Were You Told You Have Bone Loss in Your Shoulder? You May Also Have Cartilage Loss — and That Changes the Treatment.
When a patient dislocates their shoulder repeatedly, the evaluation almost always focuses on one measurement: how much bone has been lost from the glenoid socket. That measurement is important. It determines whether a soft tissue repair is sufficient or whether a bone block procedure is needed. It guides the surgical plan and predicts the risk of re-dislocation.
But bone loss and cartilage loss are not the same thing — and they are not addressed by the same solution.
Every shoulder dislocation causes the humeral head to impact the front rim of the glenoid with tremendous force. That impact erodes bone and cartilage simultaneously. The bone loss is visible on CT scan and drives the surgical decision-making. The cartilage loss — which is just as real, just as significant, and just as permanent — receives far less attention. When a stabilization procedure restores the bony rim of the glenoid without restoring the cartilage that normally covers it, the result is an anatomically incomplete joint surface. Bone contacts cartilage where cartilage should contact cartilage. Over 10 to 20 years, that incongruence produces arthritis.
Stabilizing the shoulder is a critical goal. Preserving the joint for the next two decades is an equally important one — and it requires a surgeon who is thinking about both from the beginning.
Dr. Raffy Mirzayan has been performing fresh osteochondral allograft transplantation — the transplantation of living donor cartilage and bone to restore damaged joint surfaces — since 2006, beginning in the elbow and expanding to the knee and shoulder. With more than 350 total cartilage transplantation procedures performed across multiple joints, he brings a depth of experience with this technique that is available at very few centers. His approach to shoulder instability is grounded in joint preservation: restoring not just the bony architecture of the shoulder, but the cartilage surface that makes it last.
Call (310) 746-5918 to schedule a consultation. Virtual consultations are available for patients traveling from out of state.
Understanding the Problem: Bone and Cartilage Loss in the Shoulder
Cartilage injuries in the shoulder are far less common than in the knee — and far less well understood, even among orthopedic surgeons who treat shoulder instability regularly. They arise most commonly in two clinical contexts.
Recurrent shoulder instability with glenoid and humeral head bone and cartilage loss
The glenoid — the shallow socket of the shoulder blade — is lined with articular cartilage that provides a smooth, low-friction surface for shoulder motion. When the shoulder dislocates repeatedly, the humeral head impacts the anterior glenoid rim, eroding both the bone and its overlying cartilage. CT scanning measures the bone loss. What it does not capture is the cartilage loss that accompanies it — and that cartilage, unlike bone, does not regenerate on its own.
The Hill-Sachs lesion on the humeral head — the dent created by impaction during dislocation — involves the same combined bone and cartilage deficit. A large Hill-Sachs lesion is not just a mechanical engagement problem. It is a cartilage defect that will continue to cause wear against the glenoid surface with every shoulder movement for the rest of the patient's life.
When bone loss is addressed with a coracoid transfer or bone block procedure — the Latarjet, Bristow, or distal tibial allograft — and the cartilage deficit is not addressed, the reconstruction is structurally sound but biologically incomplete. The patient is stable. But the joint is not fully preserved.
Focal cartilage defects and early arthritis
A smaller group of patients develops focal cartilage damage in the shoulder from causes other than instability — direct trauma, osteochondritis dissecans, avascular necrosis, or early degenerative changes isolated to one surface of the joint. These patients are typically too young and too active for shoulder replacement, and are poorly served by the limited cartilage restoration options traditionally available in the shoulder.
For both groups, fresh osteochondral allograft transplantation offers something no other technique can: restoration of the joint surface with living, matched donor cartilage and bone — the same approach that has transformed cartilage surgery in the knee.
Dr. Mirzayan's Approach: Fresh Osteochondral Allograft Transplantation in the Shoulder
Fresh osteochondral allograft transplantation is well established in the knee. Dr. Mirzayan has performed more than 350 such procedures, including his invented BioPFJ™ technique for the patellofemoral joint and his pioneering work as the first surgeon in the world to use this technique for OCD of the capitellum in the elbow, beginning in 2006. Translating this approach to the shoulder requires a different technical skill set and a deep understanding of shoulder anatomy — but the biological principle is identical. A precisely sized and matched graft of fresh donor cartilage and underlying bone is transplanted to the deficient area, restoring the joint surface with living tissue that integrates with the patient's own bone and provides a durable, low-friction cartilage surface.
