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Zhao L, Fu C, Lu M, He L, Shen Z, Xing J, Wang C, Hou S. Remodeling process and clinical outcomes following all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and 1-tunnel double Endobutton fixation system. J Shoulder Elbow Surg 2023; 32:1825-1837. [PMID: 36907316 DOI: 10.1016/j.jse.2023.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Arthroscopically modified Eden-Hybinette procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments, a double Endobutton fixation system has been used clinically to secure bone graft to the glenoid rim placed through a specifically designed guide. The purpose of this report was to evaluate clinical outcomes and serial glenoid remodeling process following all-arthroscopic anatomical glenoid reconstruction using autologous iliac crest bone grafting technique through 1-tunnel fixation. METHODS Forty-six patients with recurrent anterior dislocations and significant glenoid defects greater than 20% underwent arthroscopic surgery with a modified Eden-Hybinette technique. Instead of firm fixation, autologous iliac bone graft was fixed to the glenoid by double Endobutton fixation system through 1-tunnel placed in the glenoid surface. Follow-up examinations were performed at 3, 6, 12, and 24 months. The patients were followed up for a minimum of two years using the Rowe score, the Constant score, the Subjective Shoulder Value, and the Walch-Duplay score; patient satisfaction with the procedure outcome was also rated. Graft positions, healing, and absorption were evaluated postoperatively with computed tomography imaging. RESULTS At a mean follow-up of 28 months, all patients were satisfied and had a stable shoulder. The Constant score improved from 82.9 to 88.9 points (P < .001), the Rowe score, improved from 25.3 to 89.1 points (P < .001), the Subjective Shoulder Value improved from 31% to 87% (P < .001), and the Walch-Duplay score improved from 52.5 to 85.7 points (P < .001). One donor-site fracture occurred during the follow-up period. All grafts were well-positioned and achieved optimal bone healing with zero excessive absorption. The preoperative glenoid surface (72.6% ± 4.5%) increased significantly immediately after surgery to 116.5% ± 9.6% (P < .001). After a physiological remodeling process, the glenoid surface remained significantly increased at the last follow-up (99.2% ± 7.1%) (P < .001). The glenoid surface area appeared to decrease serially when compared between the first 6 months and 12 months postoperatively, while there was no significant interval change between 12 and 24 months postoperatively. CONCLUSION Patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through one-tunnel fixation system with double Endobutton. Graft absorption mostly occurred on the edge and outside the ''best-fit'' circle of the glenoid. Glenoid remodeling occurred within the first year after all-arthroscopic glenoid reconstruction with an auto iliac bone graft.
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Affiliation(s)
- Lilian Zhao
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China.
| | - Chuying Fu
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Mingfeng Lu
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China; Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lilei He
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Zhaoxiong Shen
- 6th Department of Orthopaedics, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Jisi Xing
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Changbing Wang
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
| | - Senrong Hou
- Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Guangzhou University of Chinese Medicine, Foshan, China
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Fares MY, Boufadel P, Daher M, Koa J, Khanna A, Abboud JA. Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes. Clin Orthop Surg 2023; 15:521-533. [PMID: 37529197 PMCID: PMC10375816 DOI: 10.4055/cios23018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/15/2023] [Accepted: 04/16/2023] [Indexed: 08/03/2023] Open
Abstract
The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.
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Affiliation(s)
- Mohamad Y. Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Peter Boufadel
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Mohammad Daher
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jonathan Koa
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Akshay Khanna
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A. Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Muench LN, Slater M, Archambault S, Berthold DP, Rupp MC, Obopilwe E, Cote MP, Mazzocca AD. Contact Mechanics of Elliptical and Spherical Head Implants during Axial Rotation in Anatomic Total Shoulder Arthroplasty: A Biomechanical Comparison. J Clin Med 2023; 12:4918. [PMID: 37568320 PMCID: PMC10420122 DOI: 10.3390/jcm12154918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Elliptical humeral head implants have been proposed to result in more anatomic kinematics following total shoulder arthroplasty (aTSA). The purpose of this study was to compare glenohumeral contact mechanics during axial rotation using spherical and elliptical humeral head implants in the setting of aTSA. METHODS Seven fresh-frozen cadaveric shoulders were utilized for biomechanical testing in neutral (NR), internal (IR), and external (ER) rotation at various levels of abduction (0°, 15°, 30°, 45°, 60°) with lines of pull along each of the rotator cuff muscles. Each specimen underwent the following three conditions: (1) native, and TSA using (2) an elliptical and (3) spherical humeral head implant. Glenohumeral contact mechanics, including contact pressure (CP; kPa), peak contact pressure (PCP; kPa), and contact area (CA; mm2), were measured in neutral rotation as well as external and internal rotation using a pressure mapping sensor. RESULTS Elliptical head implants showed a significantly lower PCP in ER compared to spherical implants at 0° (Δ-712.0 kPa; p = 0.034), 15° (Δ-894.9 kPa; p = 0.004), 30° (Δ-897.7 kPa; p = 0.004), and 45° (Δ-796.9 kPa; p = 0.010) of abduction, while no significant difference was observed in ER at 60° of abduction or at all angles in NR and IR. Both implant designs had similar CA in NR, ER, and IR at all tested angles of abduction (p > 0.05, respectively). CONCLUSIONS In the setting of aTSA, elliptical heads showed significantly lower PCP during ER at 0° to 45° of abduction, when compared to spherical head implants. However, in NR and IR, PCP was similar between implant designs. Both designs showed similar CA during NR, ER, and IR at all abduction angles. LEVEL OF EVIDENCE basic science; controlled laboratory study.
