1
|
Rosenow CS, Leland DP, Camp CL, Barlow JD. Sutures, Screws, Buttons, and Anchors: A Review of Current Bone Graft Fixation Devices for Glenoid Bone Loss in the Unstable Shoulder. Curr Rev Musculoskelet Med 2024; 17:207-221. [PMID: 38587597 DOI: 10.1007/s12178-024-09895-x] [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] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE OF REVIEW Anterior shoulder instability is associated with concomitant injury to several stabilizing structures of the shoulder, including glenoid bone loss. While instability is most common in young athletes and patients with predisposing conditions of hyperlaxity, recurrent shoulder instability can occur throughout various age ranges and may lead to longer term effects including pain and shoulder arthritis. Glenoid bone loss exceeding certain thresholds is generally treated by glenoid reconstruction via bone block augmentation to adequately stabilize the glenohumeral joint. These procedures increase the width of the articular surface on which the humeral head can translate before dislocation and, based on the procedure performed, provide a sling effect via the conjoined tendon, and increase tension to support the anterior capsule. The purpose of this review is to summarize the available literature regarding bone block fixation techniques. RECENT DEVELOPMENTS Various fixation techniques have been utilized to secure bone block transfers. Though screw fixation has traditionally been used for bone block fixation, suture buttons, suture anchors, and all-suture techniques have been utilized in attempts to avoid complications associated with the use of screws. Biomechanical studies report variable force-resistance, displacement, and mode of failure when comparing screw to suture button-based fixation of glenoid bone blocks. Clinical and radiographic studies have shown these novel suture-based techniques to be comparable, and in some cases advantageous, to traditional screw fixation techniques. While screw fixation has long been the standard of care in glenoid bone block procedures, it is associated with high complication rates, leading surgeons to endeavor toward new fixation techniques. In available biomechanical studies, screw fixation has consistently demonstrated high maximal load-to-failure and displacement with cyclic loading. Studies have reported similar clinical and radiographic outcomes in both screw and suture-based fixation methods, with evidence of reduced bone resorption with suture fixation. While suture button fixation is associated with a higher rate of recurrent instability, overall complication rates are low. Future research should address biomechanical shortcomings of suture-based fixation techniques and continue to assess long-term follow-up of patients treated with each fixation method.
Collapse
Affiliation(s)
- Christian S Rosenow
- Mayo Clinic Department of Orthopedic Surgery, 200 First Street SW, Rochester, 55905, MN, USA
| | - Devin P Leland
- Mayo Clinic Department of Orthopedic Surgery, 200 First Street SW, Rochester, 55905, MN, USA
| | - Christopher L Camp
- Mayo Clinic Department of Orthopedic Surgery, 200 First Street SW, Rochester, 55905, MN, USA.
| | - Jonathan D Barlow
- Mayo Clinic Department of Orthopedic Surgery, 200 First Street SW, Rochester, 55905, MN, USA
| |
Collapse
|
2
|
Hurley ET, Aman ZS, Doyle TR, Levin JM, Jazrawi LM, Garrigues GE, Namdari S, Hsu JE, Klifto CS, Anakwenze O, Dickens JF. Posterior Shoulder Instability, Part I-Diagnosis, Nonoperative Management, and Labral Repair for Posterior Shoulder Instability-An International Expert Delphi Consensus Statement. Arthroscopy 2024:S0749-8063(24)00341-4. [PMID: 38735410 DOI: 10.1016/j.arthro.2024.04.035] [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: 11/23/2023] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE To establish consensus statements on the diagnosis, nonoperative management, and labral repair 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 Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization. CONCLUSIONS The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required. LEVEL OF EVIDENCE Level V, expert opinion.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A..
| | - Zachary S Aman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Tom R Doyle
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, NYU Langone Health, New York, U.S.A
| | - Grant E Garrigues
- Midwest Orthopaedics at RUSH, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Jason E Hsu
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, U.S.A
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Oke Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A.; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, Maryland, U.S.A
| |
Collapse
|
3
|
Hurley ET, Aman ZS, Doyle TR, Levin JM, Matache BA, Chalmers PN, Waterman BR, Erickson BJ, Klifto CS, Anakwenze OA, Dickens JF. Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement. Arthroscopy 2024:S0749-8063(24)00340-2. [PMID: 38735411 DOI: 10.1016/j.arthro.2024.04.034] [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: 11/23/2023] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 05/14/2024]
Abstract
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.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A..
