Open anatomical glenoid reconstruction with an iliac crest bone autograft effectively resolves off-track Hill-Sachs lesions to on-track lesions

INTRODUCTION

The purpose of this study was to determine if "off-track" Hill-Sachs lesions in patients with dynamic anteroinferior instability were transformed into "on-track" lesions using iliac bone autografts with screw fixation. The secondary purpose was to observe if postoperative bony remodeling would occur over time, resulting in recurrent "off-track" Hill-Sachs lesions with corresponding instability.

MATERIALS AND METHODS

We retrospectively reviewed clinical and CT records of 8 patients with an "off-track" Hill-Sachs lesion who underwent open anatomical glenoid reconstruction with an iliac crest bone autograft. Hill-Sachs lesions, glenoid track widths, and glenoid surface areas were measured on a preoperative and two postoperative (6 weeks, ≥ 2 years) 3D-CT models to determine graft resorption over time. All patients were available for postoperative clinical and CT final follow-up 3 years (2-4 years) postoperatively.

RESULTS

In all patients, the Hill-Sachs lesions were "on-track" 6 weeks postoperatively and remained "on-track" at final-follow-up. Compared to preoperative values, the glenoid track width and glenoid surface area both were higher 6 weeks postoperatively (p < 0.001 and p = 0.023, respectively) and at final follow-up (p < 0.001 and p = 0.023, respectively). Whereas the glenoid track width between 6 weeks and final follow-up showed no decrease (p = 0.234), glenoid surface area tended to decrease (p = 0.055). The median SSV was 93 points (85-95 points), the Rowe score 90 points (80-100 points) and the WOSI 1980 points (1783-2067 points) at final follow-up. No recurrent dislocations or subluxations were observed.

CONCLUSIONS

An open anatomical glenoid reconstruction with an iliac crest bone autograft technique using screw fixation effectively transformed "off-track" Hill-Sachs lesions to "on-track" lesions, resulting in good short-term clinical outcomes. Whereas glenoid surface area tended to be reduced by bony remodeling processes over time, the glenoid track width did not decrease at final follow-up and consequently no recurrence of "off-track" lesions occurred.

LEVEL OF EVIDENCE

Case series; Level of evidence, IV.

Open and arthroscopic posterior bone block with iliac crest autograft for posterior shoulder instability - systematic review of clinical and radiological outcomes

INTRODUCTION

Posterior shoulder instability (PSI) is a rare and challenging pathology to manage. The aim of this review was to assess and compare whether open and arthroscopic iliac crest bone graft (ICBG) bone block procedures succeeded in improving functional and clinical outcomes as well as radiological outcomes of union and graft resorption.

HYPOTHESIS

We hypothesised that there will be no difference in recurrence rate and functional outcome between open and arthroscopic procedures but there will be a higher complication rate with open bone block procedures.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines using the online databases MEDLINE and Embase. The review was registered on the PROSPERO database. Studies of open or arthroscopic ICBG bone block procedures reporting patient reported outcome measures, recurrence, complications and progression to osteoarthritis and radiological outcomes of graft union and resorption were selected. Studies were appraised using the Methodical index for non-randomised studies (MINORS) tool.

RESULTS

14 studies satisfied the inclusion criteria; five studies were arthroscopic and nine used open techniques. A total of 183 patients and 201 shoulders were included, mean age was 25 years range (14-75 years). Recurrent instability ranged from 0% to 12.5% for arthroscopic and 0% to 36.4% for open studies. Arthroscopic studies had statistically significant increases in numerous functional outcome scores but there was no evidence for similar improvements in open studies. Osteoarthritis at follow-up ranged from 12.5% to 47% in arthroscopic and 0% to 81.8% for open studies. Arthroscopic complication rate ranged from 6.7% to 75% compared to 0% to 80% for open studies. Majority of complications were metalware related requiring surgical intervention. Partial graft resorption ranged from 7.7-100% after arthroscopic and 4.8-100% after open procedures. High union rates were seen with both open and arthroscopic techniques.

CONCLUSION

This study highlights a lack of high-level evidence for arthroscopic and open posterior bone block procedures using ICBG to manage PSI. Functional and instability outcome scores showed significant improvement with arthroscopic ICBG bone block procedures however limited evidence was available for open studies. Metalwork related complications requiring revision and radiographic progression to osteoarthritis was high in both arthroscopic and open studies.

LEVEL OF EVIDENCE

IV, systematic review.

Radiological outcomes of iliac crest bone graft augmentation for glenoid bone loss using an open all-suture anchor and washer fixation technique

Background

Many of the complications related to bone block augmentation for recurrent shoulder instability are related to metal screw fixation. Alternative fixation techniques using suspensory fixation have been described with good results, although they require an additional posterior incision to manage the button. It was postulated that the use of an all-suture anchor would remove the requirement for a posterior incision, whilst providing equivalent union rates. Thus, the aim of this study was to evaluate the radiological outcome of a technique using all-suture anchor fixation of iliac crest autograft.

