Arthroscopic bone graft procedure for anterior inferior glenohumeral instability

Glenoid track revisited

The risk of Hill-Sachs lesion (HSL) to cause instability depends not only on the HSL but also on the glenoid size. Clinically, the only method to assess the risk of instability considering the dynamic interaction of both, the HSL together with the glenoid bone loss, is the glenoid track concept. Since it was introduced in a cadaveric study, its clinical efficacy and validity have been reported in the literature. Sometimes, the medial margin of the footprint (lateral margin of the glenoid track) is difficult to identify when a HSL is overriding the footprint. In such cases, we propose a method to draw an imaginary line connecting 2 landmarks. Although 3-dimensional computed tomography is the most accurate and widely used method to assess on/off-track lesions, our interest gradually is shifting toward magnetic resonance imaging (MRI), which has no radiation concern. The current magnetic resonance method is still under way. There are various risk factors influencing the recurrent instability after surgery. The glenoid track concept deals with only 1 of these factors, that is, instability caused by bony lesions. Therefore, the following 2 issues are important: 1) how to assess the glenoid track precisely and 2) how to incorporate other risk factors into consideration. The former can be achieved by obtaining the custom-made glenoid track width using not the fixed value of 83%, but more individualized value obtained by measuring the active horizontal extension angle of the opposite shoulder in the sitting position. At the same time, the gray zone (peripheral-track lesion) needs to be clearly defined. The latter can be achieved by incorporating the risk factors other than the bony lesions. One example is the Glenoid Track Instability Management Score (GTIMS), a combination of the glenoid track concept and the instability severity index score. This new scoring system is expected to increase the predictive potential of the scoring system, and accordingly to enhance clinical decision-making.

Management of bone loss in anterior shoulder instability

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Current Evidence and Techniques for Arthroscopic Bone Augmentation

The indications for bone block augmentation of the glenoid following recurrent anterior shoulder instability are expanding. Arthroscopic anatomic glenoid reconstruction (AAGR) is an evolving technique with similar clinical results to the Latarjet procedure and other open bone block procedures. Multiple types of bone grafts and fixation techniques have been described, with varying results on bony integration, resorption, articular congruity, and recurrence rates. This review focuses on biomechanics, patient workup, indications, current evidence, and the authors' preferred surgical technique for AAGR.

Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability

BACKGROUND

Open Bankart repair and Latarjet stabilization are 2 widely used surgical procedures in the treatment of shoulder instability in contact athletes. This study evaluates the outcomes of bone block arthroscopic procedures, performed with a xenograft, in combination with Bankart repair and selective subscapularis augmentation for contact athletes with recurrent anterior shoulder instability.

METHODS

We retrospectively assessed contact athletes who underwent arthroscopic bone block with xenograft and Bankart repair with selective augmentation of the subscapularis for recurrent anterior shoulder instability between January 2017 and December 2021. Shoulders with posterior instability or multidirectional instability were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score, Western Ontario Shoulder Instability index [WOSI] score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form ASES score) were assessed. A computed tomography scan at 2-year follow-up was performed to assess the status of bone block integration, its displacement and restoration of glenoid surface.

RESULTS

Sixteen patients with a mean age of 24 years were included in the study. None of the patients treated with arthroscopic bone block and subscapularis augmentation presented new dislocation episodes. An increase in preoperative scores was observed at the last follow-up; in particular, the ASES, Rowe, and WOSI scores increased from 69 ± 7, 31 ± 9, and 1235 ± 46, respectively, to 96.1 ± 3.2, 94 ± 6, and 119 ± 51. All athletes returned to sporting activity at or near the same level as presurgery. The glenoid bone surface increase from 83% to 116% at the last follow-up.

CONCLUSION

Bone block treatment with xenograft combined with Bankart repair and arthroscopic subscapularis augmentation procedures has been shown to be effective in treating instability in contact athletes with significant glenoid deficit. All athletes returned to athletic activity at a level similar to the preintervention period.

Controversies in surgical management of anterior shoulder instability. State of the Art

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

Arthroscopic Posterior Glenoid Reconstruction With Distal Clavicle Bone-Block

Posterior glenoid bone loss is a potential cause for failure in arthroscopic capsulolabral repair. Although multiple techniques have been described to reconstruct posterior bone defects, they do not reliably yield improved patient outcomes and have high complication rates. We present a technique to reconstruct posterior glenoid bone loss using a distal clavicle autologous bone graft harvested by a mini-open approach and secured arthroscopically with suture buttons. The graft is positioned extra-articularly by repairing the posterior labral complex with a knotless fixation using labral tape.

Suspensory fixation for bone transfer procedures in shoulder instability is superior to screws in an angled construct: a biomechanical analysis

Background

The Latarjet procedure is a common bony augmentation procedure for anterior shoulder instability. Historically, screw fixation is used to secure the coracoid graft to the anterior glenoid surface; however, malpositioning of the graft leads to oblique screw insertion that contributes to complications. Suture buttons (SBs) are a more recent fixation technique that have not been studied alongside standard screw fixation in the context of biomechanical models of angulated fixation. This study aims to compare the biomechanical strength of single and double, screw and SB fixation at various levels of angulation.

Methods

Testing was performed using polyurethane models from Sawbones. The graft piece was secured with screw fixation (Arthrex, Naples, FL, USA) or suspensory button (ABS Tightrope, Arthrex, Naples, FL, USA). Single or double constructs of screws and SBs were affixed at 0°, 15°, and 30° angles to the face of the glenoid component. An aluminum testing jig held the samples securely while a materials testing system applied loads. Five constructs were used for each condition and assessed load to failure testing.

Results

For single fixation constructs, suspensory buttons were 60% stronger than screws at 0° (P < .001), and 52% stronger at 15° (P = .004); however, at 30°, both were comparable (P = .180). Interestingly, single suspensory button at 15° was equivalent to a single screw at 0° (P = .310). For double fixation, suspensory buttons (DT) were 32% stronger than screws at 0° (P < .001) and 35% stronger than screws at 15° (P < .001). Both double fixation methods were comparable at 30° (P = .061). Suspensory buttons at 15° and 30° were equivalent to double screws at 0 (P = .280) and 15° (P = .772), respectively.

Conclusion

These measurements indicate that the suspensory button has a significantly higher load to failure capacity over the screw fixation technique, perpendicularly and with up to 15° of angulation. These analyses also indicate that the suspensory button fixation offers superior strength even when positioned more obliquely than the screw fixation. Therefore, suspensory button fixation may confer more strength while offering greater margin for error when positioning the graft.

A comprehensive comparison and evaluation of surgical techniques for anterior shoulder instability: a Bayesian network meta-analysis

BACKGROUND

Anterior shoulder instability is a common clinical problem; however, conflicting evidence exists regarding optimal treatment algorithms. We perform a comparative analysis of stabilization techniques used for recurrent anterior shoulder instability to identify the one associated with the lowest rate of recurrent instability. We additionally explore how glenoid bone loss and osseus lesions affect recurrence rates.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched for clinical studies comparing surgical techniques for anterior shoulder instability. Two team members independently assessed all potential studies for eligibility and extracted data. Each included study underwent a risk of bias assessment using the Cochrane risk of bias summary tool. The primary outcome of interest was the rate of recurrent instability, which underwent a Bayesian network meta-analysis. Additional analyses were performed relating to the degree of glenoid bone loss and the presence of osseous lesions.

