Iliac Crest Bone Grafting for the Management of Anterior Shoulder Instability in Patients with Glenoid Bone Loss: a Systematic Review of Contemporary Literature

Arthroscopic Autologous Iliac Bone Grafting With Double-Row Elastic Fixation and Double Antirotating Anchors for Recurrent Anterior Shoulder Dislocation With Massive Glenoid Bone Defect

The management of recurrent anterior shoulder dislocations with massive glenoid bone defects typically involves arthroscopic intervention. Autologous iliac bone grafting with double-row elastic fixation reportedly yields excellent outcomes. In this article, we introduce a specialized technique for iliac bone grafting that uses double-row elastic fixation and double antirotating anchors. Implementation of this technique prevents the occurrence of iliac graft rotation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Distal Radius Allograft for Glenohumeral Instability: A Novel Osteochondral Allograft Reconstruction Option in the Setting of Glenoid Bone Loss

BACKGROUND

Distal tibial allograft (DTA) reconstruction for glenoid bone loss is nonanatomic, as it does not match the glenoid radius of curvature (ROC) in the anterior-posterior (AP) plane. The dorsal articular portion of the distal radius has not been previously described as an allograft reconstruction option for glenoid bone loss.

PURPOSE

To evaluate distal radius fresh-frozen allograft (DRA) as a potential match for glenoid reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen fresh-frozen human cadaveric specimens-including 6 shoulder, 6 wrist, and 6 tibia specimens-were used. The ROC and the graft length were measured in the superior-inferior (SI) plane. A 30% defect was created in all glenoid specimens, and both DTAs and DRAs were harvested to assess graft fit after fixation. Computed tomography analysis was used to assess bony ROC and bone mineral density (BMD).

RESULTS

The cadaveric specimens had a mean age of 77 years. The mean SI glenoid length was 39.7 mm compared with 36.8 mm for the DRA and 30 mm for the DTA. The ROC in the SI plane was 29 ± 5.3 mm for the glenoid, 37.8 ± 4.9 mm for the DRA, and 24 ± 3.7 mm for the DTA. In the AP plane, the ROC was 39.6 ± 6.6 mm for the glenoid, 30.4 ± 18.6 mm for the DRA, and 126.3 ± 9.5 mm for the DTA. On computed tomography analysis, the ROC in the SI plane was 30.4 ± 1.5 mm for the glenoid, 30.3 ± 5.6 mm for the DRA, and 24.5 ± 9.4 mm for the DTA. In the AP plane, the ROC was 30.8 ± 2 mm for the glenoid, 19.1 ± 2.3 mm for the DRA, and 46.7 ± 21.7 mm for the DTA. The BMD was 226.3 ± 79 Hounsfield units (HU) for the glenoid, 228.5 ± 94.7 HU for the DRA, 235 ± 96.2 HU for the coracoid process, and 235.1 ± 84.6 HU for the DTA.

CONCLUSION

Compared with the DTA, the DRA had a greater mean graft length in the SI plane, providing utilization in cases of larger bony defects; the DRA has a more acute ROC in the AP plane (closer to that of the glenoid), providing a greater potential buttress to anterior humeral translation. Compared with currently utilized grafts, the DRA BMD was not significantly diminished. This study presents the DRA as a novel allograft reconstruction option in the setting of anterior glenoid bone loss; further biomechanical and clinical investigation is indicated.

Free Bone Block Procedures for Glenoid Reconstruction in Anterior Shoulder Instability

Advances in the understanding and management of bone loss in shoulder instability have led to the development of free bone block techniques as an alternative to the Latarjet procedure. These techniques have been proposed as a theoretically safer option to Latarjet, and there is growing clinical enthusiasm in their use. The purpose of this article was to contextualize the utilization of free bone block procedures in the current treatment paradigm of anterior shoulder instability and to review the history and common types of bone autograft (eg, iliac crest, distal clavicle, scapular spine) and allograft (eg, distal tibia, preshaped blocks) techniques and approaches, as well as their clinical effectiveness and safety.