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Affiliation(s)
- Lukas N. Muench
- Department of Sports Orthopaedics, Technical University of Munich, 81675 Munich, Germany
| | - Maria Slater
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT 06030, USA (M.P.C.)
| | - Simon Archambault
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT 06030, USA (M.P.C.)
| | - Daniel P. Berthold
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, Ludwig Maximilian University Munich, 82152 Munich, Germany
| | - Marco-Christopher Rupp
- Department of Sports Orthopaedics, Technical University of Munich, 81675 Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT 06030, USA (M.P.C.)
| | - Mark P. Cote
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT 06030, USA (M.P.C.)
| | - Augustus D. Mazzocca
- Massachusetts General Hospital, Massachusetts General Brigham, Harvard Medical School, Boston, MA 02115, USA
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Muench LN, Murphey M, Oei B, Kia C, Obopilwe E, Cote MP, Mazzocca AD, Berthold DP. Elliptical and spherical heads show similar obligate glenohumeral translation during axial rotation in total shoulder arthroplasty. BMC Musculoskelet Disord 2023; 24:171. [PMID: 36882825 PMCID: PMC9990317 DOI: 10.1186/s12891-023-06273-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/27/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Elliptical shape humeral head prostheses have been recently proposed to reflect a more anatomic shoulder replacement. However, its effect on obligate glenohumeral translation during axial rotation compared to a standard spherical head is still not well understood. The purpose of the study was to compare obligate humeral translation during axial rotation using spherical and elliptical shaped humeral head prostheses. It was hypothesized that the spherical head design would show significantly more obligate translation when compared to the elliptical design. METHODS Six fresh-frozen cadaveric shoulders were utilized for biomechanical testing of internal (IR) and external (ER) rotation at various levels of abduction (0°, 30°, 45°, 60°) with lines of pull along each of the rotator cuff muscles. Each specimen underwent the following three conditions: (1) native; total shoulder arthroplasty (TSA) using (2) an elliptical and (3) spherical humeral head implant. Obligate translation during IR and ER was quantified using a 3-dimensional digitizer. The radius of curvature of the superoinferior and anteroposterior dimensions of the implants was calculated across each condition. RESULTS Posterior and inferior translation as well as compound motion of spherical and elliptical heads during ER was similar at all abduction angles (P > 0.05, respectively). Compared to the native humeral head, both implants demonstrated significantly decreased posterior translation at 45° (elliptical: P = 0.003; spherical: P = 0.004) and 60° of abduction (elliptical: P < 0.001; spherical: P < 0.001). During internal rotation at 0° abduction, the spherical head showed significantly more compound motion (P = 0.042) compared to the elliptical head. The spherical implant also demonstrated increased anterior translation and compound motion during internal rotation at 60° abduction (P < 0.001) compared to the resting state. This difference was not significant for the native or elliptical head design at this angle (P > 0.05). CONCLUSION In the setting of TSA, elliptical and spherical head implants showed similar obligate translation and overall compound motion during axial rotation. A gained understanding of the consequences of implant head shape in TSA may guide future surgical implant choice for better recreation of native shoulder kinematics and potentially improved patient outcomes. LEVEL OF EVIDENCE Controlled Laboratory Study.
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Affiliation(s)
- Lukas N Muench
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Matthew Murphey
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT, USA
| | - Bridget Oei
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT, USA
| | - Cameron Kia
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT, USA
| | - Augustus D Mazzocca
- Massachusetts General Brigham, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel P Berthold
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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Muench LN, Kia C, Murphey M, Obopilwe E, Cote MP, Imhoff AB, Mazzocca AD, Berthold DP. Elliptical heads result in increased glenohumeral translation along with micro-motion of the glenoid component during axial rotation in total shoulder arthroplasty. Arch Orthop Trauma Surg 2023; 143:177-187. [PMID: 34216260 PMCID: PMC9886581 DOI: 10.1007/s00402-021-04018-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Elliptical-shaped humeral head prostheses have recently been proposed to reflect a more anatomic shoulder replacement. However, its subsequent effect on micro-motion of the glenoid component is still not understood. MATERIALS AND METHODS Six fresh-frozen, cadaveric shoulders (mean age: 62.7 ± 9.2 years) were used for the study. Each specimen underwent total shoulder arthroplasty using an anatomic stemless implant. At 15°, 30°, 45° and 60° of glenohumeral abduction, 50° of internal and external rotations in the axial plane were alternatingly applied to the humerus with both an elliptical and spherical humeral head design. Glenohumeral translation was assessed by means of a 3-dimensional digitizer. Micro-motion of the glenoid component was evaluated using four high-resolution differential variable reluctance transducer strain gauges, placed at the anterior, posterior, superior, and inferior aspect of the glenoid component. RESULTS The elliptical head design showed significantly more micro-motion in total and at the superior aspect of glenoid component during external rotation at 15° (total: P = 0.004; superior: P = 0.004) and 30° (total: P = 0.045; superior: P = 0.033) of abduction when compared to the spherical design. However, during internal rotation, elliptical and spherical heads showed similar amounts of micro-motion at the glenoid component at all tested abduction angles. When looking at glenohumeral translation, elliptical and spherical heads showed similar anteroposterior and superoinferior translation as well as compound motion during external rotation at all tested abduction angles. During internal rotation, the elliptical design resulted in significantly more anteroposterior translation and compound motion at all abduction angles when compared to the spherical design (P < 0.05). CONCLUSION In the setting of total shoulder arthroplasty, the elliptical head design demonstrated greater glenohumeral translation and micro-motion at the glenoid component during axial rotation when compared to the spherical design, potentially increasing the risk for glenoid loosening in the long term. LEVEL OF EVIDENCE Controlled Laboratory Study.
