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

All-Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Procedure for Recurrent Anterior Shoulder Instability: Button Fixation Is a Feasible and Satisfactory Alternative to Screw Fixation

PURPOSE

To investigate the efficacy of all-arthroscopic glenoid bone augmentation surgery using the iliac crest autograft procedure. Furthermore, we sought to compare the clinical and radiographic outcomes of using screw versus button fixation, in patients with recurrent anterior shoulder instability.

METHODS

Between 2015 and 2019, 134 shoulders with persistent instability were surgically treated with an arthroscopically placed autologous iliac crest bone graft transfer procedure. Preoperative and postoperative clinical follow-up data were evaluated using the range of motion, and the Walch-Duplay, American Shoulder and Elbow Society, and Rowe scores. Radiologic assessment on 3-dimensional computed tomography scans was performed preoperatively, immediately after surgery, as well as postoperatively, at 3 months, 6 months, 1 year, and at the final follow-up stage. Graft positions, healing, and resorption were evaluated from postoperative images.

RESULTS

This study included 102 patients who underwent arthroscopic iliac crest bone grafting procedure with 2 screws fixation (n = 37; group 1) and 2 button fixation (n = 65; group 2). The mean follow-up period was 37 months. There were no significant differences between groups in terms of clinical scores, shoulder motion range, graft healing, or graft positions on computed tomography scans (P>.05). In group 1, 1 patient showed mechanical irritation and persistent pain around the screw insertion site, being treated through the arthroscopic removal of the screws. The average postoperative bony resorption percentages were 20.3% and 11.2% at 6 months, and 32.4% and 19.3% at 12 months, in group 1 and group 2, respectively. A statistically significant difference was detected between the two groups (P<.05).

CONCLUSIONS

In the arthroscopic iliac crest bone grafting procedure for the treatment of chronic osseous anterior shoulder instability, excellent functional results were obtained after both button fixation and screw fixation techniques. In addition, less graft resorption and no hardware-related complications were detected with suture button fixation technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Free bone grafting improves clinical outcomes in anterior shoulder instability with bone defect: a systematic review and meta-analysis of studies with a minimum of 1-year follow-up

BACKGROUND

Evidence on the efficacy and safety of the free bone grafting in treating anterior shoulder instability is limited. The purpose of this study was to systematically evaluate the clinical and imaging results of free bone grafting in treating anterior shoulder instability with glenoid bone defect and to explore the incidence of complications in clinically relevant subgroups.

METHODS

This systematic review was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched up to January 29, 2021, for studies that had reported on free bone grafting in treating anterior shoulder instability with glenoid bone defect with a minimum of 1-year follow-up. Two researchers independently screened studies and extracted data. A random-effects model was used to pool data on clinical function scores, imaging results, and incidence of complications (recurrent instability and non-instability-related complications). Meta-regression analysis was used to evaluate the incidence of complications in different subgroups and investigate the sources of heterogeneity.

RESULTS

A total of 29 studies were included in the meta-analysis, comprising 840 patients (845 shoulders) with average ages ranging from 21 to 34.6 years. Compared with preoperatively, free bone grafting increased the postoperative Rowe score, American Shoulder and Elbow Surgeons score, Constant score, Subjective Shoulder Value, and Oxford Shoulder Instability Score by 53.16, 31.80, 20.81, 38.63, and 4.07 points, respectively, and reduced the visual analog scale pain score by 3 points on average. During the postoperative follow-up period, the rates of return to sport and return to preoperative levels were 84.2% and 73.1%, respectively. The imaging results showed that the free bone healing rate was 98.9% and the incidence of osteoarthritis was 10.9%. The incidence rates of recurrent instability and non-instability-related complications were 3.4% and 5.6%, respectively. Meta-regression analysis showed no evidence of effect modification by the year, follow-up time, proportion of male patients, autograft or allograft, and arthroscopy or open surgery on the incidence of complications. Subgroup analysis showed that the incidence rates of recurrent instability for open surgery, arthroscopy, allograft, autograft, Latarjet revision, and non-bone block revision were 4.1%, 2.3%, 1.5%, 4.4%, 10.3%, and 3.5%, respectively.

CONCLUSION

The application of free bone grafting in treating anterior shoulder instability with glenoid bone defect can effectively improve shoulder joint function and is associated with a high return-to-sport rate and a low overall recurrence rate, but there were some differences in the complications of recurrent instability and non-instability-related complications among the subgroups. Given that these results need to be confirmed via head-to-head comparisons, we recommend that future clinical and biomechanical studies focus on comparing and investigating the advantages and disadvantages of different surgical approaches, thus providing a basis for orthopedic surgeons to make reliable choices.

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.

Editorial Commentary: A Functional Capsule, Not the Type of Bone Graft, Determines Outcome After Shoulder Stabilization in Cases of Anterior Glenoid Bone Deficiency

Many clinical results of surgical treatment of recurrent anterior shoulder instability confirm the importance of anterior bone grafting of the glenoid defect. Some studies even propose to perform a graft, even when there is no bony defect. Short- and middle-term studies report comparable results between bone grafting and Latarjet procedure. But one of the main questions that still remains is the quality and efficiency of the capsule. If Latarjet is the gold standard in anterior shoulder stabilization with very good results at very long follow-up, it is probably because the capsule is replaced by the conjoint tendon. Because Latarjet is a difficult surgery and has some complexes and/or challenging complications and because it is a nonanatomic procedure, there is a true place for anterior bone grafting. This anterior grafting under arthroscopy provides excellent results, but it is mandatory to be sure that the shoulder capsule is working. Clinical, functional, and imaging studies of this capsule need to be performed for a better understanding of the unstable shoulder function and treatment.