RESULTS

Of 2699 studies screened, 52 studies with 4209 patients were included. Patients who underwent open Latarjet demonstrated the overall lowest rate of recurrent instability [log odds ratio (LOR) 1.93], whereas patients who underwent arthroscopic Bankart repair demonstrated the highest (LOR 2.87). When glenoid bone loss was 10% to 20%, open Latarjet had significantly lower recurrent instability (P = .0016) compared to arthroscopic Bankart repair. When glenoid bone loss increased from 0%-10% to 10%-20%, arthroscopic Bankart repair had a significantly increased rate of recurrence (P = .021). In the presence of an engaging Hill-Sachs lesion, both open Latarjet (P = .01) and arthroscopic Bankart with remplissage (P = .029) had significantly reduced recurrence rates compared to arthroscopic Bankart repair. Finally, regardless of procedure, the presence of a Hill-Sachs or bony Bankart lesion was associated with an increased risk of recurrent instability (r = 0.44, P = .0003, and r = 0.40, P = .006, respectively).

CONCLUSION

The open Latarjet has the overall lowest recurrent instability and significantly lower compared to arthroscopic Bankart repair in the setting of increasing glenoid bone loss. Bone loss between 0% and 10% results in similar outcomes across all procedures.

A Systematic Review of Screw and Suture Button Glenoid Augmentation Constructs

Background

Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed.

Purpose

To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation.

Study Design

Systematic review.

Methods

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss.

Results

Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid.

Conclusion

Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.

Arthroscopic Xenograft With Cerclage Fixation: A Method for Glenoid Bone Loss Reconstruction With Cerclage Fixation Using a Specific Posterior Guide

Large glenoid bone defects are closely associated with high failure rates after arthroscopic Bankart repair in chronic anterior shoulder instability; therefore nowadays the glenoid bone grafting reconstruction procedure is strictly recommended. On the contrary, the optimal grafting procedure is still controversial because there is considerable concern about the resorption rate of allografts, donor site morbidity of the autografts, and sequelae caused by the use of metal fixation devices in proximity of the shoulder joint. We describe an all-arthroscopic technique for anatomic reconstruction of the glenoid that uses a previously shaped xenograft assembled with a metal-free fixation device using 2 ultra-high-strength sutures (FiberTape Cerclage System; Arthrex, Naples, FL), using a specific posterior guide (Arthrex, Naples, FL) in combination with upper third subscapularis augmentation.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer

PURPOSE

Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts.

METHODS

A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded.

RESULTS

177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.).

CONCLUSION

The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates.

LEVEL OF EVIDENCE

Level II.

Arthroscopic Subscapularis Augmentation With Xenograft Glenoid Bone Block in Patients With Recurrent Anterior Shoulder Instability

Introduction

The purpose of this study was to investigate the clinical and radiographic outcomes at 2 years for patients who underwent an arthroscopic xenograft bone block procedure plus ASA for recurrent anteroinferior gleno-humeral instability.

Methods

This retrospective study was conducted on patients affected by chronic anteroinferior shoulder instability. The inclusion criteria were as follows: patients must be aged 18 years or older; have recurrent anteroinferior shoulder instability, a glenoid defect >10%, assessment by the Pico area measurement system, anterior capsular insufficiency, and an engaging Hill-Sachs lesion. The exclusion criteria were as follows: multidirectional instability, glenoid bone defect <10%, arthritis, and minimum follow-up less than 24 months. Clinical outcomes were evaluated according to Western Ontario Shoulder Instability Index (WOSI) and Rowe scale. Computed tomography (CT) results were evaluated to assess any signs of resorption or displacement of the xenograft at 24 months follow-up.

Results

Twenty patients that met all the inclusion criteria underwent arthroscopic xenograft bone block procedure and ASA. The mean preoperative Rowe score was 38.3 points, and it significantly improved (P < .001), increasing to 95.5 points. ROWE level at follow-up was excellent for 18 patients (90%), fair for 1 patient (5%), and poor for another patient (5%). The mean preoperative WOSI score was 1242 points, and it improved significantly (P <.0001), with a mean score of 120 points at follow-up. In all patients, the comparative study between CT scans performed postoperatively and at final follow-up did not reveal a volume reduction of the xenografts (P > .05) and absence areas affected by signs of resorption and breakage with 34.4% of postprocedural increase of the glenoid surface, were seen.

Conclusions

The combination of ASA and bone block procedure with a xenograft was effective in the glenoid reconstruction and restoration of shoulder stability. No radiographic evidence of graft resorption, graft displacement, or glenohumeral arthritis were observed at 24-month follow-up.

Level of Evidence

Level IV, therapeutic case series.

[Management of a multifragmentary glenoid fracture : Case report of a two-stage surgical procedure]

This article describes a multifragmentary glenoid fracture in a 65-year-old patient after falling from a height of 2 m. The accident led to complete Y‑shaped destruction of the glenohumeral joint with a large posteroinferior fragment and a large anteroinferior glenoid fragment. The treatment consisted of a two-stage surgical procedure and a combination of open and arthroscopic techniques. First, open surgery of one fragment from the dorsal side was performed using screw osteosynthesis. Arthroscopic refixation of the anterior glenoid fragment (bony Bankart lesion) followed 4 weeks later using a guided Endobutton® technique (Smith & Nephew). Ideberg type 6 multifragmentary glenoid fractures are rare and should be treated surgically, especially with dislocated fragments, instability in the glenohumeral joint and in younger patients. Given the lack of evidence in the literature, individual surgical strategies are necessary.

Evaluation of the inter and intraobserver reproducibility of the "defect coverage index method", a new computed tomography assessment method of sagittal graft positioning in arthroscopic bone block procedures

PURPOSE

To assess the reproducibility of a new 2-dimensional computed tomography (CT) method of assessing graft positioning in arthroscopic bone block procedure.

METHODS

This is a prospective observational study. Twenty-seven patients, (all men, mean [Standard deviation] age at surgery 30.9 [8.49] years) were included. Vertical graft position was assessed on the sagittal view by measuring the amount of glenoid bone defect covered by the graft. The length of the bone defect and the amount of graft covering the defect were measured. Positioning of the graft on the sagittal plane was classified as accurate if the graft covered at least 90% of the defect. Intraobserver and interobserver reproducibility was analyzed using intraclass correlation coefficients (ICC) and Kappa coefficient with 95% confidence.

RESULTS

Excellent intraobserver reproducibility was found, with an ICC of 0.94 (CI 95%, 0.86-0.97). Interobserver reproducibility was good, with the ICC value of 0.71, ranging from 0.45 to 0.86 (CI 95%).

CONCLUSION

This new method of assessing graft positioning in arthroscopic bone block procedures on 2-dimensional computed tomography scans is reliable, with an excellent intraobserver and good interobserver reproducibility.

LEVEL OF EVIDENCE

III.

Arthroscopically Assisted Anterior Bone Block for Shoulder Instability

Background:

Shoulder instability is a common complaint, with treatment depending on the severity of the bony defect. Advancements in arthroscopic techniques have allowed for a less invasive surgery with decreased postoperative pain, improved graft placement, and better visualization.

Indications:

Large bony defects of the glenoid require bone block augmentation to reduce recurrent instability. In this presentation, arthroscopically assisted anterior bone block was performed with a distal tibial allograft to address recurrent anterior shoulder instability with a large glenoid defect.

