with
internal and external rotation, a true anteroposterior view of the
glenohumeral joint (Grashey view), and an axillary view.
View larger version (162K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A —32-year-old man with chondrolysis of shoulder after arthroscopy.
Preoperative T1-weighted axial (A) and axial STIR (B) MR images
of shoulder show normal articular cartilage (arrows) and subchondral
marrow signal intensity.
|
|
View larger version (164K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B —32-year-old man with chondrolysis of shoulder after arthroscopy.
Preoperative T1-weighted axial (A) and axial STIR (B) MR images
of shoulder show normal articular cartilage (arrows) and subchondral
marrow signal intensity.
|
|
View larger version (161K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C —32-year-old man with chondrolysis of shoulder after arthroscopy.
T1-weighted axial (C) and axial STIR (D) images 2 years after
surgery show extensive joint space narrowing (long arrow) and loss of
normal articular cartilage on both sides of joint with cortical irregularity
and patchy areas of change in signal intensity in subchondral marrow
(short arrows) consistent with subchondral sclerosis and marrow edema
involving osseous glenoid process and, to lesser extent, humeral head.
|
|
View larger version (162K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D —32-year-old man with chondrolysis of shoulder after arthroscopy.
T1-weighted axial (C) and axial STIR (D) images 2 years after
surgery show extensive joint space narrowing (long arrow) and loss of
normal articular cartilage on both sides of joint with cortical irregularity
and patchy areas of change in signal intensity in subchondral marrow
(short arrows) consistent with subchondral sclerosis and marrow edema
involving osseous glenoid process and, to lesser extent, humeral head.
|
|
In each case, the preoperative and postoperative MRI examinations were
performed on a 0.2-T system (Magnetom Jazz, Siemens Medical Solutions).
Sequences included axial and coronal T1-weighted spin-echo images (TR/TE,
650-750/26; bandwidth, 0.6 Hz; field of view, 159-179 mm; matrix size, 192
x 176; slice thickness, 4.0-5.0 mm; gap, 0.0 mm; acquisition time, 7
minutes 54 seconds), axial and coronal STIR images (1,210-1,380/16; bandwidth,
0.6 Hz; field of view, 159-179 mm; matrix size, 192 x 176; slice
thickness, 4.0-5.0 mm; gap, 0.0 mm; acquisition time, 8 minutes 31 seconds),
axial gradientecho images (50/18; bandwidth, 0.6 Hz; field of view, 159 mm;
matrix size, 192 x 160; slice thickness, 3.1 mm; gap, 0.0 mm;
acquisition time, 8 minutes 8 seconds), and sagittal and coronal T2-weighted
images (1,920/80; bandwidth, 0.6 Hz; field of view, 159 mm; matrix size, 192
x 168; slice thickness, 4.0 mm; gap, 0.0 mm; acquisition time, 8 minutes
41 seconds).
Results
Each of the four patients had undergone an arthroscopic procedure for
glenohumeral instability as summarized in
Table 1. All four patients did
well during surgery, and there was no reported variation from the standard of
care during the arthroscopic procedure or during the immediately postoperative
period. Each patient had the normal expected immediately postoperative course.
Three months after surgery, one patient began reporting shoulder pain and
limitation of overhead activity with decreased internal rotation. Six months
after surgery, two patients began reporting decreased range of motion;
however, only one of these patients reported associated pain with shoulder
motion. At a postoperative follow-up visit 1 month after surgery, the fourth
patient had normal findings and then was lost to follow-up for 2 years. Two
years after surgery, the patient returned, reporting that for several months
he had experienced decreased range of motion and severe pain with any movement
of the shoulder.
All four patients underwent follow-up radiography of the shoulder, and two
underwent follow-up MRI at the time of onset of postoperative symptoms.
Postoperative MR images of the two patients showed extensive diffuse loss of
articular cartilage of the glenoid process and humeral head, the most
significant changes being on the glenoid side of the joint (Figs.
1A,
1B,
1C,
1D and
2A,
2B,
2C,
2D). Focal areas of subchondral
cortical irregularity were found in the region of the osseous glenoid process
and the medial aspect of the humeral head. In addition, focal areas of
decreased T1-weighted signal abnormality corresponded to areas of increased
and decreased T2-weighted signal intensity in the subchondral region of the
glenoid process and medial aspect of the humeral head, likely representing
areas of focal subchondral marrow edema and subchondral sclerosis. Minimal
glenohumeral joint effusion was found during one examination, and the other
examination revealed no substantial accumulation of joint fluid. No evidence
of synovitis and no loose body or debris were found within the glenohumeral
joint. No marginal osteophyte formation was detected.