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Affiliation(s)
- Lukas N. Muench
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT USA ,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Cameron Kia
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT USA
| | - Matthew Murphey
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT USA
| | - Mark P. Cote
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT USA
| | - Andreas B. Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | | | - Daniel P. Berthold
- Department of Orthopaedic Surgery, UConn Health, Farmington, CT USA ,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
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Ernstbrunner L, Borbas P, Ker AM, Imhoff FB, Bachmann E, Snedeker JG, Wieser K, Bouaicha S. Biomechanical Analysis of Posterior Open-Wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-Free, J-Shaped Iliac Crest Bone Graft. Am J Sports Med 2022; 50:3889-3896. [PMID: 36305761 PMCID: PMC9729978 DOI: 10.1177/03635465221128918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterior open-wedge osteotomy and glenoid reconstruction using a J-shaped iliac crest bone graft showed promising clinical results for the treatment of posterior instability with excessive glenoid retroversion and posteroinferior glenoid deficiency. PURPOSE To evaluate the biomechanical performance of the posterior J-shaped graft to restore glenoid retroversion and posteroinferior deficiency in a cadaveric shoulder instability model. STUDY DESIGN Controlled laboratory study. METHODS A posterior glenoid open-wedge osteotomy was performed in 6 fresh-frozen shoulders, allowing the glenoid retroversion to be set at 0°, 10°, and 20°. At each of these 3 preset angles of glenoid retroversion, the following conditions were simulated: (1) intact joint, (2) posterior Bankart lesion, (3) 20% posteroinferior glenoid deficiency, and (4) posterior J-shaped graft (at 0° of retroversion). With the humerus in the Jerk position (60° of glenohumeral anteflexion, 60° of internal rotation), stability was evaluated by measuring posterior humeral head (HH) translation (in mm) and peak translational force (in N) to translate the HH over 25% of the glenoid width. Glenohumeral contact patterns were measured using pressure-sensitive sensors. Fixation of the posterior J-graft was analyzed by recording graft micromovements during 3000 cycles of 5-mm anteroposterior HH translations. RESULTS Reconstructing the glenoid with a posterior J-graft to 0° of retroversion significantly increased stability compared with a posterior Bankart lesion and posteroinferior glenoid deficiency in all 3 preset degrees of retroversion (P < .05). There was no significant difference in joint stability comparing the posterior J-graft with an intact joint at 0° of retroversion. The posterior J-graft restored mean contact area and contact pressure comparable with that of the intact condition with 0° of retroversion (222 vs 223 mm2, P = .980; and 0.450 vs 0.550 MPa, P = .203). The mean total graft displacement after 3000 cycles of loading was 43 ± 84 µm, and the mean maximal mediolateral graft bending was 508 ± 488 µm. CONCLUSION Biomechanical analysis of the posterior J-graft demonstrated reliable restoration of initial glenohumeral joint stability, normalization of contact patterns comparable with that of an intact shoulder joint with neutral retroversion, and secure initial graft fixation in the cadaveric model. CLINICAL RELEVANCE This study confirms that the posterior J-graft can restore stability and glenohumeral loading conditions comparable with those of an intact shoulder.
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Affiliation(s)
- Lukas Ernstbrunner
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia,Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia,Lukas Ernstbrunner, MD, PhD, Department of Orthopaedic Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia ()
| | - Paul Borbas
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andrew M. Ker
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian B. Imhoff
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Elias Bachmann
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland,Laboratory for Orthopaedic Biomechanics, ETH Zurich, University of Zurich, Zurich, Switzerland
| | - Jess G. Snedeker
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland,Laboratory for Orthopaedic Biomechanics, ETH Zurich, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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The Effect of Glenoid Version on Glenohumeral Instability. J Am Acad Orthop Surg 2022; 30:e1165-e1178. [PMID: 36166388 DOI: 10.5435/jaaos-d-22-00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
In recent years, an appreciation for the dynamic relationship between glenoid and humeral-sided bone loss and its importance to the pathomechanics of glenohumeral instability has substantially affected modern treatment algorithms. However, comparatively less attention has been paid to the influence of glenoid version on glenohumeral instability. Limited biomechanical data suggest that alterations in glenoid version may affect the forces necessary to destabilize the glenohumeral joint. However, this phenomenon has not been consistently corroborated by the results of clinical studies. Although increased glenoid retroversion may represent an independent risk factor for posterior glenohumeral instability, this relationship has not been reliably observed in the setting of anterior glenohumeral instability. Similarly, the effect of glenoid version on the failure rates of surgical stabilization procedures remains poorly understood.
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Implant-free iliac crest bone graft procedure shows anatomic remodelling without redislocation in recurrent anterior shoulder instability after short-term follow-up. Arch Orthop Trauma Surg 2022; 142:1047-1054. [PMID: 33486557 DOI: 10.1007/s00402-021-03777-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION With the help of a J-shaped bicortical iliac crest bone graft, the morphology of the glenoid can be augmented without having to use screws to achieve glenohumeral stability. The aim of this retrospective clinical study was to evaluate the clinical stability and function of the shoulder joint as well as the radiological remodelling process and arthropathic outcomes following the J-bone graft technique. MATERIALS AND METHODS 34 patients with recurrent shoulder dislocations and bony glenoid defects were treated with the J-bone graft technique between 2010 and 2018 at our level-I trauma centre. 15 patients (18 shoulders) could be recruited for the study. Pain levels, ASES, UCLA, SST, DASH, Rowe and WOSI Scores were collected using questionnaires. In 13 patients (16 shoulders) the Constant Score, ROM, CT with 3D reconstruction of the glenoid to assess the graft remodelling and X-rays were performed additionally. RESULTS None of the patients suffered subluxations or recurrent dislocations during the follow-up period. The overall complication rate was 11%. The evaluation using objective and subjective shoulder function scores yielded good-to-excellent results. Radiological assessment at follow-up showed a low rate of moderate-to-severe arthritis (12%) and a high rate of shoulders without any signs of arthritic degeneration (53%). The CT scans all revealed an almost complete restoration of the glenoid with none of the grafts being resorbed. A rise in the average glenoid circumference and glenoid area could be demonstrated between preoperative measurements (81.6 and 82.4%, respectively) and follow-up measurements (104 and 102.5%, respectively). CONCLUSION The results of this study show a successful stabilisation of the shoulder joint and a low complication rate following the J-bone graft technique. Remodelling of the bone graft could be demonstrated, which in turn led to an almost perfect glenoid surface area of 100%.