Glenoid reconstruction addresses the anterior glenoid bone and cartilage deficit created by recurrent instability. Dr. Mirzayan uses a distal tibial allograft — whose articular surface closely matches the curvature of the glenoid — to reconstruct the socket with anatomically appropriate cartilage-bearing tissue. The result is a glenoid that is not just structurally restored but surfaced with living cartilage, providing the kind of anatomic reconstruction that a bone-only transfer cannot achieve. Dr. Mirzayan demonstrated this technique in a surgical video produced by Arthrex: Cartiform Osteochondral Allograft Glenoid Implant — Arthrex Surgical Video
Humeral head reconstruction addresses the Hill-Sachs lesion — the combined cartilage and bone defect on the back of the humeral head. In large or off-track lesions, fresh osteochondral allograft transplantation restores the articular surface of the humeral head with biologically matched tissue — a more anatomic solution than filling the defect with capsular tissue alone.
Combined bipolar reconstruction addresses both the glenoid and humeral head simultaneously in patients with significant bone and cartilage loss on both sides of the joint. This is technically demanding surgery that requires expertise in both shoulder instability reconstruction and osteochondral allograft transplantation — a combination available at very few centers in the country.
Dr. Mirzayan has described his approach to fresh osteochondral allograft transplantation in the shoulder in a peer-reviewed journal publication and two book chapters, contributing to the growing literature on this emerging area of shoulder surgery:
Osteochondral Allograft Transplantation in the Shoulder — Peer-Reviewed Journal Publication
Fresh Osteochondral Allograft Transplantation in the Shoulder — ISAKOS Textbook Chapter
Shoulder Cartilage Restoration — Springer Book Chapter, Volume 1
Shoulder Cartilage Restoration — Springer Book Chapter, Volume 2
Clinical Results: Dr. Mirzayan's Personal Series
Dr. Mirzayan has been performing fresh osteochondral allograft transplantation in the shoulder since 2011 — among the earliest surgeons in the country to apply this technique systematically to shoulder instability and cartilage loss. His personal series spans more than 14 years and includes patients treated for recurrent instability with glenoid and humeral head cartilage loss, focal humeral head defects, posterior glenoid arthritis, and failed prior instability surgery including failed Latarjet reconstruction.
In patients with available follow-up data, the results have been outstanding across every measure. ASES scores — the gold standard functional outcome measure for the shoulder — ranged from 91 to 100. SANE scores ranged from 85 to 100. VAS pain scores at follow-up were 0 to 1 in virtually every patient. There were zero re-dislocations and zero re-operations in any patient with available follow-up data.
One patient treated for shoulder arthritis presented with a preoperative VAS pain score of 8 out of 10 and a SANE score of 65 — significant pain and functional limitation. Following humeral head osteochondral allograft transplantation, his VAS was 0, his SANE was 90, and he described himself as very satisfied. This outcome — dramatic pain relief and functional restoration in a patient who was too young for replacement — illustrates precisely what joint preservation surgery can achieve when it is applied to the right patient at the right time.
Formal publication of this series is in preparation.
Who Is a Candidate?
Patients with recurrent shoulder instability and significant glenoid bone and cartilage loss who want a reconstruction that addresses the full anatomic deficit — bone and cartilage together — rather than the structural component alone.
Patients who have failed prior instability surgery, including failed Latarjet procedures, in whom standard options have been exhausted and a more anatomic reconstruction is needed. Dr. Mirzayan has performed this procedure successfully in the revision setting.
Young, active patients with focal humeral head cartilage defects from any cause — trauma, osteochondritis dissecans, avascular necrosis — who are too young and too active for shoulder replacement and want a biological solution that preserves their native joint.
Patients with early, isolated shoulder arthritis in whom joint replacement is premature and cartilage restoration offers the potential to delay or avoid replacement entirely.
What to Expect: Surgery and Recovery
Shoulder osteochondral allograft transplantation is performed as an outpatient procedure under general anesthesia. The surgical approach — open or arthroscopic-assisted depending on the location and extent of the defect — allows precise preparation of the recipient site and secure press-fit insertion of the donor graft. When combined with instability reconstruction, both procedures are performed in the same operative setting.
