Bipolar Bone Loss of the Shoulder Joint due to Recurrent Instability: Use of Fresh Osteochondral Distal Tibia and Humeral Head Allografts

Open Bone Augmentation Solutions for the Failed Shoulder Stabilization

Utilizing fresh distal tibia allograft in anterior glenoid reconstruction has emerged as a highly advantageous approach in addressing instances of failed anterior shoulder stabilization with glenoid bone loss. This procedure offers several benefits, including the absence of donor-site morbidity, restoration of significant glenoid defects, reestablishment of joint congruity with the humeral head, restoration of glenoid biomechanics, and the addition of cartilage to the glenoid. Furthermore, it provides a robust and reliable alternative for managing failed stabilization procedures, leading to improved clinical outcomes and a high graft healing rate, while maintaining a low occurrence of recurrent instability.

Managing severe bipolar bone loss in athletes: A comprehensive approach with open Latarjet and arthroscopic remplissage

Background

Severe bipolar bone loss (BBL) represents one of the toughest challenges when managing the instability of glenohumeral joints among athletes and more specifically the ones involved in overhead sports. It refers to the significant loss of the humeral head and the glenoid bone, with an increased risk of failure. The present study aimed to evaluate the functional outcomes of a combined open Latarjet and arthroscopic remplissage in such high-risk individuals.

Methods

A retrospective evaluation was carried out among athletes with antero-inferior loss of glenoid bone of more than 15 % and large off-track Hill-Sachs defect who underwent the Latarjet technique with iliac crest bone graft (ICBG) harvest used in combination with arthroscopic remplissage between 2021 and 2023. The University of California, Los Angeles (UCLA) score, constant-Murley score (CMS), and the range of motion (ROM; measured as forward flexion, external rotation, and abduction) were evaluated pre-operative and post-operative at the timepoint of 3-month, 6-month, and 1-year. Pre-operative magnetic resonance imaging scans (MRI) and computed tomography scans (CT) were obtained among the patients with severe glenohumeral BBL, and the glenoid track was calculated to identify on-track and off-track Hill-Sachs lesions. Post-operative MRI with filled Hill-Sachs defect post remplissage procedure and 3D CT scan was also done at 6-month to evaluate the union of the ICBG to the native glenoid bone.

Results

Overall, 11 patients underwent for the combined procedure for severe BBL. The UCLA score (31.18 ± 3.74), and the CMS (93.64 ± 8.38) at the time-point of 1-year post-operatively showed remarkable improvement in comparison with the preoperative scores (P < 0.0001); and the ROM including abduction, external rotation, and forward flexion were restored to near normality. All patients showed bony union at 6-month as confirmed by post-operative CT scan. No complications such as redislocation or subluxation were observed over 1-year. There were no neurological complications or complications related to graft (graft migration or graft breakage or resorption) as well. All the athletes returned to sports activities at an average duration of 6.8-month post-operatively, with 73 % returning to sports at the level of pre-injury.

Conclusion

The combined procedure of ICBG Latarjet and arthroscopic remplissage for the treatment of severe BBL in athletes achieved satisfactory outcomes over 1-year, with all athletes returning to sports activities.

Bulk osteochondral allograft for massive Hill-Sachs defect combined with Latarjet procedure for bipolar bone loss in anterior instability

A proportion of patients with anterior glenohumeral instability present with bipolar bone loss comprising large Hill-Sachs lesions and substantial glenoid defect. These are surgically difficult cases to treat. We describe a novel surgical procedure of bulk size-matched osteochondral allograft reconstruction for massive Hill-Sachs lesions combined with the Latarjet procedure for these challenging cases.

Editorial Commentary: Shoulder Remplissage Is a Beneficial Addition to Bankart or Glenoid Bone Loss Treatment: Stay on Track and Use Wisely

In patients with on-track shoulder Hill-Sachs lesions, the addition of remplissage using a double-pulley technique to Bankart repair improves outcomes including residual apprehension and without loss of external rotation. A caveat is that measurement of both the Hill-Sachs lesion and glenoid bone loss may be inconsistent. A second caveat is that determination of the glenoid track can be affected by scapular positioning. Not all "on-track" lesions are alike. In terms of outcome assessment, apprehension has up to 95% specificity for anterior shoulder instability and is a key finding in determining the results of shoulder stabilization. Recurrent instability may not be as sensitive of an outcome measure, because patients will avoid positions of apprehension. Finally, remplissage should be used cautiously in peripheral track lesions. For smaller Hill-Sachs lesions, remplissage can provide extraordinary success, and for larger lesions that are close to engaging, glenoid bone loss must also be treated, especially in a younger, active patient.

Remplissage in addition to arthroscopic Bankart repair for shoulder instability with on-track Hill-Sachs lesions reduces residual apprehension without external rotation limitation

PURPOSE

To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill-Sachs lesion.

METHODS

Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill-Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair-only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated.

RESULTS

In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (P < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; P = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; P = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; P = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, P = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (P = .340).

CONCLUSIONS

Remplissage with arthroscopic Bankart repair in on-track Hill-Sachs lesion has a role in reducing residual apprehension without external rotation limitation.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Return to Professional Australian Rules Football After Surgery for Traumatic Anterior Shoulder Instability

BACKGROUND

The treatment of traumatic anterior shoulder instability in professional Australian Football League (AFL) players is challenging, with an emphasis on early return to play and avoidance of instability recurrence.