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Mittelsteadt M, Nelson BJ, Rohman EM, Arciero RA, Tompkins MA. Biomechanical Testing of Scapular Spine Autograft for Anterior Glenoid Bone Augmentation. Orthop J Sports Med 2022; 10:23259671221096682. [PMID: 35601735 PMCID: PMC9118475 DOI: 10.1177/23259671221096682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Augmentation of anterior glenoid defects with bone graft can improve shoulder stability and reduce the risk of redislocation. Several characteristics of the scapular spine may make it a suitable harvest site, avoiding the disadvantages associated with other glenoid augmentation procedures. Purpose: To evaluate the capacity of scapular spine autograft to restore the stabilizing joint-reaction forces of the shoulder in simulated scenarios of bony anterior shoulder instability. Study Design: Controlled laboratory study. Methods: We obtained 6 matched pairs of fresh-frozen cadaveric shoulders. Skin, subcutaneous tissues, and non–rotator cuff muscles were removed from the specimens, leaving intact the rotator cuff musculature and shoulder capsule. A customized testing device was used to translate the humerus 1 cm anteriorly on the glenoid under 25 N of axial compression force. The peak joint-reaction force of the glenohumeral joint was then measured under 3 conditions: (1) specimen with intact glenoid, (2) specimen after a bone defect measuring 25% of the maximal width of the glenoid was made in the anteroinferior glenoid, and (3) specimen after size-matched glenoid augmentation with a scapular spine tricortical autograft. The primary outcome was the change in peak joint-reaction forces between the defect state and augmented state. Results: One matched pair was removed from final analysis secondary to anatomic concerns that undermined the accuracy of test results. Among the 10 remaining specimens, all showed a significant decrease in peak joint-reaction force after the glenoid defect was created compared with the intact state (P < .001). All remaining specimens showed an increase in peak joint-reaction force in the augmented state compared with the defect state (P < .001). On average, the augmented state restored 81% of the peak reaction force of the glenohumeral joint compared with the intact state, a nonsignificant difference (P = .07). Conclusion: The study findings indicated that autograft harvested from the scapular spine increased the bony restraint to anterior shoulder dislocation in shoulders with glenoid bone loss. Clinical Relevance: The scapular spine is an alternative for bony augmentation of glenoid defects in shoulder instability.
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Affiliation(s)
- Marcus Mittelsteadt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bradley J Nelson
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,TRIA Orthopedic Center, Bloomington, Minnesota, USA
| | - Eric M Rohman
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert A Arciero
- Department of Orthopedic Surgery, UConn Health, Farmington, Connecticut, USA
| | - Marc A Tompkins
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,TRIA Orthopedic Center, Bloomington, Minnesota, USA
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Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement. Arthroscopy 2022; 38:224-233.e6. [PMID: 34332052 DOI: 10.1016/j.arthro.2021.07.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. METHODS A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. CONCLUSION Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. LEVEL OF EVIDENCE Level V, expert opinion.
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Waltenspül M, Häller T, Ernstbrunner L, Wyss S, Wieser K, Gerber C. Long-term results after posterior open glenoid wedge osteotomy for posterior shoulder instability associated with excessive glenoid retroversion. J Shoulder Elbow Surg 2022; 31:81-89. [PMID: 34216782 DOI: 10.1016/j.jse.2021.05.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Treatment of posterior shoulder instability (PSI) associated with excessive glenoid retroversion is a rare, challenging problem in shoulder surgery. One proposed technique is posterior open wedge glenoid osteotomy to correct excessive glenoid retroversion as described by Scott. However, this operation is rarely performed, and limited long-term outcomes using this approach are available. The goal of this study was to analyze the long-term outcomes of posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion. METHODS Six consecutive patients (7 shoulders) with a mean age of 24 years (range 19-34) were treated with posterior open wedge glenoid osteotomy for PSI associated with a glenoid retroversion greater than 15° and followed up clinically and radiographically at a mean age of 15 years (range 10-19). RESULTS Recurrent, symptomatic PSI was observed in 6 of 7 shoulders (86%). One necessitated revision with a posterior (iliac crest) bone block procedure and was rated as a failure and excluded from functional analysis. One patient rated his result as excellent, 3 as good, 1 as fair, and 1 as unsatisfactory. Mean relative Constant Score (CS%) was unchanged from preoperation to final follow-up (CS% = 72%) and pain did not significantly decrease (Constant Score = 7-10 points; P = .969). The mean Subjective Shoulder Value (SSV) improved postoperatively, but with 6 patients the improvement did not reach statistical significance (SSV = 42%-67%, P = .053) and the total Western Ontario Shoulder Instability Index averaged 30% at the final follow-up. Mean glenoid retroversion of all 7 shoulders was corrected from 20° (range 16°-26°) to 3° (range -3° to +8°) (P = .018). In the 5 shoulders with preoperative static posterior subluxation of the humeral head, the humeral head was not recentered. All 7 shoulders showed progression of glenoid arthritic changes. CONCLUSIONS Posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion neither reliably restored shoulder stability nor recentered the joint or prevent progression of osteoarthritis. Alternative treatments for PSI associated with excessive glenoid retroversion have to be developed and evaluated.
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Affiliation(s)
- Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Thomas Häller
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lukas Ernstbrunner
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sabine Wyss
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Tahir M, Malik S, Jordan R, Kronberga M, D'Alessandro P, Saithna A. Arthroscopic bone block stabilisation procedures for glenoid bone loss in anterior glenohumeral instability: A systematic review of clinical and radiological outcomes. Orthop Traumatol Surg Res 2021; 107:102949. [PMID: 33932578 DOI: 10.1016/j.otsr.2021.102949] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/27/2021] [Accepted: 02/12/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation. METHODS This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5-37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0-18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92-100% in 8 out of 10 studies at mean follow up range 6-78.7 months but two reported lower rates ranging from 58.3-84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10-16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation. CONCLUSION Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods. LEVEL OF EVIDENCE IV; systematic review.