Assessment of micromotion at the bone-bone interface after coracoid and scapular-spine bone-block augmentation for the reconstruction of critical anterior glenoid bone loss-a biomechanical cadaver study

BACKGROUND

Glenoid bone loss is among the most important risk factors for recurrent anterior shoulder instability, and a bony reconstruction is recommended in cases of critical bone loss (> 15%). The commonly used surgical techniques, including coracoid transfer, are associated with considerable complications. The aim of this study was to assess the motion at the glenoid-bone-block interface after coracoid and spina-scapula bone-block reconstruction of the anterior glenoid.

METHODS

Twelve cadaveric shoulders were tested. A 20% bone defect of the anterior glenoid was created, and the specimens were randomly assigned for glenoid augmentation using a coracoid bone block (n = 6) or a scapular spine bone block (n = 6). The glenoid-bone interface was cyclically loaded for 5000 cycles with a force of 170 N. The micromotion was tracked using an optical measurement system (GOM ARMIS) and was evaluated with the GOM Correlate Pro software.

RESULTS

The most dominant motion component was medial irreversible displacement for the spina-scapula (1.87 mm; SD: 1.11 mm) and coracoid bone blocks (0.91 mm; SD: 0.29 mm) (n.s.). The most medial irreversible displacement took place during the first nine cycles. The inferior reversible displacement was significantly greater for spina-scapula bone blocks (0.28 mm, SD: 0.16 mm) compared to coracoid bone blocks (0.06 mm, SD: 0.10 mm) (p = 0.02).

CONCLUSIONS

The medial irreversible displacement is the dominant motion component in a bone-block reconstruction after a critical bone loss of the anterior glenoid. The spina-scapula and coracoid bone blocks are comparable in terms of primary stability and extent of motion. Thus, spina-scapula bone blocks may serve as alternatives in bony glenoid reconstruction from a biomechanical point of view.

Arthroscopic Salvage Procedure for Iatrogenic Conjoint Tendon Avulsion Fracture Following Arthroscopic Latarjet Procedure Using Double Sling Fixation Technique - A Case Report

Introduction

We present a case report of an iatrogenic conjoint tendon avulsion fracture following arthroscopic Latarjet and salvage technique to address the complication with a novel double sling technique.

Case Report

A 16-year-old male patient who presented with recurrent instability of the right shoulder was counseled for an arthroscopic Latarjet procedure, taking account of critical glenoid bone loss and his contact sporting activities. An intraoperative coracoid tip fracture occurred, which was managed with the double sling technique. At 1-year follow-up, the patient has made a good recovery with a full range of movements and a stable shoulder; the CT scans showed a well-approximated coracoid tip fragment.

Conclusion

Iatrogenic intraoperative coracoid graft fractures during arthroscopic Latarjet can be managed depending on the site of the fracture and quality of the bone. The double sling fixation technique helps in maintaining the sling action of the conjoint tendon in patients with recurrent instability.

Scooping Technique to Acquire Cancellous Bone for Grafting in the Masquelet Procedure: A Retrospective Study

Background

The Masquelet procedure is effective in overcoming large bone defects; however, the limited number of cancellous bone and donor site complications remains a challenge. We developed a scooping technique to harvest sufficient cancellous bone from iliac crests for grafting during the Masquelet procedure. We hypothesized that this method would be efficient and safe.

Methods

This retrospective study included 13 patients who underwent the Masquelet procedure with cancellous bone grafting using the scooping technique. The following parameters were observed: (1) duration and total volume of cancellous bone extraction; (2) amount of bleeding and drainage fluid, and Visual Analog Scale (VAS) score of pain at the donor site during different periods; and (3) complications and bone regeneration at the ilium at the final follow-up.

