Indications and outcomes of glenoid osteotomy for posterior shoulder instability: a systematic review

Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement

PURPOSE

To establish consensus statements on glenoid bone grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability.

METHODS

A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their greater risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain.

CONCLUSIONS

The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired.

LEVEL OF EVIDENCE

Level V, expert opinion.

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.

Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts

» Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.» Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.» For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.» For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.

Posterior Shoulder Instability and Glenoid Bone Loss: A Review and a Free Bone Graft Technique

Posterior glenoid bone loss (pGBL) is frequently associated with posterior shoulder instability. Posterior glenohumeral instability accounts for a small percentage of shoulder pathologies, and critical bone loss in posterior instability has not been well defined in the literature. Younger patient populations who participate in activities that repetitively stress the posterior stabilizing structures of the shoulder are more prone to developing posterior shoulder instability. A variety of surgical options have been described, ranging from isolated capsulolabral repair to glenoid osteotomy. Soft-tissue repair alone may be an inadequate treatment in cases of pGBL and places patients at a high risk of recurrence. Our preferred technique for posterior glenoid reconstruction in cases of pGBL involves the transfer of a free iliac crest bone graft onto the native glenoid. The graft is contoured to fit the osseous defect and secured to provide an extension of the glenoid track. In this study, we review pGBL in the setting of posterior instability and describe our technique in detail. Further long-term studies are needed to refine the indications for glenoid bone graft procedures and quantify what constitutes a critical pGBL.

Arthroscopic Posterior Glenoid Osteotomy

Management of posterior shoulder instability in patients with excessive glenoid retroversion can be challenging. However, a corrective posterior glenoid osteotomy is an option. Although various open techniques are available, minimally invasive and arthroscopy surgery are the most advantageous. This study describes the feasibility and safety of an arthroscopic posterior open wedge glenoid osteotomy using an autologous scapular spine graft along with additional posterior capsulolabral complex reattachment. This procedure is a viable option for patients with symptomatic posterior shoulder instability.

Posterior Shoulder Instability but Not Anterior Shoulder Instability Is Related to Glenoid Version

Purpose

To assess and compare glenoid version in patients with anterior shoulder instability (ASI), posterior shoulder instability (PSI), and a control group.

Methods

The operative notes of all patients that had undergone arthroscopic shoulder instability repair between January 2017 and May 2022 were retrospectively reviewed. Magnetic resonance imaging scans were then analyzed, and glenoid version was measured by a single blinded observer. A P value <.05 was considered statistically significant.

Results

There were 100 patients included in the ASI group, 65 in PSI group, and 100 in the control group. The mean glenoid versions for the ASI group were -16°, -9.1°, and -9.2° for the vault version, simplified vault version, and chondrolabral version, respectively. The mean glenoid versions for the PSI group were -21°, -13.4°, and -16.6° for the vault version, simplified vault version, and chondrolabral version, respectively. The mean versions for the control group were -17.8°, -9.5°, and -9.8° for the vault version, simplified vault version and chondrolabral version, respectively. ANOVA testing and post hoc comparisons revealed the PSI group to be significantly more retroverted than both other groups P < .001. The ASI group's degree of glenoid version was not significantly different to that of the control P = .009.

Conclusion

Patients with PSI have a higher degree of retroversion in comparison to those with ASI and control. There is no significant difference in glenoid version among patients with ASI when compared with control.

Level of Evidence

Level III, retrospective comparative study.

Posterior Glenoid Bone Loss and Instability: An Evidence-based Approach to Diagnosis and Management

Posterior glenohumeral instability is an underappreciated cause of disability that may necessitate surgical intervention to allow functional glenoid restoration. However, posterior glenoid bone abnormalities, when sufficiently severe, may contribute to persistent instability despite a well-performed capsulolabral repair. Recognition and understanding of these lesions is critical to both surgical decision making and execution of the surgical plan. Numerous procedures have been described to address posterior instability including recent developments in arthroscopic grafting techniques. The purpose of this article was to provide an evidence-based strategy for diagnosis and management of posterior shoulder instability and glenoid bone loss.