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Affiliation(s)
- Muaaz Tahir
- Trauma and orthopaedic surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2TH Birmingham, UK.
| | - Shahbaz Malik
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Robert Jordan
- Trauma and orthopaedic surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2TH Birmingham, UK
| | - Madara Kronberga
- Trauma and orthopaedic surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2TH Birmingham, UK
| | | | - Adnan Saithna
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
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Ernstbrunner L, Häller T, Waltenspül M, Wieser K, Gerber C. Posterior Open-wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-free, J-shaped Iliac Crest Bone Graft in Atraumatic Posterior Instability with Pathologic Glenoid Retroversion and Dysplasia: A Preliminary Report. Clin Orthop Relat Res 2021; 479:1995-2005. [PMID: 33847693 PMCID: PMC8373563 DOI: 10.1097/corr.0000000000001757] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery. QUESTIONS/PURPOSES In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up? METHODS Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care. RESULTS In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned. CONCLUSION In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Lukas Ernstbrunner
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Thomas Häller
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Maiotti M, Russo R, Zanini A, Castricini R, Castellarin G, Schröter S, Massoni C, Savoie FH. Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity. Arthroscopy 2021; 37:2055-2062. [PMID: 33581299 DOI: 10.1016/j.arthro.2021.01.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | - Raffaele Russo
- Orthopedics and Traumatology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Antonio Zanini
- Orthopedics and Traumatology Unit, San Clemente Hospital, Mantua, Italy
| | | | | | - Steffen Schröter
- Department of Orthopedics, Eberhard Karls University, Tübingen, Germany
| | - Carlo Massoni
- Orthopedics and Traumatology Unit, Pio XI Hospital, Rome
| | - Felix Henry Savoie
- Tulane Institute of Sports Medicine, Tulane University, New Orleans, LA, USA
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Camenzind RS, Gossing L, Martin Becerra J, Ernstbrunner L, Serane-Fresnel J, Lafosse L. Restoration of the Posterior Glenoid in Recurrent Posterior Shoulder Instability Using an Arthroscopically Placed Iliac Crest Bone Graft: A Computed Tomography-Based Analysis. Orthop J Sports Med 2021; 9:2325967120976378. [PMID: 33553454 PMCID: PMC7844463 DOI: 10.1177/2325967120976378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/04/2020] [Indexed: 01/25/2023] Open
Abstract
Background Posterior shoulder instability is uncommon, and its treatment is a challenging problem. An arthroscopically assisted technique for posterior iliac crest bone grafting (ICBG) has shown promising short- and long-term clinical results. Changes as shown on imaging scans after posterior ICBG for posterior shoulder instability have not been investigated in the recent literature. Purpose To evaluate changes on computed tomography (CT) after arthroscopically assisted posterior ICBG and to assess clinical outcomes. Study Design Case series; Level of evidence, 4. Methods Patients with preoperative CT scans and at least 2 postoperative CT scans with a minimum follow-up of 2 years were included in the evaluation. Of 49 initial patients, 17 (follow-up rate, 35%) met the inclusion criteria and were available for follow-up. We measured the glenoid version angle and the glenohumeral and scapulohumeral indices on the preoperative CT scans and compared them with measurements on the postoperative CT scans. Postoperatively, graft surface, resorption, and defect coverage were measured and compared with those at early follow-up (within 16 months) and final follow-up (mean ± SD, 6.6 ± 2.8 years). Results The mean preoperative glenoid version was -17° ± 13.5°, which was corrected to -9.9° ± 11.9° at final follow-up (P < .001). The humeral head was able to be recentered and reached normal values as indicated by the glenohumeral index (51.8% ± 6%; P = .042) and scapulohumeral index (59.6% ± 10.2%; P < .001) at final follow-up. Graft surface area decreased over the follow-up period, from 24% ± 9% of the glenoid surface at early follow-up to 17% ± 10% at final follow-up (P < .001). All clinical outcome scores had improved significantly. Progression of osteoarthritis was observed in 47% of the shoulders. Conclusion Arthroscopically assisted posterior ICBG restored reliable parameters as shown on CT scans, especially glenoid version and the posterior subluxation indices. Graft resorption was common and could be observed in all shoulders. Patient-reported clinical outcome scores were improved. Osteoarthritis progression in almost 50% of patients is concerning for the long-term success of this procedure.