Results

The median follow-up duration was 17 months. There were 3 unilateral and 10 bilateral extraction sites. The mean total amount extracted, extraction duration, bleeding, and drainage were 39 mL, 23 min, 49 mL, and 44 mL, respectively. Only three patients felt pain (VAS score: 1 point) at the final follow-up. Postoperatively, one case each of hematoma and lateral femoral cutaneous nerve injury supervened, and no infections or other complications occurred. The last computed tomography examination showed varying degrees of bone regeneration in the ilium.

Conclusion

The scooping technique for the iliac crest produced a substantial amount of autogenous cancellous bone using a small incision. It retained the appearance and morphology of the ilium with few complications. We believe it is a successful and safe option for treating bone defects.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

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.

Management of off-track Hill-Sachs lesions in anterior glenohumeral instability

Bone loss has been identified as a risk factor for recurrent shoulder dislocations or failure after soft tissue repair. Although the range for "critical" bone loss is yet to be determined, glenoid and humeral bone defects should not be regarded as independent problems, but the interaction between them during shoulder motion should be evaluated as suggested by the glenoid track concept. The glenoid track concept is now widely accepted and considered essential for making decisions about surgery. Soft-tissue procedures usually work well in patients with on-track Hill-Sachs lesions but in off-track lesions do not. In this situation additional procedures should be performed.Different surgical options have been described to address off-track Hill-Sachs lesions, most commonly remplissage, Latarjet or free bone block procedures. Coracoid graft and free bone grafts convert the off-track Hill-Sachs lesion into on-track by lengthening the glenoid-track, whereas remplissage fill-in the humeral lesion so that it does not engage. In the setting of a Hill-Sachs lesion with little or no glenoid bone loss, remplissage has demonstrated satisfactory outcomes with a low complications and recurrence rate. Favorable results have been reported with glenoid bone grafting when managing isolated Hill-Sachs or bipolar lesions. Studies analyzing Latarjet and Eden-Hybinette procedures show that both procedures are safe and effective in the management of anterior glenohumeral instability. Attention should be paid to those patients with large bone defects not amenable to be restored with an isolated Latarjet that may be better addressed with an Eden-Hybinnete or adding a remplissage to the Latarjet procedure.

Arthroscopic Autologous Iliac Crest Grafting Results in Similar Outcomes and Low Recurrence Compared to Remplissage Plus Bankart Repair for Anterior Shoulder Instability With Bipolar Bone Defects

PURPOSE

To compare the functional outcomes, range of motion (ROM), recurrence rates, and complication rates of arthroscopic autologous iliac crest grafting (AICG) and Remplissage plus Bankart repair (RB) for anterior shoulder instability with bipolar bone defects.

METHODS

This study enrolled patients undergoing arthroscopic AICG or RB with 13.5-25% glenoid bone defect combined with Hill-Sachs lesion between January 2013 and April 2020, who had a minimum 2-year follow-up. Patient-reported outcomes were evaluated by Subjective Shoulder Value (SSV), Oxford Shoulder Instability Score (OSIS), Rowe score, Constant score, and visual analog scale (VAS) for pain. Active ROM, return to sports, recurrence, self-reported apprehension, and complications were recorded.

RESULTS

This study included 60 patients, including 28 AICG (Group A) and 32 RB (Group R). Mean glenoid bone defect was similar (17.7% ± 3.1% vs 16.6% ± 2.4%; P = .122). Both groups showed significant postoperative improvement in Rowe score, SSV, OSIS, and Constant score. No significant difference was found in postoperative Rowe Score (87.7 vs 85.2; P = .198). A total of 20/28 (71.4%) patients in Group A versus 26/32 (81.3%) patients in Group R met the Patient Acceptable Symptomatic State determined by VAS pain score (P = .370). Both groups showed high return-to-sports rates (67.8% vs 71.8%; P = .735) and slightly decreased ROM. There were two cases of recurrence in Group A versus one in Group R (P = .594). Group R had insignificantly higher positive self-reported apprehension rate (40.6% vs 17.9%; P = .055).