PURPOSE

To investigate return-to-sport (RTS) outcomes and complications after 2 different procedures for traumatic anterior shoulder instability in professional AFL players.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively reviewed our surgical database for professional AFL players who underwent capsulolabral stabilization or open Latarjet procedure by a single surgeon between 2006 and 2017. Outcomes included RTS, on-field performance, and complications. Between-group analyses for RTS and complications were estimated using Kaplan-Meier survival analyses. Within-group analyses for on-field performance data were performed using paired t tests with significance set at .05.

RESULTS

A total of 58 capsulolabral stabilization procedures in 54 players and 32 Latarjet procedures in 29 players were included in the analysis; 93.1% of capsulolabral patients and 96.9% of Latarjet patients returned to professional AFL. The median RTS time was 6.8 months for the capsulolabral group and 7.3 months for the Latarjet group. There was no significant difference in RTS rates between the 2 groups (P = .270). Of those undergoing surgery early in the season, 75% of the capsulolabral and 71% of Latarjet group were able to RTS within the same season, at a mean time of 16.9 weeks and 18.8 weeks, respectively. There was a significant difference in instability recurrence, with 19% for the capsulolabral group and no recurrence in the Latarjet group (P = .017). There was no significant reduction in player on-field performance in either group (P < .05).

CONCLUSION

In this study, the median RTS in AFL players was approximately 7 months after capsulolabral and Latarjet surgery with no compromise to on-field performance. Instability-related complications occurred only in the capsulolabral group, and the incidence increased with time.

Distal tibia allograft glenoid reconstruction for shoulder instability: outcomes after lesser tuberosity osteotomy

BACKGROUND

Distal tibia allograft reconstruction of the glenoid in shoulder instability has garnered significant attention over the last decade. Prior studies demonstrate significant improvement in all reported patient outcomes albeit the approach is through a subscapularis split. There have not been prior studies evaluating outcomes after lesser tuberosity osteotomy which provides excellent exposure to the anterior glenoid.We hypothesize there is significant improvement in functional outcomes and no deleterious effects after lesser tuberosity osteotomy for distal tibia allograft reconstruction of the glenoid for shoulder instability.

METHODS

A retrospective review was performed from 2016 of 2019 of patients undergoing distal tibia allograft reconstruction of the glenoid through a lesser tuberosity osteotomy. Patients were indicated if they had recurrent anterior shoulder instability with >20% glenoid bone loss and evidence of an off-track lesion. Clinical, imaging, and operative data were evaluated. Objective follow-up data evaluated at minimum 2 years included radiographs, range of motion, DASH, SANE, VAS, SST, ASES, and Constant scores.

RESULTS

A total of 12 patients were available with average follow-up 28 months, average age 26 years old, and average glenoid bone loss of 33%. The patients demonstrated significant improvement in their clinical outcomes at final follow-up: DASH 42.9-8.9 (P = .004), SANE 32.2-85 (P = .00005), VAS 4.6-1.1 (P = .003), SST 7-11.4 (P = .01), ASES 50.2-90.5 (P = .001), and Constant 37.6-86.2 (P = .01). Range of motion at final follow-up was forward flexion to 161.4° (135-170°), external rotation 49.5° (40-65°), and internal rotation to T12-L1 (T7-L2) vertebral body.

CONCLUSION

The present study demonstrates the effectiveness of a lesser tuberosity osteotomy in exposure of the glenoid for reconstruction with a distal tibia allograft. The functional integrity of the subscapularis is maintained and the patient-reported outcomes are comparable with current literature.

Use of Allografts in Orthopaedic Surgery: Safety, Procurement, Storage, and Outcomes

The use of allografts has become a vital option for orthopaedic surgeons in the treatment of a variety of musculoskeletal lesions, ranging from osteochondral defects in the glenohumeral joint to meniscal deficiency in the young athlete. Nevertheless, barriers to treating a patient with an allograft-based procedure may arise from concerns over disease transmission, the navigation of tissue banks that supply allografts, the process of obtaining insurance approval, or optimal storage methods. This review serves to support orthopaedic surgeons in the incorporation of allografts into their practice by quelling these potential concerns. Fresh osteochondral allografts, fresh-frozen meniscal allografts, soft tissue allografts, and off-the-shelf cartilage products are the focus of this review amid broad overviews of allograft safety and tissue bank practices in the United States.

[Research progress of surgical treatment for anterior shoulder dislocation and combined injuries]

Objective

To summarize the research progress of surgical treatment for anterior shoulder dislocation and combined injuries.

Methods

The related literature was reviewed, and the surgical treatment options for the anterior shoulder dislocation and its combined injuries were summarized.

Results

Anterior shoulder dislocation can combine with anteroinferior capsular ligament complex injury (Bankart injury), bony Bankart defect, and Hill-Sachs lesion. For Bankart and bony Bankart injuries, arthroscopic repair or coracoid osteotomy combined with bony graft reconstruction can be performed. For Hill-Sachs lesion, conservative treatment, soft tissue repair, or bony reconstruction should be selected based on the extent of the bone defect. For bipolar injury, the Bankart repair, Remplissage, or arthroplasty should be selected based on the extent of the glenoid defect.

Conclusion

With the development of arthroscopy and the improvement of the surgical concept, there is a complete set of surgical options for various injuries of the anterior shoulder dislocation. When choosing a surgical procedure, the patient's specific injury and age, exercise level, and other relating factors should be comprehensively assessed in order to achieve the best results.

Allograft Use in Shoulder Surgery: Instability and Rotator Cuff

Shoulder instability and rotator cuff pathology can provide a challenging problem, especially in the revision setting. Allograft use in primary or revision surgical intervention for shoulder instability and rotator cuff tear may be a valuable resource. This paper reviews allograft tissue use in shoulder surgery for instability and rotator cuff tear.