Recovery follows a staged protocol designed to protect the healing graft while progressively restoring motion and strength. The shoulder is protected in a sling initially, with range of motion beginning in the first weeks under physical therapy guidance. Strengthening progresses over the following months, and return to full activity — including overhead sport and physical labor — typically occurs between 6 and 9 months depending on the extent of reconstruction. Dr. Mirzayan will give you a personalized recovery timeline based on your specific anatomy, the procedures performed, and your activity goals.
Coming from Las Vegas, Phoenix, or Out of State?
Fresh osteochondral allograft transplantation in the shoulder is performed at a very small number of centers in the United States. The combination of instability reconstruction expertise and cartilage transplantation experience required to perform this procedure safely and effectively is genuinely rare. Dr. Mirzayan has been performing this technique in the shoulder since 2011, has contributed to the peer-reviewed literature on the topic, and brings more than 350 total osteochondral allograft procedures across the knee, elbow, and shoulder to every case.
For patients who want a more anatomic, joint-preserving approach to their instability reconstruction — or who have been told their only option after failed instability surgery is a shoulder replacement — a consultation with Dr. Mirzayan is worth pursuing before accepting that conclusion.
If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have strong out-of-network benefits. His office will verify your coverage before you commit to anything. Many patients find the out-of-pocket cost of traveling to Los Angeles for the right surgeon is comparable to — or less than — what they would pay locally for in-network care.
Virtual consultations are available. Please submit your MRI and CT imaging in advance so that bone loss can be quantified and the appropriate surgical plan discussed before your visit.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is the difference between bone loss and cartilage loss in the shoulder?
Bone loss refers to the erosion of the bony rim of the glenoid socket that occurs with repeated shoulder dislocations. It is measured on CT scan and is the primary driver of surgical decision-making in instability cases. Cartilage loss refers to the erosion of the articular cartilage that covers that bone — which occurs simultaneously with bone loss but is not captured on standard CT measurements. Restoring the bone without restoring the cartilage leaves the joint surface anatomically incomplete, with bare bone contacting cartilage during shoulder motion. Over time this produces arthritis. Dr. Mirzayan's approach addresses both deficits together.
Is fresh osteochondral allograft transplantation established in the shoulder?
It is an emerging technique that is well established in principle — the same biological approach that has been used successfully in the knee for decades — but applied to the shoulder by a small number of surgeons with the relevant experience. Dr. Mirzayan has been performing this technique in the shoulder since 2011 and has contributed to the peer-reviewed literature on the topic through book chapters in the ISAKOS textbook and Springer surgical reference series.
Can this be done at the same time as my instability surgery?
Yes — and in most cases, that is the preferred approach. Addressing the cartilage deficit at the time of the stabilization procedure avoids a second surgery and ensures that the joint is fully reconstructed from the outset rather than requiring revision surgery later.
Can this be done if I have already had a Latarjet that failed?
Yes. Dr. Mirzayan has performed fresh osteochondral allograft reconstruction in patients with failed Latarjet procedures, restoring both stability and joint surface integrity in a revision setting. Revision instability surgery requires detailed imaging analysis — including CT scan for bone loss quantification — before a plan can be made, but failed prior surgery is not a disqualifying factor.
Is there a risk of rejection with donor cartilage?
No. Cartilage is immunologically privileged tissue — the chondrocytes within the cartilage matrix are protected from immune recognition. In Dr. Mirzayan's shoulder series spanning more than 14 years, there have been no graft rejections and no re-operations for graft failure.
Am I too young for this procedure?
This procedure is specifically designed for patients who are too young and too active for shoulder replacement. The typical candidate is in their teens, 20s, 30s, or 40s — an age group for whom replacement is premature and the long-term consequences of an anatomically incomplete repair are most significant.
Do you offer virtual consultations for out-of-state patients?
Yes. Please submit your MRI and CT imaging in advance so that bone loss can be quantified and the appropriate surgical plan discussed before your visit. Call (310) 746-5918 to schedule.
Does being out-of-network mean I will pay full price out of pocket?
Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon and one of the earliest and most experienced surgeons in the United States performing fresh osteochondral allograft transplantation in the shoulder. He has been applying this technique to shoulder instability and cartilage loss since 2011 — drawing on more than 350 total osteochondral allograft procedures across the knee, elbow, and shoulder — and has contributed to the peer-reviewed literature on shoulder cartilage restoration through book chapters published in the ISAKOS textbook and Springer surgical reference series. His approach is grounded in a principle that guides every instability case he treats: stabilizing the shoulder is the first goal; preserving the joint for the next 20 years is the goal that matters most. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