CONCLUSION

For anterior shoulder instability with bipolar bone defects, both arthroscopic AICG and RB can result in satisfactory clinical outcomes, good postoperative ROM, and low recurrence and complication rates.

LEVEL OF EVIDENCE

Level III; retrospective cohort study.

CT-scan Evaluation of Osteointegration and Osteolysis in Different Graft Types and Surgical Techniques for the Treatment of Shoulder Instability

Background

Bone graft is often needed in treating anterior shoulder instability in glenoid bone loss and graft integration is crucial in achieving good results. This study aimed to evaluate bone graft remodeling in different techniques for shoulder anterior-inferior instability.

Methods

Graft osteointegration and osteolysis were retrospectively evaluated with CT-scan imaging performed 6 to 12 months after surgery to compare the outcome of three procedures: Latarjet, bone block with allograft, and bone block with xenograft. Screw fixation and double endobuttons fixation were also compared.

Results

CT scans of 130 patients were analyzed. Of these, 30 (23%) were performed after the bone block procedure with xenograft and endobuttons fixation, 55 (42%) after the bone block procedure with allograft and endobuttons fixation, 13 (10%) Latarjet with screw fixation and 32 (25%) Latarjet with endobuttons fixation. The prevalence of osteolysis was significantly inferior (P<.01) in the bone block procedure compared to the Latarjet procedure (11.7 % vs. 28.8 %). Bone integration was higher in bone block procedures (90.5%) than in Latarjet (84.4%), but the difference was not statistically significant. Among the Latarjet procedures, endobuttons fixation resulted in a higher integration rate (87.5% vs. 73.6%) and lower osteolysis rate than screw fixation (24.6% vs. 38.5%), despite these differences did not reach a statistical significance. Among the bone block procedures, using a xenograft resulted in a lower osteolysis rate (6.7%) than an allograft (14.5%), but the result was not statistically significant.

Conclusion

This study shows a significantly lower rate of graft osteolysis after bone block procedures compared to Latarjet procedure between 6 and 12 months postoperatively. Moreover, our findings suggest good results in osteolysis and graft integration with xenograft compared to allograft and double endobuttons fixation compared to screw fixation, despite these differences being not-significant. Further studies on this topic are needed to confirm our results at a longer follow-up and thoroughly investigate the clinical relevance of these findings.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.

Arthroscopic Autologous Scapular Spine Bone Graft for Recurrent Anterior Shoulder Dislocation With Subcritical (10%-15%) Glenoid Bone Loss

For anterior shoulder instability with subcritical glenoid bone loss (10%-15%), there is no consensus on the optimal treatment. Now, we describe the technique of using autogenous scapular spine bone graft for recurrent anterior shoulder dislocation. This procedure can effectively increase the anterior bone barrier and strengthen the effect of Bankart repair. In addition, this procedure not only avoids coracoid or iliac crest transfer, but also adopts nonrigid fixation, which makes it safer and more convenient. We believe that this technique will provide a promising alternative to the surgical treatment of recurrent anterior shoulder dislocation in subcritical glenoid bone loss (10%-15%).

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.

Bony reconstruction after failed labral repair is associated with higher recurrence rates compared to primary bony reconstruction: a systematic review and meta-analysis of 1319 shoulders in studies with a minimum of 2-year follow-up

BACKGROUND

There is uncertainty with regard to the optimal revision procedure after failed labral repair for anterior shoulder instability. An overview of outcomes of these procedures with quantitative analysis is not available in literature. The aim of this review is (1) to compare recurrence rates after revision labral repair (RLR) and revision bony reconstruction (RBR), both following failed labral repair. In addition, (2) recurrence rates after RBR following failed labral repair and primary bony reconstruction (PBR) are compared to determine if a previous failed labral repair influences the outcomes of the bony reconstruction.