Technique Description:

The patient is placed in a lateral decubitus position. Standard arthroscopic portals are made. The bone block is fashioned from a distal tibial allograft. Using a guide, drill holes are placed in the bone block. The guide is inserted from the posterior portal and placed parallel to the joint surface. Using drill sleeves, superior and inferior screw holes are drilled and a metal cannula is left in place to allow for shuttling of suture. Two anchors are placed on the glenoid to allow for capsule labral junction to be brought up to the graft once the graft is in place. The bone block is delivered through a dilated anterior portal and reduced. The sutures are tensioned. A button is placed on each set of looped sutures, a Nice knot is placed into each, and a tensioning device is tensioned. Once compression is achieved, knots are tied to perform final fixation over the buttons. A suture passing device is used to grab inferior capsule and labrum to the priorly placed anchor on the inferior glenoid and tied.

Results:

Arthroscopically assisted anterior bone block for shoulder instability has been demonstrated to have similar clinical and radiographic outcomes when compared with open treatment. However, arthroscopically assisted Latarjet has been shown to have decreased soft tissue disruption and possible improvements in graft placement.

Discussion/Conclusion:

Arthroscopically assisted anterior bone block is a technically demanding surgery but has been shown to have similar outcomes when compared with open treatment. In this video, we demonstrate an arthroscopically assisted anterior bone block for recurrent anterior shoulder instability.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Autologous Iliac Crest Grafting Results in Similar Outcomes and Low Recurrence Compared to Remplissage Plus Bankart Repair for Anterior Shoulder Instability With Bipolar Bone Defects

PURPOSE

To compare the functional outcomes, range of motion (ROM), recurrence rates, and complication rates of arthroscopic autologous iliac crest grafting (AICG) and Remplissage plus Bankart repair (RB) for anterior shoulder instability with bipolar bone defects.

METHODS

This study enrolled patients undergoing arthroscopic AICG or RB with 13.5-25% glenoid bone defect combined with Hill-Sachs lesion between January 2013 and April 2020, who had a minimum 2-year follow-up. Patient-reported outcomes were evaluated by Subjective Shoulder Value (SSV), Oxford Shoulder Instability Score (OSIS), Rowe score, Constant score, and visual analog scale (VAS) for pain. Active ROM, return to sports, recurrence, self-reported apprehension, and complications were recorded.

RESULTS

This study included 60 patients, including 28 AICG (Group A) and 32 RB (Group R). Mean glenoid bone defect was similar (17.7% ± 3.1% vs 16.6% ± 2.4%; P = .122). Both groups showed significant postoperative improvement in Rowe score, SSV, OSIS, and Constant score. No significant difference was found in postoperative Rowe Score (87.7 vs 85.2; P = .198). A total of 20/28 (71.4%) patients in Group A versus 26/32 (81.3%) patients in Group R met the Patient Acceptable Symptomatic State determined by VAS pain score (P = .370). Both groups showed high return-to-sports rates (67.8% vs 71.8%; P = .735) and slightly decreased ROM. There were two cases of recurrence in Group A versus one in Group R (P = .594). Group R had insignificantly higher positive self-reported apprehension rate (40.6% vs 17.9%; P = .055).

CONCLUSION

For anterior shoulder instability with bipolar bone defects, both arthroscopic AICG and RB can result in satisfactory clinical outcomes, good postoperative ROM, and low recurrence and complication rates.

LEVEL OF EVIDENCE

Level III; retrospective cohort study.

CT-scan Evaluation of Osteointegration and Osteolysis in Different Graft Types and Surgical Techniques for the Treatment of Shoulder Instability

Background

Bone graft is often needed in treating anterior shoulder instability in glenoid bone loss and graft integration is crucial in achieving good results. This study aimed to evaluate bone graft remodeling in different techniques for shoulder anterior-inferior instability.

Methods

Graft osteointegration and osteolysis were retrospectively evaluated with CT-scan imaging performed 6 to 12 months after surgery to compare the outcome of three procedures: Latarjet, bone block with allograft, and bone block with xenograft. Screw fixation and double endobuttons fixation were also compared.

Results

CT scans of 130 patients were analyzed. Of these, 30 (23%) were performed after the bone block procedure with xenograft and endobuttons fixation, 55 (42%) after the bone block procedure with allograft and endobuttons fixation, 13 (10%) Latarjet with screw fixation and 32 (25%) Latarjet with endobuttons fixation. The prevalence of osteolysis was significantly inferior (P<.01) in the bone block procedure compared to the Latarjet procedure (11.7 % vs. 28.8 %). Bone integration was higher in bone block procedures (90.5%) than in Latarjet (84.4%), but the difference was not statistically significant. Among the Latarjet procedures, endobuttons fixation resulted in a higher integration rate (87.5% vs. 73.6%) and lower osteolysis rate than screw fixation (24.6% vs. 38.5%), despite these differences did not reach a statistical significance. Among the bone block procedures, using a xenograft resulted in a lower osteolysis rate (6.7%) than an allograft (14.5%), but the result was not statistically significant.

Conclusion

This study shows a significantly lower rate of graft osteolysis after bone block procedures compared to Latarjet procedure between 6 and 12 months postoperatively. Moreover, our findings suggest good results in osteolysis and graft integration with xenograft compared to allograft and double endobuttons fixation compared to screw fixation, despite these differences being not-significant. Further studies on this topic are needed to confirm our results at a longer follow-up and thoroughly investigate the clinical relevance of these findings.

Morphometric and Biomechanical Comparison of the Scapular Spine and Coracoid Graft in Anterior Shoulder Instability

BACKGROUND

The scapular spine has been described as a relatively new bone graft alternative used in glenoid augmentation. The classic Latarjet procedure, which transfers the coracoid as a graft, is regarded as the gold standard. The comparison of these 2 techniques has not been fully reported.

PURPOSE

To compare the anatomic and biomechanical properties of glenoid augmentation using scapular spine graft or coracoid graft.

STUDY DESIGN

Controlled laboratory study.

METHODS

The study used 20 fresh-frozen human cadaveric shoulders. A 25% anterior glenoid defect was created, and the specimens were divided randomly to receive glenoid augmentation by scapular spine or coracoid grafts. For both procedures, the grafts were secured to the glenoid defect with 2 screws. Morphometric data, including the glenoid articular area, amount of restoration, and graft dimensions, were obtained. A biomechanical test was conducted in a direct-loading scenario. The construct stiffness, cyclic displacement, and ultimate failure of each specimen were collected.

RESULTS

No significant difference was found in glenoid articular restoration between the scapular spine group and the coracoid group (31% vs 33%, respectively; P = .311). Morphometric analysis indicated that coracoid grafts exhibited significantly greater thickness and height than scapular spine grafts. In biomechanical results, the scapular spine group exhibited significantly greater construct stiffness than the coracoid group (206.3 ± 58.8 vs 148.3 ± 76.0 N/mm, respectively; P = .023). The average failure load in the scapular spine group was not significantly higher than that in the coracoid group. No significant differences in cyclic displacement were found between the 2 techniques.

CONCLUSION

In a simulated 25% anterior glenoid bony defect, a scapular spine graft was comparable with the classic Latarjet procedure in restoring the glenoid articular dimension and exhibited superior construct stiffness in a cadaveric model.