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Affiliation(s)
- Roland S Camenzind
- Alps Surgery Institute, Clinique Générale d'Annecy, Annecy, France.,Department of Orthopaedic Surgery, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Louis Gossing
- Alps Surgery Institute, Clinique Générale d'Annecy, Annecy, France.,Department of Orthopaedic Surgery, Braine-l'Alleud-Waterloo Hospital, Centre Hospitalier Interrégional Edith Cavell (CHIREC), Braine-l'Alleud, Belgium
| | - Javier Martin Becerra
- Alps Surgery Institute, Clinique Générale d'Annecy, Annecy, France.,Ortomove, Centro Medico ABC, Mexico City, Mexico
| | - Lukas Ernstbrunner
- Department of Orthopaedic Surgery, University of Zurich, Balgrist University Hospital, Zurich, Switzerland
| | - Julien Serane-Fresnel
- Alps Surgery Institute, Clinique Générale d'Annecy, Annecy, France.,IECEM - Research Unit, Polyclinique Saint Côme, Compiègne, France
| | - Laurent Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, Annecy, France
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Lemmex D, Cárdenas G, Ricks M, Woodmass J, Chelli M, Boileau P. Arthroscopic Management of Anterior Glenoid Bone Loss. JBJS Rev 2020; 8:e0049. [DOI: 10.2106/jbjs.rvw.19.00049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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17
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Imhoff FB, Camenzind RS, Obopilwe E, Cote MP, Mehl J, Beitzel K, Imhoff AB, Mazzocca AD, Arciero RA, Dyrna FGE. Glenoid retroversion is an important factor for humeral head centration and the biomechanics of posterior shoulder stability. Knee Surg Sports Traumatol Arthrosc 2019; 27:3952-3961. [PMID: 31254026 DOI: 10.1007/s00167-019-05573-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/17/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Glenoid retroversion is a known independent risk factor for recurrent posterior instability. The purpose was to investigate progressive angles of glenoid retroversion and their influence on humeral head centration and posterior translation with intact, detached, and repaired posterior labrum in a cadaveric human shoulder model. METHODS A total of 10 fresh-frozen human cadaveric shoulders were investigated for this study. After CT- canning, the glenoids were aligned parallel to the floor, with the capsule intact, and the humerus was fixed in 60° of abduction and neutral rotation. Version of the glenoid was created after wedge resection from posterior and fixed with an external fixator throughout the testing. Specimens underwent three conditions: intact, detached, and repaired posterior labrum, while version of the glenoid was set from + 5° anteversion to - 25° retroversion by 5° increments. Within the biomechanical setup, the glenohumeral joint was axially loaded (22 N) to center the joint. At 0° of glenoid version and intact labrum, the initial position was used as baseline and served as point zero of centerization. After cyclic preloading, posterior translation force (20 N) was then applied by a material testing machine, while start and endpoints of the scapula placed on an X-Y table were measured. RESULTS The decentralization of the humeral head at glenoid version angles of 5°, 10°, 15°, and 20° of retroversion and 5° of anteversion was significantly different (P < 0.001). Every increment of 5° of retroversion led to an additional decentralization of the humeral head overall by (average ± SD) 2.0 mm ± 0.3 in the intact and 2.0 mm ± 0.7 in the detached labrum condition. The repaired showed significantly lower posterior translation compared to the intact condition at 10° (P = 0.012) and 15° (P < 0.01) of retroversion. In addition, CT measured parameters (depth, diameter, and native version) of the glenoid showed no correlation with angle of dislocation of each specimen. CONCLUSION Bony alignment in terms of glenoid retroversion angle plays an important role in joint centration and posterior translation, especially in retroversion angles greater than 10°. Isolated posterior labrum repair has a significant effect on posterior translation in glenoid retroversion angles of 5° and 10°. Bony correction of glenoid version may be considered to address posterior shoulder instability with retroversion > 15°.
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Affiliation(s)
- Florian B Imhoff
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Roland S Camenzind
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Julian Mehl
- Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Knut Beitzel
- Department of Shoulder Surgery, ATOS Clinic, Cologne, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Robert A Arciero
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA
| | - Felix G E Dyrna
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building W1, 48149, Münster, Germany.
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18
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Willemsen K, Berendes TD, Geurkink T, Bleys RL, Leeflang MA, Weinans H, Castelein RM, Nelissen RG, van der Wal BC. A Novel Treatment for Anterior Shoulder Instability: A Biomechanical Comparison Between a Patient-Specific Implant and the Latarjet Procedure. J Bone Joint Surg Am 2019; 101:e68. [PMID: 31318812 PMCID: PMC6641476 DOI: 10.2106/jbjs.18.00892] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anterior glenohumeral instability with >20% glenoid bone loss is a disorder that can be treated with the Latarjet stabilizing procedure; however, complications are common. The purposes of this study were to (1) evaluate the effect of an anatomic-specific titanium implant produced by 3-dimensional (3D) printing as a treatment option for recurrent shoulder instability with substantial glenoid bone loss and (2) compare the use of that implant with the Latarjet procedure. METHODS Ten fresh-frozen cadaveric shoulders (mean age at the time of death, 78 years) were tested in a biomechanical setup with the humerus in 30° of abduction and in neutral rotation. The shoulders were tested under 5 different conditions: (1) normal situation, (2) creation of an anterior glenoid defect, (3) implantation of an anatomic-specific titanium implant produced by 3D printing, and the Latarjet procedure (4) with and (5) without 10 N of load attached to the conjoined tendon. In each condition, the humerus was translated 10 mm anteriorly relative to the glenoid, and the maximum peak translational force that was necessary for this translation was measured. RESULTS After creation of the glenoid defect, the mean translational peak force decreased by 30% ± 6% compared with that for the normal shoulder. After restoration of the original glenoid anatomy, the translational force needed to dislocate the humeral head from the glenoid significantly increased compared with that in the defect condition-to 119% ± 16% of normal (p < 0.01) with the 3D-printed anatomic-specific implant and to 121% ± 48% of normal (p < 0.01) following the Latarjet procedure. No significant differences in mean translational force were found between the anatomic-specific implant and the Latarjet procedure (p = 0.72). CONCLUSIONS The mean translational peak force needed to dislocate the humerus 10 mm anteriorly on the glenoid was higher after glenoid restoration with the 3D-printed anatomic-specific implant compared with when the glenoid had a 20% surface defect but also compared with when the glenoid was intact. No differences in mean translational peak force were found between the 3D-printed anatomic-specific glenoid implant and the Latarjet procedure, although there was less variability in the 3D-implant condition. CLINICAL RELEVANCE Novel 3D-printing technology could provide a reliable patient-specific alternative to solve problems related to traditional treatment methods for shoulder instability.