METHODS

Randomized controlled trials and cohort studies with a minimum follow-up of 2 years and reporting recurrence rates of (1) RBR following failed labral repair and PBR and/or (2) RLR following failed labral repair and RBR following failed labral repair were identified by searching PubMed, Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics.

RESULTS

Thirteen studies met the inclusion criteria and comprised 1319 shoulders. Meta-analyses showed that RBR has a significantly higher recurrence rate than PBR (risk ratio [RR] 0.51, P < .008) but found no significant difference in the recurrence rates for RLR and RBR (RR 1.40, P < .49). Also, no significant differences were found between PBR and RBR in return to sport (RR 1.07, P < .41), revision surgery (RR 0.8, P < .44), and complications (RR 0.84, P < .53). Lastly, no significant differences between RLR and RBR for revision surgery (RR 3.33, P < .19) were found.

CONCLUSION

The findings of this meta-analyses show that (1) RBR does not demonstrate a significant difference in recurrence rates compared with RLR and that (2) RBR has a significantly higher recurrence rate than PBR.

The Addition of Remplissage to Free Bone Block Restores Translation and Stiffness Compared to Bone Block Alone or Latarjet in a Bipolar Bone Loss Model

PURPOSE

The purpose of this study was to compare glenohumeral stability following a Latarjet, a free bone block (FBB), and a FBB with remplissage for bipolar bone loss.

METHODS

Nine matched pairs of fresh frozen cadavers were tested in a custom biomechanical apparatus with rotation and progressive translational loading. The free bone block group consisted of a distal tibial allograft with an all-suture tape construct. The Latarjet group was performed with the native coracoid and two partially threaded cannulated screws. A bipolar bone loss model was created with 20% glenoid bone loss and an off-track Hill-Sachs lesion. Testing conditions included the 1) native state, 2) bipolar bone loss model, 3) Latarjet, 4) FBB with distal tibial allograft secured with cerclage sutures, and 5) FBB with remplissage. Each condition was tested for translation, humeral head apex shift, stiffness, and dislocation force.

RESULTS

There were no differences in translation, stiffness, or dislocation forced between the FBB alone and Latarjet groups. The FBB with remplissage group demonstrated the lowest anterior-inferior translation at 90° of ER, which was statistically significant compared to Latarjet 20N (P = .013) and compared to the FBB alone at 40N (P = .024) and 50N (P = .011). The FBB with remplissage group was significantly stiffer compared to FBB alone at 90° ER with approximately 60% change in stiffness (P = .028). The force required to dislocate the humeral head after treatment was highest in the FBB with remplissage group, which was statistically significant compared to the FBB alone (P = .003) and Latarjet groups (P = .018).

CONCLUSION

The addition of remplissage to a FBB restores translation and stiffness closer to the intact state compared to a FBB alone or Latarjet in a bipolar bone loss model with an off-track Hill-Sachs lesion. In this model, dislocation force significantly increased with the addition of remplissage to the FBB.

CLINICAL RELEVANCE

This biomechanical study provides evidence that Latarjet and FBB are both acceptable forms of treatment for bipolar bone loss, but stability can be enhanced with the addition of remplissage following glenoid reconstruction.

Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation

PURPOSE

To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity.

METHODS

From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning.

RESULTS

All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6-8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001).

CONCLUSION

Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation.

LEVEL OF EVIDENCE

IV.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019

BACKGROUND

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR).

METHODS

We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR).

RESULTS

Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men.

CONCLUSION

ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Satisfactory Functional Results and Complication Rates After Anterior Glenoid Bone Block Reconstruction in Recurrent Shoulder Dislocation: A Mean 4-Year Follow-up Comparative Study

BACKGROUND

Anterior recurrent instability of the glenohumeral joint is a common clinical problem among the young population. Glenoid reconstruction with bone graft has become the treatment of choice, particularly in significant deficiency (˃ 20%). This study aims to assess the functional results of glenoid reconstruction using Latarjet and iliac bone graft in management of glenoid insufficiency associated with recurrent anterior dislocation of the glenohumeral joint.