| | - Zachary S Aman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Tom R Doyle
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Bogdan A Matache
- Department of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, The University of Utah, Salt-Lake City, Utah, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest, Winston-Salem, North Carolina, U.S.A
| | | | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Oke A Anakwenze
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, U.S.A.; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, Maryland, U.S.A
| |
Collapse
|
4
|
Parnes N, Klahs KJ, Sandler AB, Wynkoop EI, Goldman A, Fishbeck K, Rolf RH, Scanaliato JP. The Perfect-Circle Technique Demonstrates Poor Inter-Rater Reliability in Measuring Posterior Glenoid Bone Loss on Magnetic Resonance Imaging. Arthrosc Sports Med Rehabil 2024; 6:100889. [PMID: 38333570 PMCID: PMC10851202 DOI: 10.1016/j.asmr.2024.100889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/28/2023] [Indexed: 02/10/2024] Open
Abstract
Purpose To evaluate the reliability of the "perfect-circle" methodology for measurement of glenoid bone loss with magnetic resonance imaging (MRI) in patients with posterior glenohumeral instability. Methods A prospective chart review was performed on patients who underwent isolated arthroscopic posterior labral repairs in our institution's electronic medical records between January 1, 2021, and June 30, 2021. Inclusion criteria included isolated posterior shoulder instability with posterior labral repair and corroborated tears on MRI. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder MRI scans twice, at over 2 weeks apart. Measurements followed the "perfect-circle" technique and included projected anterior-to-posterior (AP) glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Results Ten consecutive patients between the ages of 17 and 46 years with diagnosed posterior glenohumeral instability were selected. The average age was 28 ± 10 years, and 60% of patients were male. The patient's dominant arm was affected in 40%, and 50% of cases involved the right shoulder. The average glenoid diameter was 29.62 ± 3.69 mm, and the average measured bone loss was 2.8 ± 1.74 mm. The average percent posterior glenoid bone loss was 9.41 ± 5.78%. The inter-rater reliability was poor for the AP diameter and for the posterior glenoid bone loss with intraclass correlation coefficients at 0.30 (0.12-0.62) and 0.22 (0.07-0.54) respectively. The intrarater reliability was poor for AP diameter and moderate for posterior glenoid bone loss, with intraclass correlation coefficients at 0.41 (0.22-0.57) and 0.50 (0.33-0.64), respectively. Conclusions Using the "perfect-circle" technique for evaluating posterior glenohumeral bone loss has poor-to-moderate inter- and intrarater reliability from MRI. Level of Evidence Level IV, prospective diagnostic study.
Collapse
Affiliation(s)
- Nata Parnes
- Department of Orthopaedic Surgery and Rehabilitation, Carthage Area Hospital, Carthage, New York, U.S.A
- Department of Orthopaedic Surgery and Rehabilitation, Claxton Hepburn Medical Center, Ogdensburg, New York, U.S.A
| | - Kyle J. Klahs
- Department of Orthopaedic Surgery, Texas Tech University Health Science Center, El Paso, Texas, U.S.A
| | - Alexis B. Sandler
- Department of Orthopaedic Surgery, Texas Tech University Health Science Center, El Paso, Texas, U.S.A
| | | | - Adam Goldman
- Beacon Orthopaedics & Sports Medicine, Cincinnati, Ohio, U.S.A
| | - Keith Fishbeck
- Beacon Orthopaedics & Sports Medicine, Cincinnati, Ohio, U.S.A
| | - Robert H. Rolf
- Beacon Orthopaedics & Sports Medicine, Cincinnati, Ohio, U.S.A
| | - John P. Scanaliato
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| |
Collapse
|
5
|
Smith WR, Edwards TB. Posterior Shoulder Instability and Glenoid Bone Loss: A Review and a Free Bone Graft Technique. J Clin Med 2024; 13:2016. [PMID: 38610781 PMCID: PMC11012477 DOI: 10.3390/jcm13072016] [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: 02/18/2024] [Revised: 03/19/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
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.
