Arthroscopic bone graft procedure combined with arthroscopic subscapularis augmentation (ASA) for recurrent anterior instability with glenoid bone defect: a cadaver study

Shoulder Prosthetic Infection and Humerus Osteomyelitis From Cutibacterium Following Eden-Hybinette Procedure

We describe the case of a patient who recently underwent a guided arthroscopic Eden-Hybinette procedure for the revision of a previous failed procedure of Latarjet and resurgence of shoulder instability. The subsequent development of painful infectious arthritis of the left shoulder complicated by osteomyelitis of the humerus, caused by Cutibacterium acnes, and accompanied by high fever was resolved only after the removal of synthetic screws and bone grafting and thanks to prolonged intravenous antibiotic treatment. The antibiotic regime was continued, both intramuscularly and orally, after discharge, allowing the full healing of the severe osteoarticular infection of the shoulder.

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

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

Transglenoid Fixation Technique for Arthroscopic Subscapularis Augmentation Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

The optimal surgical management of anterior shoulder instability remains controversial. Although it has low recurrence rates and good clinical results, the Latarjet procedure has some disadvantages and is considered "overtreatment" in inactive patients with moderate glenoid bone loss. Several studies have described an arthroscopic technique called arthroscopic subscapularis augmentation. We developed a technical variation of the arthroscopic subscapularis augmentation technique involving tenodesis of the upper third of the subscapularis tendon using a graft. This technique uses a transglenoid fixation-immobilization with 2 knotless TightRope devices instead of anchors.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case series.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bone integration in acetabular revision hip arthroplasty using equine-derived bone grafts: a retrospective study

PURPOSE

During the last decade, total hip arthroplasty has become a common procedure performed in young patients, as well as elderly ones. This has led to an increase in total hip arthroplasty revisions. Loosening of primary components with associated bone loss represents the major cause of total hip arthroplasty revision. This study evaluates the safety and performance of an enzyme-deantigenic equine-derived bone graft material in acetabular defect reconstruction.

METHODS

Records of 55 patients who were treated for Paprosky type II or III acetabular bone defects with arthroplasty revisions using equine-derived bone and followed for an average of 34 months (range from 24 to 48 months) were analyzed.

RESULTS

Of the 55 revisions, 49 (89%) were regarded as successful, showing good osteointegration without signs of mobilization. Failures included six cases (11%) of mobilization: five cases of aseptic mobilization (9.1% of revisions, 83% of failures) and one case of septic mobilization (1.9% of revisions, 17% of failures). These results are consistent with those of studies having a similar follow-up period for allografts used in combination with trabecular metal components.

CONCLUSIONS

Results of the present study suggest that enzyme-treated equine-derived bone grafts may be a valid alternative to autogenous and homologous bone grafts in total hip arthroplasty revision.

Arthroscopic subscapularis augmentation combined with capsulolabral reconstruction is safe and reliable

PURPOSE

The study aimed to compare modified arthroscopic subscapularis augmentation (MASA) with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction (Group A) or Bankart repair (Group B) for recurrent anterior shoulder instability (RASI).

METHODS

A retrospective series of 49 patients underwent primary surgery for RASI with glenoid bone loss (GBL) < 25%. Outcomes included the Oxford Shoulder Instability Score (OSIS), Visual Analogue Scale (VAS) score, Rowe score, and American Shoulder and Elbow Surgeons (ASES) functional outcome scale score. Recurrent instability, sports activity level, and range of motion (ROM) were also analysed.

RESULTS

No significant differences were observed at baseline. Forty-six patients were available for more than 2 years of follow-up. At the last follow-up after surgery, the patients in both groups had experienced significant improvements in all outcome scores (P < 0.05 for all), and obvious decreases in forward flexion and external rotation were noted in both groups (P < 0.05 for all). Group A had superior ASES scores, VAS scores, and OSISs (P < 0.05) but did not experience significant differences in either the Rowe score or ROM compared to Group B. Group A had lower rates of recurrent instability and superior outcomes for the return to sports activities. One patient in Group A had subluxation, and 4 patients in Group B had dislocation or subluxation. No patients in either group experienced neurovascular injury, joint stiffness, or surgical wound infection.

CONCLUSION

For RASI with GBL < 25%, MASA with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction was a safe technique that produced better outcomes in terms of ASES scores, VAS scores, OSISs, the return to sports, and postoperative recurrent instability and did not decrease the ROM compared to that achieved by arthroscopic Bankart repair.

LEVEL OF EVIDENCE

III.

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

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

Biomechanical Comparison of the Long Head of the Biceps Tendon Versus Conjoint Tendon Transfer in a Bone Loss Shoulder Instability Model

Background:

Augmentation of Bankart repair with long head of the biceps tendon transfer has been previously described, although there is a paucity of literature describing its biomechanical effects.

Purpose/Hypothesis:

The purpose of this study was to assess the effect of augmenting Bankart repair with either the conjoint tendon or the long head of the biceps tendon, both with and without subcritical (13%) glenoid bone loss. We hypothesized that, in a cadaveric model, augmenting Bankart repair with the long head of the biceps tendon would restore a greater degree of stability compared with augmenting Bankart repair with the conjoint tendon.

Study Design:

Controlled laboratory study.

Methods:

A total of 12 cadaveric shoulders were tested on a 6-degrees-of-freedom robotic musculoskeletal simulator to measure the peak resistance force due to an anterior displacement of 1 cm. The rotator cuff muscles were loaded during testing to simulate physiological conditions. The following test conditions were used for each specimen: (1) intact shoulder, (2) Bankart lesion with 13% anterior bone loss, (3) 13% bone loss with Bankart repair (anchors placed at the 3-, 4-, and 5-o’clock positions), (4) 13% bone loss with both Bankart repair and transfer of the long head of the biceps tendon, and (5) 13% bone loss with Bankart repair and transfer of the conjoint tendon.

Results:

Labral repair with the addition of long head of the biceps tendon transfer had the greatest peak resistance force to anterior displacement among all groups (54.1 ± 5.5 N) and was significantly stronger than both standard Bankart repair by 16.3% (46.5 ± 7.6 N; P = .039) and the conjoint transfer procedure by 16.6% (46.4 ± 7.7 N; P = .008).

Conclusion:

Given the susceptibility of recurrent instability in shoulders with subcritical bone loss after isolated labral repair, it is important to consider augmenting Bankart repair in high-risk patients to avoid potential recurrence and the need for reoperations. Transferring the long head of the biceps tendon to the anterior glenoid represents one possible augmentation.

Clinical Relevance:

We present biomechanical data for a relatively novel technique for augmenting capsulolabral repair strength in an anterior instability model with subcritical bone loss. These data represent biomechanical justification for the utilization of this relatively novel technique.

Arthroscopic treatment of posterior instability of the shoulder with an associated reverse Hill-Sachs lesion using an iliac bone-block autograft

Posterior dislocation of the shoulder is often accompanied by an impression fracture in the anterior surface of the humeral head, called a reverse Hill-Sachs injury. This bone defect can engage on the posterior glenoid rim, which can lead to recurrent instability and progressive joint destruction. We describe a new arthroscopic procedure that fills the reverse Hill-Sachs lesion with an iliac bone-block autograft and repairs the posterior articular capsule arthroscopically, which can stabilize the posterior shoulder. It avoids the need to detach the subscapularis tendon and can reduce the risks associated with open procedures. LEVEL OF EVIDENCE: V, technical note.