METHODS

Patients suffering from anterior shoulder instability with glenoid defect > 20% were included in this study between 2016 and 2021. University of California at Los Angeles (UCLA) shoulder scale and Constant score were used to assess the functional improvement. Preoperative and final postoperative continuous outcomes were compared with one-tailed paired t-test and the outcomes across groups were compared using two-tailed independent t-test. P-value of < 0.05 was considered statistically significant for both tests.

RESULTS

This trial included 50 patients; twenty-five underwent mini-open Latarjet, and 25 underwent arthroscopic tricortical iliac bone grafting (ICBG). The mean follow-up durations were 50.1 ± 5.9 months for Laterjet and 51.6 ± 6.8 months for ICBG. Both techniques showed statistically significant improvement in the final UCLA (31.1± 2.1 in Laterjet, and 30.2± 2.2 in ICBG) and Constant (90.2± 4.6 in Laterjet, and 89± 5.01 in ICBG) scores. There was no statistically significant difference regarding mean age, sex, side of injury, mechanism of injury, follow-up period, and clinical outcome between both surgical treatments. At the end of the study, both groups demonstrated statistically significant improvement in the range of motion (p˂ 0.00001). Only one, non-adherent patient in Laterjet group had post-operative dislocation. In ICBG group, two patients had partial bone graft resorption, 3 graft site morbidities, and 1 hardware prominence.

CONCLUSION

Both Laterjet and iliac bone graft procedures had satisfactory functional results in reconstruction of glenoid defect > 20% in unstable shoulders with a mean 4-year follow-up. No statistically significant difference was reported in the last postoperative Constant and UCLA scores between both techniques, but Latarjet procedure had fewer complications (4%) than iliac bone grafting (24%).

LEVEL OF EVIDENCE

prospective non-randomized comparative study; level Ⅱ.

[Arthroscopic Pushlock anchor fixation with iliac creast bone autograft in the treatment of recurrent anterior shoulder instability with critical bone defect]

OBJECTIVE

To evaluate the effectiveness of arthroscopic Pushlock anchor fixation with iliac creast bone autograft in the treatment of recurrent anterior shoulder instability with critical bone defect.

METHODS

The clinical data of 80 patients with recurrent anterior shoulder instability with critical bone defect treated by arthroscopic Pushlock anchor fixation with iliac creast bone autograft between January 2016 and January 2019 were retrospectively analyzed. The patients were all male; they were 18-45 years old at the surgery, with an average of 25 years old. The disease duration ranged from 3 months to 5 years, with an average of 2 years. The shoulder joint dislocated 3-50 times, with an average of 8 times. X-ray films, MRI, CT scans and three-dimensional reconstruction of the shoulder were performed before operation. The area of the anterior glenoid defect was 25%-45%, with an average of 27.3%. The shoulder mobility (forward flexion and external rotation in abduction at 90°), the Constant-Murley score, and the Rowe score were used to evaluate the shoulder function before operation and at last follow-up.

RESULTS

Patients were followed up 1-3 years, with an average of 2 years. No shoulder dislocation occurred again during follow-up. All partial graft absorption occurred after operation, CT scan showed that the graft absorption ratio was less than 30% at 1 week and 3 months after operation. CT three-dimensional reconstruction at 1 year after operation showed that all grafts had healed to the glenoid. The anterior glenoid bone defect was less than 5% (from 0 to 5%, with an average of 3.2%). At last follow-up, the shoulder mobility (forward flexion and external rotation in abduction at 90°), the Constant-Murley score, and the Rowe score significantly improved when compared with preoperative ones ( P<0.05). The shoulder mobility of external rotation in abduction at 90° of the affected side limited when compared with the healthy side [(6.7±5.1)°].

CONCLUSION

Arthroscopic Pushlock anchor fixation with iliac creast bone autograft has a good effectiveness in the treatment of recurrent anterior shoulder instability with critical bone defect. The method is relatively simple and the learning curve is short.