View larger version (169K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A —19-year-old man with chondrolysis of shoulder after arthroscopy.
T2-weighted axial (A) and coronal STIR (B) images show superior
labral anteroposterior tear (arrow, B) that extends
posteriorly to involve posterior labrum (arrow, A). Articular
cartilage and subchondral marrow of both osseous glenoid process and humeral
head are normal.
|
|
View larger version (182K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B —19-year-old man with chondrolysis of shoulder after arthroscopy.
T2-weighted axial (A) and coronal STIR (B) images show superior
labral anteroposterior tear (arrow, B) that extends
posteriorly to involve posterior labrum (arrow, A). Articular
cartilage and subchondral marrow of both osseous glenoid process and humeral
head are normal.
|
|
View larger version (160K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C —19-year-old man with chondrolysis of shoulder after arthroscopy.
Axial (C) and coronal (D) T1-weighted images obtained 11 months
after surgery show joint space narrowing (long arrow) and loss of
articular cartilage with extensive subchondral sclerosis and marrow edema
(short arrows) diffusely involving osseous glenoid process and, to
lesser degree, medial aspect of humeral head.
|
|
View larger version (168K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D —19-year-old man with chondrolysis of shoulder after arthroscopy.
Axial (C) and coronal (D) T1-weighted images obtained 11 months
after surgery show joint space narrowing (long arrow) and loss of
articular cartilage with extensive subchondral sclerosis and marrow edema
(short arrows) diffusely involving osseous glenoid process and, to
lesser degree, medial aspect of humeral head.
|
|
Postoperative radiographs of all four patients showed marked joint space
narrowing with extensive subchondral sclerosis and patchy areas of subchondral
radiolucency compared with the preoperative radiographs (Figs.
3A,
3B and
4A,
4B,
4C,
4D). Areas of cortical
thinning and irregularity also were found. These changes appeared most
prominent in the region of the superior glenohumeral joint. The most extensive
involvement was found in the areas of the superior medial aspect of the
humeral head and the adjacent superior aspect of the osseous glenoid process.
No loose intraarticular bodies or marginal osteophytes were found.
View larger version (120K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A —18-year-old man with chondrolysis of shoulder after arthroscopy.
Preoperative anteroposterior radiograph of shoulder shows normal-appearing
glenohumeral joint with joint space (arrows) well preserved.
|
|
View larger version (111K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B —18-year-old man with chondrolysis of shoulder after arthroscopy.
Follow-up anteroposterior radiograph 6 months after surgery shows extensive
narrowing (long arrows) of joint space. Extensive subchondral
sclerosis is present, and subchondral cyst formation (short arrows)
involves medial aspect of humeral head and osseous glenoid process.
|
|
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C —14-year-old girl with chondrolysis of shoulder after arthroscopy.
Follow-up anteroposterior (C) and axillary (D) radiographs 6
months after surgery show extensive joint space narrowing (long
arrows) with subchondral sclerosis and cyst formation (short
arrows) diffusely involving medial aspect of humeral head and osseous
glenoid process.
|
|
View larger version (108K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4D —14-year-old girl with chondrolysis of shoulder after arthroscopy.
Follow-up anteroposterior (C) and axillary (D) radiographs 6
months after surgery show extensive joint space narrowing (long
arrows) with subchondral sclerosis and cyst formation (short
arrows) diffusely involving medial aspect of humeral head and osseous
glenoid process.
|
|
The clinical and imaging findings in these four cases were considered
diagnostic of glenohumeral chondrolysis. For this reason, histologic
evaluation and cultures were not performed. Because of their young ages, these
patients were treated with conservative palliative measures, including
physical therapy in an attempt to maintain range of motion and pain control
with nonsteroidal antiinflammatory drugs. Total shoulder replacement may be
necessary.
Discussion
Chondrolysis is a devastating condition in which cell death of chondrocytes
results in irreversible loss of articular cartilage and leads to rapidly
progressive and extensive osteoarthritis of the joint. Chondrolysis of the hip
was first reported in 1930 and has been reported to involve the shoulder, hip,
knee, and ankle [8]. In most
instances, the mechanism leading to cell death remains poorly understood. In
some cases, however, exposure of the articular surface to a toxic substance is
the clear etiologic factor. In nearly all instances, rapid destruction of the
articular cartilage occurs on both sides of the joint and leads to the
clinical presentation of progressively worsening pain, decreased range of
motion, and stiffness of the joint.