CLINICAL RELEVANCE

The scapular spine may serve as an alternative graft choice in glenoid augmentation surgery considering the amount of articular restoration and initial fixation stability.

Open latarjet procedure versus all-arthroscopic autologous tricortical iliac crest bone grafting for anterior-inferior glenohumeral instability with glenoid bone loss

PURPOSE

The purpose of this study is to compare the open Latarjet procedure versus the all-arthroscopic autologous tricortical iliac crest bone grafting (AICBG) technique for recurrent anterior-inferior glenohumeral instability with glenoid bone loss.

METHODS

All open Latarjet and AICBG procedures for recurrent anterior-inferior shoulder instability with glenoid bone loss performed at two institutions between September 2015 and April 2019 were retrospectively analyzed. Inclusion criteria were a traumatic etiology, a glenoid surface deficiency >13.5%, and a minimum follow-up (FU) of 18 months. Primary outcomes included the subjective shoulder value, the Western Ontario Shoulder Instability (WOSI), Rowe scores including subdomains, and the four subdomains of the Constant score (pain, activities of daily living, internal rotation, external rotation). Secondary outcomes were subjective shoulder instability, EQ-5D-3 L, pain level on the VAS, level of overall satisfaction, operative time, return-to-work rate, and return-to-sports rate.

RESULTS

Forty-three patients were available for final analysis (Latarjet: n = 21; AICBG: n = 22) at an average FU of 34.9 months (range, 22-66 months). Both techniques provided good outcomes and improved stability. The Rowe score, Rowe-range of motion, and CS-internal rotation (p = 0.008, p<0.001, p = 0.001) were slightly better in the AICBG group. Furthermore, the WOSI physical symptoms subdomain was significantly better (p = 0.04) in the AICBG group, while its total score did not reach statistical significance (p = 0.07). There was no statistically significant difference in the secondary outcomes besides operative time, which was significantly shorter in the Latarjet procedure group (p = 0.04). Overall complication rate was similar in both groups (Latarjet: 9.5% (n = 2), AICBG: 9.1% (n = 2)).

CONCLUSION

Open Latarjet and AICBG procedures provide comparable clinical outcomes except for significantly better Rowe score, Rowe-range of motion, WOSI physical symptoms subdomain, and internal rotation capacity in the AICBG group. However, these results should be carefully interpreted in the context of known minimal clinically important differences of these scores.

Arthroscopic Allograft Bone Block Procedure with Remplissage for Bipolar Lesions

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankart repair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performed in conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that include reduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complications while preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromised outcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of "sling effect" with free bone graft reconstruction.

Arthroscopy with subscapularis upper one-third tenodesis for treatment of recurrent anterior shoulder instability independent of glenoid bone loss

BACKGROUND

Recurrent anterior shoulder instability is a common traumatic injury, the main clinical manifestation of which is recurrent anteroinferior dislocation of the humeral head. The current follow-up study showed that the effect of arthroscopic Bankart repair is unreliable.

AIM

To evaluate the clinical efficacy of arthroscopy with subscapularis upper one-third tenodesis for treatment of anterior shoulder instability, and to develop a method to further improve anterior stability and reduce the recurrence rate.

METHODS

Between January 2015 and December 2018, male patients with recurrent anterior shoulder instability were selected. One hundred and twenty patients had a glenoid defect < 20% and 80 patients had a glenoid defect > 20%. The average age was 25 years (range, 18–45 years). Patients with a glenoid defect < 20% underwent arthroscopic Bankart repair with a subscapularis upper one-third tenodesis. The patients with a glenoid defect > 20% underwent an arthroscopic iliac crest bone autograft with a subscapularis upper one-third tenodesis. All patients were assessed with Rowe and Constant scores.

RESULTS

The average shoulder forward flexion angle was 163.6° ± 8.3° and 171.8° ± 3.6° preoperatively and at the last follow-up evaluation, respectively. The average external rotation angle when abduction was 90° was 68.4° ± 13.6° and 88.5° ± 6.2° preoperatively and at the last follow-up evaluation, respectively. The mean Rowe scores preoperatively and at the last follow-up evaluation were 32.6 ± 3.2 and 95.2 ± 2.2, respectively (P < 0.05). The mean Constant scores preoperatively and at the last follow-up evaluation were 75.4 ± 3.5 and 95.8 ± 3.3, respectively (P < 0.05). No postoperative dislocations were recorded by the end of the follow-up period.

CONCLUSION

Arthroscopy with subscapularis upper one-third tenodesis was effective for treatment of recurrent anterior shoulder instability independent of the size of the glenoid bone defect, enhanced anterior stability of the shoulder, and did not affect postoperative range of motion of the affected limb.

Comparison of the Coracoid, Distal Clavicle, and Scapular Spine for Autograft Augmentation of Glenoid Bone Loss: A Radiologic and Cadaveric Assessment

BACKGROUND

Glenohumeral instability caused by bone loss requires adequate bony restoration for successful surgical stabilization. Coracoid transfer has been the gold standard bone graft; however, it has high complication rates. Alternative autologous free bone grafts, which include the distal clavicle and scapular spine, have been suggested.

STUDY DESIGN

Controlled laboratory study.

PURPOSE

The purpose of this study was to determine the percentage of glenoid bone loss (GBL) restored via coracoid, distal clavicle, and scapular spine bone grafts using a patient cohort and a cadaveric evaluation.

METHODS

Autologous bone graft dimensions from a traditional Latarjet, congruent arc Latarjet, distal clavicle, and scapular spine were measured in a 2-part study using 52 computed tomography (CT) scans and 10 unmatched cadaveric specimens. The amount of GBL restored using each graft was calculated by comparing the graft thickness with the glenoid diameter.

RESULTS

Using CT measurements, we found the mean percentage of glenoid restoration for each graft was 49.5% ± 6.7% (traditional Latarjet), 45.1% ± 4.9% (congruent arc Latarjet), 42.2% ± 7.7% (distal clavicle), and 26.2% ± 8.1% (scapular spine). Using cadaveric measurements, we found the mean percentage of glenoid restoration for each graft was 40.2% ± 5.0% (traditional Latarjet), 53.4% ± 4.7% (congruent arc Latarjet), 45.6% ± 8.4% (distal clavicle), and 28.2% ± 7.7% (scapular spine). With 10% GBL, 100% of the coracoid and distal clavicle grafts, as well as 88% of scapular spine grafts, could restore the defect (P < .001). With 20% GBL, 100% of the coracoid and distal clavicle grafts but only 66% of scapular spine grafts could restore the defect (P < .001). With 30% GBL, 100% of coracoid grafts, 98% of distal clavicle grafts, and 28% of scapular spine grafts could restore the defect (P < .001). With 40% GBL, a significant difference was identified (P = .001), as most coracoid grafts still provided adequate restoration (congruent arc Latarjet, 82.7%; traditional Latarjet, 76.9%), but distal clavicle grafts were markedly reduced, with only 51.9% of grafts maintaining sufficient dimensions.

CONCLUSIONS

The coracoid and distal clavicle grafts reliably restored up to 30% GBL in nearly all patients. The coracoid was the only graft that could reliably restore up to 40% GBL.

CLINICAL RELEVANCE

With "subcritical" GBL (>13.5%), all autologous bone grafts can be used to adequately restore the bony defect. However, with "critical" GBL (≥20%), only the coracoid and distal clavicle can reliably restore the bony defect.