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Affiliation(s)
- Koen Willemsen
- Departments of Orthopaedics (K.W., T.G., H.W., R.M.C., and B.C.H.v.d.W.) and Anatomy (R.L.A.W.B.), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Thomas D. Berendes
- Department of Orthopaedics, Meander Medical Centre, Amersfoort, the Netherlands
| | - Timon Geurkink
- Departments of Orthopaedics (K.W., T.G., H.W., R.M.C., and B.C.H.v.d.W.) and Anatomy (R.L.A.W.B.), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ronald L.A.W. Bleys
- Departments of Orthopaedics (K.W., T.G., H.W., R.M.C., and B.C.H.v.d.W.) and Anatomy (R.L.A.W.B.), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Marius A. Leeflang
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Harrie Weinans
- Departments of Orthopaedics (K.W., T.G., H.W., R.M.C., and B.C.H.v.d.W.) and Anatomy (R.L.A.W.B.), University Medical Centre Utrecht, Utrecht, the Netherlands,Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - René M. Castelein
- Departments of Orthopaedics (K.W., T.G., H.W., R.M.C., and B.C.H.v.d.W.) and Anatomy (R.L.A.W.B.), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Bart C.H. van der Wal
- Departments of Orthopaedics (K.W., T.G., H.W., R.M.C., and B.C.H.v.d.W.) and Anatomy (R.L.A.W.B.), University Medical Centre Utrecht, Utrecht, the Netherlands
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19
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Haas M, Plachel F, Wierer G, Heuberer P, Hoffelner T, Schulz E, Anderl W, Moroder P. Glenoid morphology is associated with the development of instability arthropathy. J Shoulder Elbow Surg 2019; 28:893-899. [PMID: 30509607 DOI: 10.1016/j.jse.2018.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/06/2018] [Accepted: 09/16/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Instability arthropathy (IA) is a major long-term concern in patients with anterior shoulder instability. This study investigated the association of glenoid morphology with the development of IA. METHODS The study included 118 patients with unilateral anterior shoulder instability and available bilateral computed tomography scans. Instability-specific information was obtained from all patients. The glenoid morphology of the affected shoulder was compared with the nonaffected contralateral side resembling the constitutional preinjury glenoid shape. Both shoulders were evaluated independently by 3 observers to assess the grade of IA according to a Comprehensive Arthropathy Rating (CAR) system. Associations between IA and the glenoid morphology parameters were investigated. RESULTS The average glenoid retroversion (P < .001), glenoid depth (P < .001), glenoid diameter (P < .001), and the bony shoulder stability ratio (P < .001) of the affected shoulder were significantly reduced compared with the contralateral side due to bony defects in 79.6% of the patients. The CAR of the affected side was significantly higher (P < .001), with more osteophytes (P = .001) and more sclerosis and cysts (P < .001). Differences in CAR (Δ-CAR) correlated positively with the age at the time of the computed tomography scan (P < .001), age at the initial dislocation (P = .001), size of the glenoid defect (P = .005), and the contralateral glenoid depth (P = .011), glenoid diameter (P = .016), and bony shoulder stability (P = .029), and negatively with glenoid retroversion of the affected side (P = .027). CONCLUSION Development of IA arthropathy is associated not only with the age of the patients but also with morphologic parameters of the glenoid, including glenoid defect size and the constitutional glenoid concavity shape.
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Affiliation(s)
- Maximilian Haas
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria.
| | - Fabian Plachel
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria; Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin, Berlin, Germany
| | - Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Philipp Heuberer
- Department of Orthopedic Surgery, St. Vincent Shoulder & Sports Clinic, Vienna, Austria
| | - Thomas Hoffelner
- Department of Orthopedic Surgery, St. Vincent Shoulder & Sports Clinic, Vienna, Austria
| | - Eva Schulz
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Salzburg, Austria
| | - Werner Anderl
- Department of Orthopedic Surgery, St. Vincent Shoulder & Sports Clinic, Vienna, Austria
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin, Berlin, Germany
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20
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Mehl J, Otto A, Imhoff FB, Murphy M, Dyrna F, Obopilwe E, Cote M, Lädermann A, Collin P, Beitzel K, Mazzocca AD. Dynamic Anterior Shoulder Stabilization With the Long Head of the Biceps Tendon: A Biomechanical Study. Am J Sports Med 2019; 47:1441-1450. [PMID: 30964697 DOI: 10.1177/0363546519833990] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The concept of dynamic anterior shoulder stabilization (DAS) combines a Bankart repair with the additional sling effect of the long head of the biceps (LHB) tendon to treat anterior glenohumeral instability. This surgical technique was created to close the gap between the indications for isolated Bankart repair and those requiring bone transfer techniques. PURPOSE To biomechanically investigate the stabilizing effects of the DAS technique in comparison with the standard Bankart repair in different defect models. STUDY DESIGN Controlled laboratory study. METHODS Twenty-four fresh-frozen cadaveric shoulders (mean ± SD age, 60.1 ± 8.6 years) were mounted in a 6 degrees of freedom shoulder testing system. With cross-sectional area ratios, the rotator cuff muscles and LHB tendon were loaded with 40 N and 10 N, respectively. Anterior and inferior glenohumeral translation was tested in 60° of abduction and 60° of external rotation (ABER position) while forces of 20 N, 30 N, and 40 N were applied to the scapula in the posterior direction. Total translation and relative translation in relation to the native starting position were measured with a 3-dimensional digitizer. Maximal external rotation and internal rotation after application of 1.5-N·m torque to the humerus were measured. All specimens went through 4 conditions (intact, defect, isolated Bankart repair, DAS) and were randomized to 1 of 3 defect groups (isolated Bankart lesion, 10% anterior glenoid defect, 20% anterior glenoid defect). The DAS was performed by transferring the LHB tendon through a subscapularis split to the anterior glenoid margin, where it was fixed with an interference screw. RESULTS Both surgical techniques resulted in decreased anterior glenohumeral translation in comparison with the defect conditions in all defect groups. As compared with isolated Bankart repair, DAS showed significantly less relative anterior translation in 10% glenoid defects at translation forces of 20 N (0.3 ± 1.7 mm vs 2.2 ± 1.8 mm, P = .005) and 30 N (2.6 ± 3.4 mm vs 5.3 ± 4.2 mm, P = .044) and in 20% glenoid defects at all translation forces (20 N: -3.2 ± 4.7 mm vs 0.8 ± 4.1 mm, P = .024; 30 N: -0.9 ± 5.3 mm vs 4.0 ± 5.2 mm, P = .005; 40 N: 2.1 ± 6.6 mm vs 6.0 ± 5.7 mm, P = .035). However, in 20% defects, DAS led to a relevant posterior and inferior shift of the humeral head in the ABER position and to a relevant increase in inferior glenohumeral translation. Both surgical techniques did not limit the rotational range of motion. CONCLUSION In the context of minor glenoid bone defects, the DAS technique demonstrates less relative anterior translation as compared with an isolated Bankart repair at time zero. CLINICAL RELEVANCE The new DAS technique seems capable of closing the gap between the indications for isolated Bankart repair and bone transfer techniques.