Chondrolysis of the hip has been reported after intraarticular leakage of
methylmethacrylate in the management of benign subchondral cyst
[3]. It also has been reported
to occur in the hip after trauma and epiphyseolysis
[9]. Chondrolysis has occurred
after various hip procedures, including transfer of the greater trochanter and
rotational acetabular osteotomy, and after penetration of the articular
surface of the femoral head with pins placed through the femoral neck
[9]. The exact mechanism
leading to chondrocyte death was unclear in most of these cases, but some
authors [10,
11] have suggested a mechanism
whereby deposition of immunocomplexes causes an autoimmune response against
the articular cartilage and synovitis develops. A single case of idiopathic
chondrolysis of the ankle after arthroscopy and bupivacaine (Marcaine, Sanofi)
pump placement has been reported
[11]. No known toxic substance
was introduced into the joint in that case. Chondrolysis of the knee after
accidental chlorhexidine irrigation during arthroscopy has been reported
[1,
2].
There have been only a few case reports of chondrolysis involving the
glenohumeral joint. In 1997, two cases were reported after color test-assisted
rotator cuff repair. In that procedure, gentian violet was introduced into the
joint in an attempt to identify a small fullthickness tear of the rotator cuff
that was not readily apparent at surgery
[12]. Five cases of
glenohumeral chondrolysis have been reported in two separate series.
Although the exact cause of development of chondrolysis is unclear, this
condition has been most commonly reported in young patients who have undergone
shoulder reconstructive procedures to manage shoulder instability. There has
been some suggestion in the literature that glenohumeral chondrolysis may be
related to the use of thermal or radiofrequency energy within the glenohumeral
joint. One scientific study [7]
showed that marked cellular death occurs in human chondrocytes after energy
application with radiofrequency probes. However, not every reported case of
acute glenohumeral chondrolysis has been associated with exposure to thermal
energy [5,
6].
A retrospective review [13]
of 14,277 thermal procedures on the shoulder revealed no cases of chondrolysis
of the glenohumeral joint. Other causal agents in glenohumeral chondrolysis
being considered include use of a bupivacaine pump after shoulder arthroscopy,
an unknown infectious agent, and an event during arthroscopy that triggers an
immune response and subsequent migration of inflammatory cells into the
glenohumeral joint [6,
11]. Use of bioabsorbable
materials within the joint, mechanical trauma to the joint during arthroscopy,
and chemical trauma to the hyaline cartilage have been suggested as etiologic
factors that may be associated with acute chondrolysis of the glenohumeral
joint [6]. In each of our four
cases, thermal energy was used as either a primary method of capsulorrhaphy or
as an adjunct to suture capsulorrhaphy. In these cases, thermal energy may
have been an etiologic factor in chondrolysis.
In our series of patients, postoperative radiographs showed rapidly
progressive and uniform loss of the glenohumeral joint space. Diffuse
subchondral sclerosis was found on both sides of the joint. The subchondral
changes in the humeral head appeared most prominent along the medial aspect of
the humeral head opposite the superior glenoid process. Focal areas of
subchondral cortical irregularity and subchondral cyst formation were found
within both the osseous glenoid process and the humeral head. In all four
cases, there was a noticeable lack of osteophyte formation, which is a
hallmark of osteoarthritis and may be helpful in differentiating this entity
from radiographic findings of osteoarthritis.
Findings of glenohumeral chondrolysis on MRI are similar to the
radiographic findings: extensive uniform narrowing of the joint space and
extensive loss of articular cartilage on both sides of the joint. Once again,
the most important area of involvement of the humeral head is the medial
border opposite the superior aspect of the glenoid process. Cortical
irregularity can be seen on both sides of the joint, focal areas of both
increased and decreased T2-weighted signal intensity corresponding to focal
areas of low T1-weighted signal intensity. These areas of subchondral change
in signal intensity likely represent areas of subchondral marrow edema and
sclerosis. A small joint effusion was present in a single case, but no
intraarticular debris or loose intraarticular body was identified, and no
evidence of synovitis was found on MRI. It is generally accepted that MRI with
a highfield-strength magnet more accurately depicts articular cartilage
abnormalities. In our cases, however, diffuse chondral loss coupled with
underlying cortical irregularity and changes in signal intensity in the
subchondral marrow were adequately depicted with a low-field-strength magnet,
and we confidently established the diagnosis of chondrolysis of the
glenohumeral joint.
