Shoulder osteoarthritis in elderly is increasingly being treated with total shoulder arthroplasty/ hemiarthroplasty which provides excellent functional outcome and improved implant survivorship [1]. The treatment is challenging in relatively younger patients with degenerative shoulder conditions. This patient population has higher functional demands and expectations. Moreover longer implant survivorship is warranted due to their increased life expectancy [2]. As a result, these patients require a biological and bone conserving surgery.

Case Report

Our patient is 59 years old Caucasian male who complained of increasing pain and discomfort in right shoulder which aggravated with movements of the joint. He is a construction worker who lifts heavy weighs and wanted to partially continue his work after surgery. He had no medical co-morbidities. On examination, he had decreased active and passive range of movements with palpable crepitus. Rotator cuff power was normal. Standard radiographs showed all the features of osteoarthritis including reduction in joint space, subchondral sclerosis and inferior humeral head and glenoid osteophytes. MRI showed cartilage loss in both humeral head and glenoid, and that the rotator cuff was intact.

In beach chair position, Mckenzie's approach was utilized to expose the shoulder joint. Sub acromian bursa was excised and acromioplasty was completed. Subscapularis tendon and capsule was divided and humeral head expose with external rotation. Osteophytectomy and sizing of humeral head was done. Preparation and trialling of humeral head was completed. Microfracture of glenoid was done, followed by application of a mixture of stem cell concentrate and fibrin glue over the prepared glenoid surface. Uncemented metal prosthesis was then inserted over the prepared humeral head and reduction was obtained and checked for joint stability and tension.


Shoulder arthritis is an increasing problem in the aging population. Shoulder abuse especially heavy weight lifting is a risk factor [3] for early wear as seen in our patient.

Although physical therapy and medications are the early modes of treatment, more advanced disease unresponsive to conservative treatment is managed surgically such as arthroscopic debridement, hemiarthroplasty, total shoulder replacement and more recently shoulder resurfacing [4,5,6]. Although total shoulder arthroplasty is the gold standard treatment in management of osteoarthritis, concerns of early glenoid component loosening exist especially in younger patients [7,8]. Even though the survivorship of hemiarthroplasty with stemmed implants was 97% at 5 years follow up in one series [8], around 47% of patients had unsatisfactory results. Hemiarthroplasty with glenoid reaming is an option in older patients [9,10] with increased short term revision rates in younger cohort [9].

Shoulder resurfacing is emerging as a preferable alternative in patients less than 60 years [2]. Advantages of humeral head resurfacing include minimal bone resection, a short operative time, low prevalence of humeral periprosthetic fractures, maintenance of native inclination, offset, head-shaft angle and version of the humerus [11], and an ease of revision to a conventional total shoulder replacement, if needed and ability to implant in deformed shaft. Outcomes of various surface replacement arthroplasty designs have been comparable with those of arthroplasties with a stemmed prosthesis in numerous short and mid-term follow-up studies [12,13].

Biological resurfacing of glenoid with anterior capsule autograft, fascia lata autograft, lateral meniscal allograft, and Achilles tendon allograft has been advocated in young patients with good results by some authors [14]. These results have not been reproduced in other series and they documented 44-77% failure rates [15,16,17,18]. Significant foreign body reaction with this procedure has been reported in one series [19].

Micro fracture technique has been used by many authors in various joints either through open or arthroscopic means for full thickness cartilage loss [20]. This resulted in formation of combination of fibro cartilage with hyaline like cartilage resulting in good patient outcomes [21]. This technique was used in shoulder joint in our patient.

Our patient was treated with cementless humeral resurfacing of humeral head with micro fracture of glenoid socket. Then stem cell concentrate was mixed with glue of clotting factors and was applied over the micro fractured glenoid surface. This technique of biological resurfacing is unique and is not described in any of the previous reports.


  1. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, et al. (2010) Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 19(8): 1115–1120.
  2. Bailie DS, Llinas PJ, Ellenbecker TS (2008) Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. Journal of Bone and Joint Surgery Am 90(1): 110–117.
  3. Yucesoya B, Charlesb LE, Bakera B, Burchfielb CM (2015) Occupational and genetic risk factors for osteoarthritis: A review. Work 50(2): 261– 273. doi:10.3233/WOR-131739.
  4. Norris TR and Iannotti JP (2002) Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicentre study. J Shoulder Elbow Surg 11(2): 130–135.
  5. Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU et al. (2007) Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg 16(4): 396–402.
  6. Levy O, Copeland SA (2004) Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder. Journal of Shoulder and Elbow Surgery 13(3): 266–271.
  7. Bohsali KI, Wirth MA, Rockwood CA Jr (2006) Current Concepts Review: Complications of Total Shoulder Arthroplasty. J Bone Joint Surg 88(10): 2279-2292.
  8. Bartelt R, Sperling JW, Schleck CD, Cofield RH (2011) Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg 130–123 :)1(20.
  9. Saltzman MD, Chamberlain AM, Mercer DM, Warme WJ, Bertelsen AL, et al. (2011) Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less. J Shoulder Elbow Surg 20(4): 609–615.
  10. Lynch JR, Franta AK, Montgomery WH Jr, Lenters TR, Mounce D, et al. (2007) 3rd Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming. J Bone Joint Surg Am 89(6): 1284–1292.
  11. Levy O, Copeland SA (2001) Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 83(2): 213-221.
  12. Rachbauer F, Ogon M, Wimmer C, Sterzinger W, Huter B (2000) Glenohumeral osteoarthrosis after the Eden-Hybbinette procedure. Clin Orthop Relat Res 373: 135–140.
  13. Alizadehkhaiyat O, Kyriakos A, Singer MS, Frostick SP (2013) Outcome of Copeland shoulder resurfacing arthroplasty with a 4-year mean follow-up. J Shoulder Elbow Surg 22(10): 1352–1358.
  14. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ (2007) Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes. J Bone Joint Surg Am 89(4): 727–734.
  15. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ (2009) Softtissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am 91(2): 419–424.
  16. Namdari S, Alosh H, Baldwin K, Glaser D, Kelly JD (2011) Biological glenoid resurfacing for glenohumeral osteoarthritis: A systematic review. J Shoulder Elbow Surg 20(7): 1184–1190.
  17. Strauss EJ, Verma NN, Salata MJ, McGill KC, Klifto C, et al. (2014) The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elbow Surg 23(3): 409–419.
  18. Wirth MA (2009) Humeral head arthroplasty and meniscal allograft resurfacing of the glenoid. J Bone Joint Surg Am 91(5): 1109–1119.
  19. Namdari S, Melnic C, Huffman GR (2013) Foreign body reaction to acellular dermal matrix allograft in biologic glenoid resurfacing. Clin Orthop Relat Res 471(8): 2455–2458.
  20. Solheim E, Øyen J, Hegna J, Austgulen OK, Harlem T, et al. (2010) Microfracture treatment of single or multiple articular cartilage defects of the knee; a 5 year median follow up of 110 patients. Knee surg sports traumatol arthrosc; 18(4):504-508.
  21. Bae DK, Yoon KH, Song SJ (2006) Cartilage healing after microfracture in osteoarthritis of knee. Arthroscopy 22(4): 367-374.