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Affiliation(s)
- Julian Mehl
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Alexander Otto
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA.,Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Florian B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Matthew Murphy
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Felix Dyrna
- Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Mark Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire, Saint-Grégoire, France
| | - Knut Beitzel
- Department of Orthopaedic Sports Medicine, Technical University, Munich, Germany
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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21
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Holschen M, Agneskirchner JD. Innovationen bei der arthroskopischen Therapie der Schulterinstabilität. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-018-0242-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Russo R, Maiotti M, Taverna E, Rao C. Arthroscopic Bone Graft Procedure Combined With Arthroscopic Subscapularis Augmentation for Recurrent Anterior Instability With Glenoid Bone Defect. Arthrosc Tech 2018; 7:e623-e632. [PMID: 29955568 PMCID: PMC6020248 DOI: 10.1016/j.eats.2018.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/17/2018] [Indexed: 02/03/2023] Open
Abstract
Glenoid bone loss and capsular deficiency represent critical points of arthroscopic Bankart repair failures. The purpose of this Technical Note is to present an all-arthroscopic bone block procedure associated with arthroscopic subscapularis augmentation for treating glenohumeral instability with glenoid bone loss and anterior capsulolabral deficiency. Two glenoid tunnels are set up from the posterior to the anterior side using a dedicated bone block guide, and 4 buttons are used to fix the graft to the glenoid. The subscapularis tenodesis is performed using a suture tape anchor. This combined arthroscopic technique (bone block associated with arthroscopic subscapularis augmentation) could be a valid and safe alternative to the arthroscopic or open Latarjet procedures.
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Affiliation(s)
- Raffaele Russo
- Orthopedics and Traumatology Unit, Pellegrini Hospital, Naples, Italy
| | - Marco Maiotti
- Sports Medicine Unit and Orthopedic Center, San Giovanni Addolorata Hospital, Rome, Italy
| | - Ettore Taverna
- Orthopedics and Traumatology Unit, Galeazzi Hospital, Milan, Italy
| | - Cecilia Rao
- Orthopedics and Traumatology Unit, University of Tor Vergata, Rome, Italy
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23
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Anderl W, Heuberer P, Resch H, Ernstbrunner L. Authors' Response to the Editorial Commentary "Is Arthroscopic Bone Grafting Nearly Equivalent to Open Bone Grafting for Glenoid Bone Defects in Recurrent Anterior Shoulder Instability?" by Matthew T. Provencher. Arthroscopy 2018; 34:1752-1754. [PMID: 29804598 DOI: 10.1016/j.arthro.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/04/2018] [Indexed: 02/02/2023]
Affiliation(s)
| | | | - Herbert Resch
- Paracelsus Medical University Salzburg, Salzburg, Austria
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24
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Russo R, Maiotti M, Taverna E. Arthroscopic bone graft procedure combined with arthroscopic subscapularis augmentation (ASA) for recurrent anterior instability with glenoid bone defect: a cadaver study. J Exp Orthop 2018; 5:5. [PMID: 29484517 PMCID: PMC5826913 DOI: 10.1186/s40634-018-0121-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 02/14/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Glenoid bone loss and capsular deficiency represent critical points of arthroscopic Bankart repair failures. The purpose of this study was to evaluate an all-arthroscopic bone block procedure associated with arthroscopic subscapularis augmentation (ASA) for treating gleno-humeral instability with glenoid bone loss (GBL) and anterior capsulo-labral deficiency. Our hypothesis was that these two procedures could be combined arthroscopically. The feasibility of this technique and its reproducibility, and potential neurovascular complications were evaluated. METHODS A tricortical bone graft was harvested from the cadaveric clavicle, and in one case a Xenograft was used. An anterior-inferior GBL of about 25% was created. Two glenoid tunnels were set up from the posterior to the anterior side using a dedicated bone block guide, and four buttons were used to fix the graft to the glenoid. The subscapularis tenodesis was performed using a suture tape anchor. Afterwards, the shoulder was dissected to study the relationship between all portals and nerves. The size of the bone block, its position on the glenoid and the relationship with the subscapularis tendon were investigated. RESULTS In all seven specimens (five left and two right shoulders), the bone block was flush with the cartilage and fixed to the anterior-inferior part of the glenoid. No lesions of the surrounding neurovascular structures were observed. No interference was found between the two bone block tunnels and the anchor tunnel used for the tenodesis. CONCLUSIONS This study demonstrated the feasibility and reproducibility of this combined arthroscopic technique (bone block associated with ASA) in the treatment of anterior shoulder instability associated with anterior bone loss and anterior capsular deficiency.
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Affiliation(s)
- Raffaele Russo
- Orthopedics and Traumatology Unit, Pellegrini Hospital, Via Portamedina alla Pignasecca 41, 80134 Naples, Italy
| | - Marco Maiotti
- Sports Medicine Unit & Orthopedic Center, San Giovanni Addolorata Hospital, Via dell’Amba Aradam 9, 00184 Rome, Italy
| | - Ettore Taverna
- Orthopedics and Traumatology Unit, Galeazzi Hospital, Via Riccardo Galeazzi 4, 20161, Milan, Italy
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