Because radiography and MRI showed similar findings in glenohumeral
chondrolysis after arthroscopy, radiography alone appears adequate for
establishing the diagnosis in the proper clinical setting. However, the main
differential possibilities in this clinical setting are those of infectious
versus reactive synovitis. These entities typically manifest as a thickened,
enhancing capsule, large joint effusion, cartilage loss, subchondral cyst
formation and erosions, and MRI may be helpful in differentiating chondrolysis
and infectious synovitis if there is clinical concern about infection
[14]. These entities were not
considered as diagnostic possibilities in our cases, so histologic evaluation
and cultures were not performed.
At times, the interpreting radiologist may not have the history of recent
arthroscopic surgery or the preoperative studies for comparison. In these
cases, the presence of centrally located chondrolysis with subchondral marrow
edema and sclerosis in the absence of osteophyte formation, a relative absence
of joint effusion, and synovitis are important imaging features that can help
differentiate chondrolysis from other entities, such as osteoarthritis,
juvenile rheumatoid arthritis, and septic arthritis.
Chondrolysis of the glenohumeral joint is a devastating postoperative
complication that can occur after shoulder arthroscopy. Radiologists should be
aware of this complication because in the proper clinical setting the
radiographic and MRI findings of chondrolysis are quite specific.
References
- Van Huyssteen AL, Bracey DJ. Chlorhexidine and chondrolysis in the
knee. J Bone Joint Surg Br 1999;81
: 995-996[CrossRef][Medline]
- Douw CM, Bulstra SK, Vandenbroucke J, Geesink RG, Vermeulen A.
Clinical and pathological changes in the knee after accidental chlorhexidine
irrigation during arthroscopy: case report and review of the literature.
J Bone Joint Surg Br 1998;80
: 437-440[CrossRef][Medline]
- Leclair A, Gangi A, Lacaze F, et al. Rapid chondrolysis after
intra-articular leak of bone cement in treatment of a benign acetabular
subchondral cyst: an unusual complication of percutaneous injection of acrylic
cement. Skeletal Radiol 2000;29
: 275-278[CrossRef][Medline]
- Rowe LJ, Ho EK. Idiopathic chondrolysis of the hip.
Skeletal Radiol 1996;25
: 178-182[CrossRef][Medline]
- Levine WN, Clark AM, D'Alessandro DF, Yamaguchi K. Chondrolysis
following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A
report of two cases. J Bone Joint Surg Am2005; 87:616
-621[Free Full Text]
- Petty DH, Jazrawi LM, Estrada LS, Andrews JR. Glenohumeral
chondrolysis after shoulder arthroscopy: case report and review of the
literature. Am J Sports Med 2004;32
: 509-515[Free Full Text]
- Caffey SC, McPerson E, Moore B, Hedman T, Vangsness CT Jr. Effects
of radiofrequency energy on human articular cartilage. Am J Sports
Med 2005; 33:1
-5
- Duncan JW, Nasca R, Schrantz J. Idiopathic chondrolysis of the hip.
J Bone Joint Surg Am 1979;61
: 1024-1028[Abstract/Free Full Text]
- Abril JC, Calvo E, Castillo F, Alvarez L. Chondrolysis of the hip
after transfer of the greater trochanter. J Pediatr
Orthop 1998; 18:242
-245[CrossRef][Medline]
- Garcia AD, Fernandez PL, Gonzalez MP, et al. Idiopathic
chondrolysis of the hip: long-term evolution. J Pediatr
Orthop 1999; 19:449
-454[CrossRef][Medline]
- Bojescul JA, Wilson G, Taylor DC. Idiopathic chondrolysis of the
ankle. Arthroscopy 2005;21
: 224-227[Medline]
- Tamai K, Higashi A, Cho S, Yamaguchi T. Chondrolysis of the
shoulder following a "color test"-assisted rotator cuff repair: a
report of two cases. Acta Orthop Scand1997; 68:401
-402[Medline]
- Wong KL, Williams GR. Complications of thermal capsulorrhaphy of
the shoulder. J Bone Joint Surg Am 2001;83
[suppl 2]:151
-155[Medline]
- Weishaupt D, Schweitzer ME. MR imaging of septic arthritis and
rheumatoid arthritis of the shoulder. Magn Reson Imaging Clin N
Am 2004; 12:111
-124[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
C. R. Chu, N. J. Izzo, C. H. Coyle, N. E. Papas, and A. Logar
The in vitro effects of bupivacaine on articular chondrocytes
J Bone Joint Surg Br,
June 1, 2008;
90-B(6):
814 - 820.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