Methods

Eleven patients (mean age 28 years, 10 males, 1 female) underwent open anterior shoulder stabilization using an autologous iliac crest bone graft that was fixed with all-suture anchors and supplemented by 2-hole tibial plate. Union of the graft was evaluated 6 months postoperatively using computed tomography.

Results

There were no intraoperative complications and none of the participants needed further surgery. All patients reported a stable shoulder at 6 months follow-up. The grafts united in 10 out of the 11 patients.

Conclusion

An all-suture anchor construct is a viable alternative to metal screw fixation for iliac crest bone grafting in shoulder instability with critical bone loss, and unlike suspensory techniques does not require a second posterior incision.

Chronic type C3 distal humeral fracture associated with massive bone defects treated by open reduction and internal fixation with iliac crest autografts: a case report

Background

Chronic intercondylar fractures of the distal humerus with massive bone defects and severe comminution in the metaphysis are rare and complex injuries that are challenging for surgeons to treat, as reconstructing the triangular structure of the distal humerus is difficult and may have a severe impact on functional outcomes, especially in young patients, for whom total elbow arthroplasty is usually not a suitable option due to significant impairment in upper limb strength. Here, we report a patient in such scenario who was young and active and was treated by structural iliac bone autografting and internal fixation.

Case presentation

A 26-year-old male patient experienced a major car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Surgical debridement, negative pressure vacuum sealing drainage, and immobilization by braces were initially performed, and the wound was closed after 15 days. When the wound had finally healed and the soft tissue was in good condition without infection or effusion 45 days later, this young and active patient was diagnosed with a chronic type C3 distal humeral fracture associated with massive bone defects at the supracondylar level in both columns and severe comminution at the trochlear groove. We performed surgical debridement and arthrolysis around the fracture site, and then, we successfully reconstructed the triangular structure of the distal humerus using structural iliac crest autografts in both columns as well as in the defective trochlear groove. Finally, internal fixation via a parallel double-plate configuration was performed. Over a follow-up period of 3 years, the patient achieved almost full recovery of range of motion and an excellent functional score, without minor or major postoperative complications.

Conclusion

In this study, we proposed a surgical reconstruction strategy for complex chronic distal humeral fractures associated with massive bone defects and severe articular involvement in young and active patients using metaphyseal shortening and structural iliac crest bone autografting together with open reduction and internal fixation via a parallel configuration.

Management of C2 Body Giant Cell Tumor by Innovatively Fashioned Iliac Crest Graft and Modified Cervical Mesh Cage Used as Plate

BACKGROUND

Locally aggressive vertebral body tumors of the axis must be treated with wide local excision for best outcome. Reconstruction of the load-bearing vertebra needs to be done after tumor resection in such a manner so as to give stable, long-term fusion in this young population.

METHODS

We describe the management strategy of a 25-year-old acutely quadriplegic patient, with respiratory distress, with a C2 giant cell tumor. The use of a novel iliac crest graft modification used for C2 reconstruction along with a modified mesh cage used as an anterior plate has been reported.

RESULTS

The patient had a good outcome at 18 months' follow-up, with neurologic improvement and a solid fusion.

CONCLUSIONS

Iliac crest autograft is inexpensive and easy to harvest and can be considered as a C2 prosthesis, especially in a resource-constrained setting. Modified iliac crest graft can be used for load transmission from C1 lateral mass to C3 body, and the mesh cage can be modified according to need as a plate with good results in an emergency.

A case report

Treatment of forearm nonunion associated with bone defects can be challenging. Restoring the correct length and rotation are two main principles for the management of these patients. Herein, we describe a patient with isolated radius nonunion already treated with an iliac crest autograft with no success. A free vascularized osteoseptocutaneous fibular autogenous graft was harvested as the final solution to managed long bone defect after previous multiple surgeries. At the 1- year follow-up, the patient gained full range of motion and was functioning well.

Delayed union of humeral shaft fractures: comparison of autograft with and without platelet-rich plasma treatment: a randomized, single blinded clinical trial

INTRODUCTION

Despite an adequate orthopedic treatment with functional bracing, some patients develop a delayed union in humeral shaft fractures. The objective of the present study was to determine the bone consolidation time among patients with delayed union of diaphyseal humeral fractures who were managed with locking compression plate (LCP) fixation combined with an iliac crest autograft using platelet-rich plasma (PRP) as a co-adjuvant.

MATERIALS AND METHODS

This study was a controlled, randomized, experimental, longitudinal, comparative, prospective, blind clinical trial. Patients diagnosed with delayed union of a diaphyseal humeral fracture with at least 4 months of evolution were treated with an open reduction and LCP osteosynthesis combined with an iliac crest autograft. The experimental group also received PRP. The patients were assessed radiographically until 36 weeks of evolution.

RESULTS

A total of 16 patients were included. Both groups had similar demographic characteristics. The patients treated with PRP had an earlier beginning of bone consolidation. Furthermore, these same patients exhibited bone consolidation at 19.9 weeks, on average, in contrast to 25.4 weeks in the control group.

CONCLUSIONS

The use of PRP promotes earlier bone consolidation in patients with delayed union of the humeral shaft.