Metal-Free Fixation for Free Bone-Block Reconstruction of Chronic Anteroinferior Shoulder Instability

Background:

Anterior shoulder instability is common and may cause a considerable effect on quality of life. For cases with glenoid bone loss, there is still a controversial discussion regarding the optimal treatment. Most of the recent methods are using metal implants to attach the needed graft to the glenoid with reported disadvantages such as metal impingement, damage to the humeral head, cartilage destruction, and premature arthritis.

Indications:

(1) Erosion-type defects with significant bone loss (>15%-20%); (2) chronic fragment-type defects if the size of the fragment is not large enough for an anatomical reconstruction; and (3) non-reconstructible, multifragmented acute fragment type of lesions.

Technique Description:

After placing the patient in a lateral decubitus position and fixing the arm in a traction devise, 3 arthroscopic entries are established: a posterior portal, an anterosuperior portal, and an anteroinferior portal. A harvested tricortical iliac crest bone graft is provided with 2 drilling holes which match the drilling holes through the glenoid. The tapes are then placed from the posterior to the anterior side of the glenoid, and then the graft is passed from the anterior to the posterior side, thus compressing the cancellous side of the bone block onto the glenoid defect. A following interconnection of the sutures creates a continuous loop. The end of the tapes was loaded into a pretied racking hitch knot system, which creates sliding knots between the 2 pair of tapes, whereon the knots can be reduced to the glenoid in a symmetrical fashion. Finally, the reconstruction of the anterosuperior labrum can be done, to cover the bone block with enough soft tissue.

Results:

First short-term results show radiographic consolidation after 3 months and an increased median glenoid estimated surface area at 12 months. The functional scores showed good outcomes, and there were no serious complications reported.

Discussion/Conclusion:

The presented arthroscopic reconstruction of the glenoid using a tricortical bone graft and high-strength fiber tapes provides a metal-free technique which results in a high primary stability of the construct and should therefore be considered when treating anterior shoulder instability with significant bone loss.

[Arthroscopic Pushlock anchor fixation with iliac creast bone autograft in the treatment of recurrent anterior shoulder instability with critical bone defect]

OBJECTIVE

To evaluate the effectiveness of arthroscopic Pushlock anchor fixation with iliac creast bone autograft in the treatment of recurrent anterior shoulder instability with critical bone defect.

METHODS

The clinical data of 80 patients with recurrent anterior shoulder instability with critical bone defect treated by arthroscopic Pushlock anchor fixation with iliac creast bone autograft between January 2016 and January 2019 were retrospectively analyzed. The patients were all male; they were 18-45 years old at the surgery, with an average of 25 years old. The disease duration ranged from 3 months to 5 years, with an average of 2 years. The shoulder joint dislocated 3-50 times, with an average of 8 times. X-ray films, MRI, CT scans and three-dimensional reconstruction of the shoulder were performed before operation. The area of the anterior glenoid defect was 25%-45%, with an average of 27.3%. The shoulder mobility (forward flexion and external rotation in abduction at 90°), the Constant-Murley score, and the Rowe score were used to evaluate the shoulder function before operation and at last follow-up.

RESULTS

Patients were followed up 1-3 years, with an average of 2 years. No shoulder dislocation occurred again during follow-up. All partial graft absorption occurred after operation, CT scan showed that the graft absorption ratio was less than 30% at 1 week and 3 months after operation. CT three-dimensional reconstruction at 1 year after operation showed that all grafts had healed to the glenoid. The anterior glenoid bone defect was less than 5% (from 0 to 5%, with an average of 3.2%). At last follow-up, the shoulder mobility (forward flexion and external rotation in abduction at 90°), the Constant-Murley score, and the Rowe score significantly improved when compared with preoperative ones ( P<0.05). The shoulder mobility of external rotation in abduction at 90° of the affected side limited when compared with the healthy side [(6.7±5.1)°].

CONCLUSION

Arthroscopic Pushlock anchor fixation with iliac creast bone autograft has a good effectiveness in the treatment of recurrent anterior shoulder instability with critical bone defect. The method is relatively simple and the learning curve is short.

Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibial Allograft and Hybrid Fixation

Glenoid grafting is the standard surgical treatment for recurrent shoulder instability with significant glenoid bone loss. Arthroscopic anatomic glenoid reconstruction using a distal tibial allograft for anatomic glenoid reconstruction has recently been gaining attention. This article describes the use of a hybrid graft fixation technique with 1 suture-EndoButton device and 1 compression screw in arthroscopic anatomic glenoid reconstruction using distal tibial allograft.

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person-years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill-Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

Current concepts in anterior glenohumeral instability: diagnosis and treatment

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.

Arthroscopic Iliac Bone Grafting for Traumatic Anterior Shoulder Instability With Significant Glenoid Bone Loss Yields Low Recurrence and Good Outcome at a Minimum of Five-Year Follow-Up

PURPOSE

The purpose of this study was to investigate the clinical and radiographic outcomes of arthroscopic iliac bone grafting with capsulolabral reconstruction for severe glenoid bone loss with a minimum of 5 years' follow-up.

METHODS

The inclusion criterion was shoulders that underwent arthroscopic iliac bone grafting for >20%-25% glenoid defect between January 2007 and April 2014, and the exclusion criterion was <5 years' follow-up. Iliac crest bone grafts of approximately 2.0 cm length and 0.8 cm height were arthroscopically fixed to the anterior glenoid using 2 cannulated screws followed by capsulolabral repair. Rowe score, Western Ontario Shoulder Instability Index (WOSI), and passive range of motion were evaluated. Radiographic findings including the Kellgren and Lawrence osteoarthritis grade and graft integration on 3-dimensional computed tomography at the final follow-up were also evaluated.

RESULTS

Forty-eight shoulders met the inclusion criteria, and 24 shoulders with ≥5 years' follow-up were included (1 died; 23 were lost follow-up): 22 males, 2 females; a mean age at surgery, 30 years (range, 18-52 years); a mean follow-up of 8 years (range, 5-11 years). The mean preoperative glenoid bone defect was 22% (range, 20%-28%). All shoulders had a Hill-Sachs lesion including 4 on-track lesions. One shoulder experienced traumatic redislocation at 5 years after surgery. The scores significantly improved: Rowe score, 19 ± 8 to 94 ± 8 (P < .001); WOSI, 1547 ± 241 to 439 ± 318 (P < .001). Postoperative flexion showed significant improvement from 158 ± 18 to 169 ± 11 (P = .008), whereas internal rotation deteriorated from T8 ± 3 to T10 ± 3 (P = .005). Graft integration showed remodeling in 54% and excessive absorption in 13%. Osteoarthritis grades progressed significantly (P < .001), but only grade 1 osteoarthritic changes were seen, except for 4 shoulders with grade 2 osteoarthritis.

CONCLUSIONS

Arthroscopic iliac bone grafting for traumatic anterior shoulder instability with severe glenoid bone loss yielded satisfactory outcomes with mid-term follow-up. Arthritic changes progressed in half of the shoulders; however, most shoulders only demonstrated grade 1 osteoarthritis.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity

PURPOSE

The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity.

METHODS

In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL) < 15%. Exclusion criteria were GBL > 15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results.

RESULTS

Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test > 85°) met all inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P = .037), and the ASES score rose from 71.5 to 97.4 (P = .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position).

CONCLUSIONS

The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (<15%) and hyperlaxity, without compromising external rotation.