[Harvesting cancellous bone or composite corticocancellous bone grafts from the posterior iliac crest]

OBJECTIVE

Harvesting bone-either cancellous bone or composite corticocancellous bone grafts-from the iliac crest is an efficient method for filling or bridging bony defects commonly encountered in comminuted epimetaphyseal fractures (e.g., tibial head fractures), in nonunions or during reconstructive measures as in arthrodesis of major joints or spondylodesis, bone defects due to tumor resection or following eradication of chronic infection.

INDICATIONS

All bone defects with a maximum size of 4-5 cm.

CONTRAINDICATIONS

Rejection of surgery by the patient, infection or evidence of pathological bony changes in the posterior pelvic rim, inexperience of the surgeon with the procedure.

SURGICAL TECHNIQUE

Incision at the posterior iliac crest and removal of a structural or cancellous bone graft of predetermined length. Depending on the bleeding tendency, a suction drain can be inserted.

POSTOPERATIVE MANAGEMENT

After surgery supine positioning is favorable for wound compression to avoid bleeding as well as sufficient analgesia. Mobilization is dictated by the main operation. The pelvis is not compromised in its mechanical integrity and allows for full weight bearing on the operated side.

Eden-Hybinette Procedure for Revision Surgery in Recurrent Anterior Shoulder Instability in Epilepsy

AIMS

The purpose of this study was to analyze the clinical outcomes after Eden-Hybinette procedure for revision surgery in recurrent anterior shoulder instability in patients with epilepsy.

MATERIALS AND METHODS

We retrospectively evaluated eight such patients between 2015 and 2018. Four patients had failed Latarjet/Bristow procedure and two had failed arthroscopic Bankart procedure, while two had history of both the procedures. After medical control of epilepsy, Eden-Hybinette procedure was performed in all patients. WOSI score and Rowe shoulder score was recorded preoperatively and in subsequent post-operative follow-up. A paired t test was used to analyze and compare preoperative and postoperative outcomes and was considered significant if p value was < 0.05.

RESULTS

The average follow-up was 30 months (range 24-48 months). There was no recurrence of shoulder instability. The mean WOSI score before surgery was 77.3 (range 70-83), which improved to 24.2 (range 19-30) at 24-month follow-up. The mean Rowe score before surgery was 11.3 (range 5-15), which improved to 81.8(range 65-90) at 24-month follow-up. The improvement in WOSI and Rowe score was found to be statistically significant [p value < 0.05].

CONCLUSIONS

We conclude that Eden-Hybinette is a useful revision procedure to manage recurrent anterior shoulder dislocation in patients with epilepsy. Optimum medical control of seizure is also an important factor in preventing recurrent shoulder instability.

Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up

PURPOSE

To evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability.

METHODS

A retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon's signed rank test otherwise.

RESULTS

The final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed.

CONCLUSIONS

The all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy.

LEVEL OF EVIDENCE

IV, therapeutic, retrospective case series.

Arthroscopic Autologous Iliac Crest Bone Grafting for Reconstruction of the Glenoid: A Nonrigid Fixation Technique

Massive glenoid bone loss in recurrent anterior instability of the shoulder represents a surgical challenge. Some clinical trials have been published assessing the role of arthroscopic iliac crest bone grafting techniques for the management of recurrent anterior instability with glenoid bone loss. However, bone graft fixation is still controversial. We developed a method for anatomic reconstruction of anterior glenoid bone defects using autologous iliac crest graft. This technique is based on the assumption that anatomic restoration of glenoid depth and width is essential to restore stability to the shoulder.

Risk Factors of Graft Resorption after Arthroscopic Autologous Scapular Spine Bone Graft for Recurrent Shoulder Instability

Objective

To analyze if general factors such as age, gender, dominant side, fasting blood sugar level, BMI (body mass index), smoking, and drinking play a role in graft resorption after arthroscopic autologous scapular spine bone grafting.