Collapse
Affiliation(s)
| | - T. Bradley Edwards
- Fondren Orthopedic Group, Fondren Orthopedic Research Institute, Texas Orthopedic Hospital, Houston, TX 77030, USA;
| |
Collapse
|
6
|
Green CK, Scanaliato JP, Sandler AB, Wynkoop EI, Goldman A, Turner RC, Czajkowski H, Rolf RH, Parnes N. Risk Factors for Glenoid Bone Loss in the Setting of Posterior Glenohumeral Instability. Orthop J Sports Med 2023; 11:23259671231202301. [PMID: 37859754 PMCID: PMC10583519 DOI: 10.1177/23259671231202301] [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: 04/07/2023] [Accepted: 04/27/2023] [Indexed: 10/21/2023] Open
Abstract
Background Posterior instability has been reported to account for up to 24% of cases of shoulder instability in certain active populations. However, there is a paucity of data available regarding the risk factors associated with posterior glenoid bone loss. Purpose To characterize the epidemiology of, and risk factors associated with, glenoid bone loss within a cohort of patients who underwent primary arthroscopic shoulder stabilization for isolated posterior-type glenohumeral instability. Study Design Cross-sectional study; Level of evidence, 3. Methods This was a retrospective analysis of patients who underwent primary arthroscopic shoulder stabilization for posterior-type instability between January 2011 and December 2019. Preoperative magnetic resonance arthrograms were used to calculate posterior glenoid bone loss using a perfect circle technique. Patient characteristics and revision rates were obtained. Bone loss (both in millimeters and as a percentage) was compared between patients based on sex, age, arm dominance, sports participation, time to surgery, glenoid version, history of trauma, and number of anchors used for labral repair. Results Included were 112 patients with a mean age of 28.66 ± 10.07 years; 91 patients (81.25%) were found to have measurable bone loss. The mean bone loss was 2.46 ± 1.68 mm (8.98% ± 6.12%). Significantly greater bone loss was found in athletes versus nonathletes (10.09% ± 6.86 vs 7.44% ± 4.56; P = .0232), female versus male patients (11.17% ± 6.53 vs 8.17% ± 5.80; P = .0212), and patients dominant arm involvement versus nondominant arm involvement (10.26% ± 5.63 vs 7.07% ± 6.38; P = .0064). Multivariate regression analysis identified dominant arm involvement as an independent risk factor for bone loss (P = .0033), and dominant arm involvement (P = .0024) and athlete status (P = .0133) as risk factors for bone loss >13.5%. At the conclusion of the study period, 7 patients had experienced recurrent instability (6.25%). Conclusion The findings of this study are in alignment with existing data suggesting that posterior glenoid bone loss is highly prevalent in patients undergoing primary arthroscopic stabilization for posterior-type shoulder instability. Our results suggest that patients with dominant arm involvement are at risk for greater posterior glenoid bone loss. Athlete status and dominant arm involvement were identified as independent risk factors for bone loss >13.5%.
Collapse
Affiliation(s)
- Clare K. Green
- School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - John P. Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Alexis B. Sandler
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | | | - Adam Goldman
- Beacon Orthopaedics & Sports Medicine, Cincinnati, Ohio, USA
| | - Robert C. Turner
- Department of Orthopaedic Surgery, Fort Drum, Fort Drum, New York, USA
| | - Hunter Czajkowski
- Department of Orthopaedic Surgery, Carthage Area Hospital, Claxton-Hepburn Medical Center, Carthage, New York, USA
| | - Robert H. Rolf
- Beacon Orthopaedics & Sports Medicine, Cincinnati, Ohio, USA
- Department of Orthopaedic Surgery, TriHealth Hospital System, Cincinnati, Ohio, USA
| | - Nata Parnes
- Department of Orthopaedic Surgery, Carthage Area Hospital, Claxton-Hepburn Medical Center, Carthage, New York, USA
| |
Collapse
|