LEVEL OF EVIDENCE

Level IV, case series.

Anterior and posterior glenoid bone augmentation options for shoulder instability: state of the art

Bony lesions are highly prevalent in anterior shoulder instability and can be a significant cause of failure of stabilisation procedures if they are not adequately addressed. The glenoid track concept describes the dynamic interaction between the humeral head and glenoid defects in anterior shoulder instability. It has been beneficial for understanding the role played by bone defects in this entity. As a consequence, the popularity of glenoid augmentation procedures aimed to treat anterior glenoid bone defects; reconstructing the anatomy of the glenohumeral joint has risen sharply in the last decade. Although bone defects are less common in posterior instability, posterior bone block procedures can be indicated to treat not only posterior bony lesions, attritional posterior glenoid erosion or dysplasia but also normal or retroverted glenoids to provide an extended glenoid surface to increase the glenohumeral stability. The purpose of this review was to analyse the rationale, current indications and results of surgical techniques aimed to augment the glenoid surface in patients diagnosed of either anterior or posterior instability by assessing a thorough review of modern literature. Classical techniques such as Latarjet or free bone block procedures have proven to be effective in augmenting the glenoid surface and consequently achieving adequate shoulder stability with good clinical outcomes and early return to athletic activity. Innovations in surgical techniques have permitted to perform these procedures arthroscopically. Arthroscopy provides the theoretical advantages of lower morbidity and faster recovery, as well as the identification and treatment of concomitant pathologies.

Management einer chronischen vorderen, verhakten Schulterluxation während des COVID-19-Lockdowns

In diesem Beitrag wird der Fall einer chronisch verhakten vorderen Schulterluxation bei einem 25-jährigen, geistig retardierten Patienten geschildert, welcher während des ersten COVID-19-Lockdowns eine verspätete orthopädisch-fachärztliche Versorgung erhielt. Die Therapie bestand in der offenen Reposition mittels Tuberculum-minus-Osteotomie, einer Auffüllung des Hill-Sachs-Defekts sowie einer knöchernen Glenoidaugmentation, jeweils mit autologem trikortikalem Beckenkammspan. Die hierzulande seltene Verletzung zeigt in Ländern mit erschwertem Zugang zum Gesundheitssystem eine höhere Inzidenz mit hochgradiger Funktionseinschränkung.

Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up

PURPOSE

To evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability.

METHODS

A retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon's signed rank test otherwise.

RESULTS

The final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed.

CONCLUSIONS

The all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy.

LEVEL OF EVIDENCE

IV, therapeutic, retrospective case series.

Distal clavicle autograft for anterior-inferior glenoid augmentation: A comparative cadaveric anatomic study

INTRODUCTION

The aim of this study was to anatomically compare distal clavicle and coracoid autografts and their potential to augment anterior-inferior glenoid bone loss.

METHODS

Ten millimeters of distal clavicle and 20 mm of coracoid were harvested bilaterally from 32 cadavers. Length, weight, and height were measured and surface area and density were calculated. For each graft, ipsilateral measurements were compared and the ability to restore corresponding glenoid bone loss was calculated.

RESULTS

Distal clavicle grafts were larger than coracoid grafts with respect to length (22.3 mm versus 17.7 mm; p < 0.001), height (12.49 mm versus 9.65 mm; p < 0.001), mass (2.72 g versus 2.45 g; p = 0.0437), and volume (2.36 cm³ versus 1.96 cm³; p = 0.002). Coracoid grafts had larger widths (14.56 mm versus 10.52 mm; p < 0.001) and greater density (1.24 g/cm³ versus 1.18 g/cm³; p < 0.001). Distal clavicle surface area was greater on both the articular (2.93 cm² versus 1.5 cm²; p < 0.001) and superior surfaces (2.76 cm² versus 1.5 cm²; p < 0.001) when compared to lateral coracoid surface area.

DISCUSSION

Distal clavicle grafts were larger and restored larger bony defects but had greater variability and lower density than coracoid grafts. Clinical studies are needed to compare these graft options.

On-lay grafting of a calcium hydroxyapatite bone substitute: A preliminary animal experimental study

BACKGROUND

Bone substitutes are widely accepted for various clinical applications. However, the usage is predominantly intraosseous implantation, whereas extraosseous on-lay grafting is rare and lacks scientific evidence. The purpose of this study is to elucidate whether osteoconduction occurs in on-lay grafted bone substitute.

METHODS

Custom-made interconnected porous calcium hydroxyapatite ceramic (IPCHA) was on-lay grafted with screw or anchor fixation (S- and A-groups, respectively) at the anterior aspect of the femur of skeletally mature Japanese white rabbits. At 3, 6 and 12 weeks postoperatively, 4 samples for each time point and each group were evaluated by microfocus computed tomography (micro-CT) and histology.

RESULTS

Volume-rendered three-dimensional micro-CT images showed a high-density calcified area infiltrating IPCHA from the femoral cortex as of 6 weeks. When quantified, the calcified volume per unit volume first showed no difference between the two groups at 3 weeks but increased over time, and became significantly greater in the S-group than in the A-group (p = 0.012 and 0.004 at 6 and 12 weeks, respectively). Histologically, IPCHA pores were first occupied by fibrous tissue at 3 weeks; then, the pores adjacent to the femoral cortex were gradually replaced by bony tissue as of 6 weeks for both fixations.

CONCLUSIONS

IPCHA allowed new bone formation inside the material even though it was implanted in an on-lay fashion on the cortical bone. Our results suggested that on-lay grafted IPCHA exerted its osteoconductivity well, with more new bone forming in screw-fixated samples than in anchor-fixated samples.

Arthroscopic Reduction and Stable Fixation of an Anterior Glenoid Fracture With 4 Buttons

An arthroscopic technique for the reduction and stable fixation of an articular glenoid fracture with a 2-button compression system, originally designed for the treatment of shoulder instability with bone deficiency in the anterior glenoid, is presented. This technique allows direct visualization of the joint, reduction of the fracture, precise placement of the buttons according to the fracture line, and stable fixation. It is a safe and reproducible technique, using the standard shoulder arthroscopy portals.

Revision guided suture-button bone block stabilization of the shoulder in the presence of significant retained glenoid metalwork

Aim

Positioning and fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, can be challenging. We present the results of a series of patients who underwent a revision bone block procedure secured with double suture buttons using a drill guide system, the position of which was calculated from a preoperative computed tomography (CT) scan.

Materials and methods

We undertook a revision bone block stabilization of the shoulder, using a guided double suture-button fixation, in 10 patients with significant retained glenoid metalwork from previous procedures. A preoperative CT scan was used to determine a position for the guide to allow a safe drill trajectory that would avoid any retained metalwork. A coracoid transfer was undertaken in 4 patients and an Eden-Hybinette in 6. Patients were assessed preoperatively and at final follow-up clinically and using the Oxford Shoulder Instability Score and the Subjective Shoulder Value score. Bone block position and healing was assessed by a CT scan at 6 months. The median follow-up was 36 months (range, 24-47 months).

Results

There were 3 female and 7 male patients with a median age of 24.5 years (17-49 years). At final follow-up, the mean Oxford Shoulder Instability Score had decreased from 25.9 (range, 21-35) to 5.8 (range, 3-14) (P < .005). The mean Subjective Shoulder Value score had risen from 87.1 (range, 10-60) to 80 (range, 60-90) (P < .05). All of the patients considered their shoulder to be stable apart from 1 patient. There had been no redislocations. The bone block positioned in the glenoid lower quadrant had healed for all of the patients on CT at 6 months.