Methods

From July 2016 to August 2018, patients who were diagnosed with anterior shoulder instability with subcritical bone loss (10%–15%) and underwent arthroscopic autologous scapular spine bone graft transplant were retrospectively reviewed and enrolled in this study. The age, gender, dominant side, fasting blood sugar level, BMI, smoking, and drinking conditions of the enrolled patients were recorded. The graft resorption rate at postoperative 1 year was also measured on three‐dimensional computed tomography (3D‐CT) scans. The Pearson test and the Spearman test were used to identify any significant correlation between the general factors and graft resorption rate.

Results

A total of 27 patients who underwent arthroscopic autologous scapular spine bone graft for recurrent shoulder instability qualified and were included in this study. There were 20 males and seven females, the mean age was 30.8 ± 9.4 years, the mean follow‐up time was 29.3 months (range, 25–39 months), during which no severe complications such as infection, neurovascular injury, or re‐dislocation were observed. The bone graft healed in all cases, the mean healing time was 2.6 ± 0.5 months (range, 2–3 months). At the last follow‐up, the mean Constant–Murley score was 89.74 ± 3.71, the mean Disabilities of Arm, Shoulder and Hand (DASH) score was 9.77 ± 5.31, and the mean visual analogue score (VAS) was 0.74 ± 0.64. The apprehension test was all negative at final follow‐up. The fasting blood sugar level was 4.78 ± 0.42 mmol/L, BMI was 23.70 ± 4.70. Five patients were “smoking” and 22 “non‐smoking”, four patients were “drinking” and 23 were “non‐drinking.” The graft resorption rate at postoperative 1 year was 19.4% ± 7.5%. The Pearson test and the Spearman test showed no significant correlation between age, gender, dominant side, fasting blood sugar level, BMI, smoking, drinking, and graft resorption rate.

Conclusion

Age, gender, dominant side, fasting blood sugar level, BMI, smoking, and drinking were not significantly correlated with graft resorption after the arthroscopic autologous scapular spine bone graft for recurrent shoulder instability.

Use of allograft to reconstruct anterior bony glenoid defect in chronic glenohumeral instability: a systematic review

INTRODUCTION

Bone-block procedures are well-established in anterior chronic shoulder instability treatment. Autograft with the coracoid process (Bristow-Latarjet procedures) and iliac crest (Eden-Hybbinette) are the most frequent source of bone but the use of allograft is also possible. The objective of this review is to assess clinical and radiographic outcomes after bony allograft reconstruction in anterior glenohumeral instability.

MATERIAL AND METHODS

Medline, Cochrane, Embase databases were searched for studies reporting on bone allograft reconstruction in anterior glenohumeral instability with glenoid defect. We conducted a systematic review of studies with all levels of evidence reporting on clinical or radiological outcomes or both.

LEVEL OF EVIDENCE

IV.

RESULTS

Ten studies met the inclusion criteria for the review; 283 shoulders were included with a mean age of 26 years (17-63) and mean follow-up of 34 months (4-168). Glenoid reconstruction was performed using bone from different source: femoral head (1 study), distal tibia allograft (5 studies), and iliac crest (4 studies). Allografts were fresh in 4 studies, demineralized in 2 studies, and freeze-dried after sterilization in 1 study. All scores performed in the different studies increased between pre-operative and post-operative evaluations (mean + 36.8 points for the ASES). Global rate of recurrence was 3.9% (11 patients) (0-11%), comprising 6 cases of dislocation (2.1%) and 5 subluxations (1.8%). Allograft healing occurred in 93.5% of cases.

CONCLUSIONS

This systematic review data suggest that allograft reconstructions in anterior glenohumeral instability could be a viable alternative to similar reconstructions with autografts and provide close clinical/radiological outcomes, at short and mid-term follow-up. Prospective randomized studies are needed to confirm these results.