Conclusion

Guided suture-button fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, provides a satisfactory outcome in terms of shoulder stability, graft position, and healing.

A new mini-open technique of arthroscopically assisted Latarjet

BACKGROUND

The aim is to describe a new arthroscopically assisted Latarjet technique.

METHODS

We evaluated the clinical and radiological findings of 60 patients with chronic recurrent anterior gleno-humeral instability who underwent, between September 2013 and November 2014, an arthroscopically-assisted Latarjet procedure with double round endobutton fixation. Inclusion criteria were: chronic anterior recurrent instability, Instability Severity Index Score (ISIS) greater than three points, a glenoid bone defect > 15% or a Hill Sachs lesion with concomitant glenoid bone defect > 10%. During surgery the joint capsule and the anterior glenoid labrum were detached. Two drill tunnels perpendicular to the neck of the glenoid were made through a guide. An accessible pilot hole through the glenoid was created to allows the passage of guidewires for coracoid guidance and final fixation onto the anterior glenoid. Through a restricted deltopectoral access a coracoid osteotomy was made. Finally, the graft was prepared, inserted and secured using half-stitches.

RESULTS

The mean follow-up was 32.5 months (range 24-32 months). At a mean follow-up, 56 of the 60 subjects claimed a stable shoulder without postoperative complaints, two (3.3%) had an anterior dislocation after new traumatic injury, and two (3.3%) complained of subjective instability. At the latest follow-up, four subjects complained of painful recurrent anterior instability during abduction-external rotation with apprehension. At 1 year, the graft had migrated in one patient (1.7%) and judged not healed and high positioned in another patient (1.7%). Moreover, a glenoid bony gain of 26.3% was recorded. At the latest follow-up, three patients had grade 1 according to Samilson and Prieto classification asymptomatic degenerative changes. Nerve injuries and infections were not detected. None of the 60 patients underwent revision surgery. Healing rate of the graft was 96.7%.

CONCLUSIONS

This technique of arthroscopically assisted Latarjet combines mini-open and arthroscopic approach for improving the precision of the bony tunnels in the glenoid and coracoid placement, minimizing any potential risk of neurologic complications. It can be an option in subjects with anterior gleno-humeral instability and glenoid bone defect. Further studies should be performed to confirm our preliminary results.

TRIAL REGISTRATION

Trial registration number 61/int/2017 Name of registry: ORS Date of registration 11.5.2017 Date of enrolment of the first participant to the trial: September 2013 'retrospectively registered' LEVEL OF EVIDENCE: IV.

Arthroscopic Iliac Bone Block Augmentation for Glenoid Reconstruction: Transglenoid Fixation Technique Using an All-Suture Anchor

Arthroscopic Bankart repair of anterior instability has shown relatively good results, but its effectiveness is unclear in cases wherein there is a bone defect in the glenoid bone. The surgical management of recurrent anterior shoulder instability with severe glenoid bone loss has been challenging until now. Therefore the Latarjet procedure was introduced as an alternative that provided good results in cases of full instability with a bone defect. In cases of recurrent anterior shoulder instability, bone defects are often present within the glenoid. To restore glenohumeral stability, a bone augmentation procedure is required, and the Latarjet procedure to use bony transfer from the coracoid is the most popular technique. However, resorption of the bone graft with metal screw protrusion is a serious concern, whereas the relative contribution of the dynamic sling effect of the Latarjet procedure remains controversial. The Latarjet procedure also destroys the normal kinematics, resulting in side effects such as scapular dyskinesia. Here we introduce an arthroscopic anterior bone block procedure for reconstructing anterior glenoid bone defects using an autologous iliac crest graft. This technique enables precise bone block placement and fixation using one all-suture anchor instead of screw fixation.

Arthroscopic Anatomic Glenoid Reconstruction in the Setting of a Failed Latarjet Using Distal Tibial Allograft

Treatment of traumatic anterior glenohumeral dislocation has evolved over the years in terms of surgical approaches and methods of repair. Recurrence of instability following surgical repair remains challenging with conventional methods of open reconstruction. We describe the utilization of arthroscopic anatomic glenoid reconstruction using a distal tibial allograft after a failed Latarjet procedure. Preoperative and operative methodology are described with relevant imaging investigations and a detailed intraoperative arthroscopic technique.

Arthroscopic Technique for Bone Augmentation With Suture Button Fixation for Anterior Shoulder Instability

Glenoid bone loss remains a significant risk factor for recurrent instability after shoulder dislocation. Several options exist for glenoid bone graft augmentation, including autograft and allograft options. Strengths and weaknesses exist for each. Graft fixation with screws remains a key concern for technical viability requiring a medial portal as well as the risk of graft osteolysis. Suture button suspensory fixation is a new technique recently described for arthroscopic iliac crest bone graft; however, no description exists concerning osteochondral graft fixation. We describe an arthroscopic technique for distal tibial allograft glenoid augmentation with suspensory suture button fixation. The rationale and technical aspects of this procedure are discussed.

Arthroscopic Bone Block Cerclage: A Fixation Method for Glenoid Bone Loss Reconstruction Without Metal Implants

Large glenoid bone loss defects are associated with higher failure rates after arthroscopic Bankart repair in cases of glenohumeral anterior instability, further necessitating bone graft reconstruction. Because most techniques use strong initial fixation using metal devices, bone graft resorption considered to be closely related to the presence of metal components is a potential shortcoming of these techniques. We describe an arthroscopic technique for anatomical reconstruction of the glenoid that uses a tricortical iliac crest with a metal-free fixation method using 2 ultra-high-strength sutures (FiberTape Cerclage System; Arthrex, Naples, FL), which provide substantial stability to the graft, and finishing with a capsulolabral reconstruction.

Arthroscopic Transosseous Suture Button Fixation Technique for Treatment of Large Anterior Glenoid Fracture

To date, several open and arthroscopic surgical procedures are available for the treatment of anterior glenoid fractures after anterior shoulder dislocation. Open approaches require extensive soft-tissue dissection and are associated with poorer outcomes. Arthroscopic screw fixation techniques are technically challenging and related to complications as well, for example, risk of brachial plexus injury or hardware impingement. Alternative arthroscopic fixation techniques use suture anchors placed along the fracture rim with sutures passed around the fragment. However, these techniques require an intact capsulolabral complex and cannot be used effectively for large fracture fragments. This article describes a safe interfragmentary, transosseous, all-arthroscopic procedure using a double-cortical button fixation technique. This method can be used to achieve anatomic reduction and stable fixation of intermediate to large anterior glenoid fractures while minimizing the difficulties associated with previously described arthroscopic or open approaches.

Analysis of complication after open coracoid transfer as a revision surgery for failed soft tissue stabilization in recurrent anterior shoulder instability

BACKGROUND

The coracoid transfer represents a treatment option for patients with recurrent shoulder instability. Only a few studies exist about the complication rate of the coracoid transfer as a revision surgery following failed soft tissue stabilization. The purpose of this study was to analyze the results and complication rate after coracoid transfer as a revision surgery.

METHODS

In this study 38 patients (4 females, 34 males, mean age 27 years) were included of whom 29 patients were available for follow-up after a mean of 27 months. Previous shoulder stabilization procedures were predominantly arthroscopic (n = 25). Complications were divided according to their timely appearance into early (< 3 months) and late (> 3 months) postoperatively as well as need for revision. Clinical scores [Constant Score (CS), Rowe Score (RS), Walch-Duplay-Score (WDS), WOSI and Subjective-Shoulder-Value (SSV)] were evaluated preoperatively and at final follow-up.

RESULTS

In this patient cohort, the overall complication rate was 27.6%, all of them occurred > 3 months postoperatively. In seven of eight cases (24.1%) a repeat surgical procedure was conducted. Recurrent instability occurred in three patients (10.3%) of which two received a revision surgery (n = 1 iliac-crest bone graft, n = 1 labral repair). Due to persistent pain five patients underwent an arthroscopic implant removal. The complication rate was with 40% higher in patients with two or more previous surgeries (n = 4 out of 10 patients) compared to patients with one previous surgery (21%, n = 4 out of 19 patients). The scores increased significantly comparing pre- to postoperative [CS 74-90 points, RS 27-91 points, WDS 16-89 points, WOSI 40-76% and SSV 41-82% (p < 0.05)].

CONCLUSION

The open coracoid transfer as a revision surgery after failed soft tissue stabilization leads to satisfying clinical results. However, the complication rate is high though comparable to data in the literature when used as a primary surgery. The indication for a coracoid transfer should be judged carefully and possible alternatives should be considered.

All-Arthroscopic Treatment of Glenoid Rim Fractures

We describe an arthroscopic technique for the management of glenoid rim fractures. It is performed with the patient placed in lateral decubitus position. The fracture is assessed through the anterosuperior portal, and the fragment is mobilized. A special glenoid guide is used from the posterior portal to reduce the fragment and to create 2 tunnels through the glenoid and through the glenoid rim fragment. Two pairs of round buttons are connected with high-strength sutures and are tightened posteriorly. This allows strong fixation of the fractured fragment and avoids all the anterior structures since all the instruments are inserted posteriorly.

Scapular Spine Dimensions and Suitability as a Glenoid Bone Graft Donor Site

BACKGROUND

Current structural bone graft options used for glenoid augmentation in glenohumeral instability have known drawbacks. The scapular spine may be a possible alternative graft choice, but its dimensions and anatomy are not fully reported.

HYPOTHESIS

The scapular spine's harvestable graft dimensions will be similar to harvestable dimensions of the coracoid and iliac crest.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The scapular spine, coracoid, and iliac crest dimensions were recorded and compared bilaterally in 50 patients with 3-dimensional computed tomography imaging. The portion of the scapular spine with the largest harvestable dimensions was quantified and its location defined. Measurements were independently taken by 2 investigators and averaged for the final result.

RESULTS

The scapular spine has 81.5 mm of harvestable length and a "flare" located approximately 49.6 mm lateral to the medial scapular border, where the widest harvestable cross section is located (mean harvestable dimensions: 10.9-mm height, 11.5-mm width). Mean coracoid dimensions were 24-mm length, 14.2-mm height, and 10.6-mm width. Mean iliac crest width was 14.7 mm. In sum, 96% of scapular spines, 85% of coracoids, and 100% of iliac crests exceeded minimum dimensions of 8 mm × 8 mm × 20 mm. The coronal radius of curvature of the glenoid was significantly different from the corresponding plane of all measured structures.

CONCLUSION/CLINICAL RELEVANCE

The scapular spine has dimensions similar to the coracoid and iliac crest in the majority of patients and is therefore appropriate for further investigation as a potential graft choice in glenohumeral instability. A harvest location 49.6 mm lateral to the medial scapular border will provide the largest cross-sectional graft while avoiding the acromial base.

The Combined Arthroscopic Revision Technique After the Latarjet Procedure

The Latarjet procedure is very popular and is the method of choice in cases of glenoid bone loss and anterior-inferior instability or revision procedures. However, recurrence is common after this procedure. One of the methods of revision after the Latarjet procedure is the Eden-Hybinette technique. However, recurrence occurs after this bone grafting procedure as well. The primary reasons for recurrence are graft resorption and capsular deficiency. To improve these outcomes, transfer of the long head of the biceps for capsular reinforcement has been recommended by several authors. We describe an all-arthroscopic procedure, performed after the Latarjet technique, that combines bone block transfer, trans-subscapular transposition of the long head of the biceps, and anterior labroplasty. This technique can significantly reinforce the deficient capsule through the sling effect and cover the graft for prophylaxis against bone resorption.

Innovative Approaches in the Management of Shoulder Instability: Current Concept Review

PURPOSE OF REVIEW

This article summarises the latest innovations and concepts in the management of shoulder instability associated with glenoid bone loss.

RECENT FINDINGS

The management of shoulder instability has undergone significant evolution in the last century with rapid strides being made in the last few decades due to the transition from open to arthroscopic techniques allowing management of pathological entities which were previously untreatable. However, there is no consensus on treatment methods, especially in the presence of glenoid bone loss. The complication profile associated with non-anatomic glenoid bony reconstruction procedures has triggered research for alternate techniques using free bone grafts. Open Latarjet procedure continues to be the gold standard in the face of glenoid bone loss; however, arthroscopic anatomic glenoid reconstruction with bone block grafts is gaining in popularity and is associated with excellent short-term clinico-radiologic outcomes. Arthroscopic anatomic glenoid reconstruction using bone grafts has been proposed as an alternative to the complex all-arthroscopic Latarjet procedure with excellent short-term results, minimal complications and a relatively easier learning curve. Capsular reconstruction has emerged as option for the management of instability with poor quality or absent capsular tissue. Future long-term outcome studies and randomised comparative trials will determine if these innovations stand the test of time.

Neer Award 2019: Latarjet procedure vs. iliac crest bone graft transfer for treatment of anterior shoulder instability with glenoid bone loss: a prospective randomized trial

BACKGROUND

The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are competing treatment options for anterior shoulder instability with glenoid bone loss.

METHODS

In this bicentric prospective randomized study, 60 patients with anterior shoulder instability and glenoid bone loss were included and randomized to either an open Latarjet or open ICBGT (J-bone graft) procedure. Clinical evaluation was completed before surgery and 6, 12, and 24 months after surgery, including the Western Ontario Shoulder Instability index, Rowe score, Subjective Shoulder Value, pain level, satisfaction level, and work and sports impairment, as well as assessment of instability, range of motion, and strength. Adverse events were prospectively recorded. Radiographic evaluation included preoperative, postoperative, and follow-up computed tomography analysis.

RESULTS

None of the clinical scores showed a significant difference between the 2 groups (P > .05). Strength and range of motion showed no significant differences except for diminished internal rotation capacity in the Latarjet group at every follow-up time point (P < .05). A single postoperative traumatic subluxation event occurred in 2 ICBGT patients and 1 Latarjet patient. The type and severity of other adverse events were heterogeneous. Donor-site sensory disturbances were observed in 27% of the ICBGT patients. Computed tomography scans revealed a larger glenoid augmentation effect of the ICBGTs; this, however, was attenuated at follow-up.

CONCLUSION

The Latarjet and ICBGT procedures for the treatment of anterior shoulder instability with glenoid bone loss showed no difference in clinical and radiologic outcomes except for significantly worse internal rotation capacity in the Latarjet group and frequently noted donor-site sensory disturbances in the ICBGT group.