Massive graft resorption after iliac crest allograft reconstruction for glenoid bone loss in recurrent anterior shoulder instability

Medial position of the bone block by CT assessment is associated with excessive bone resorption after the modified Eden-Hybinette procedure for recurrent anterior shoulder instability

PURPOSE

To quantitatively evaluate the effects of initial medial-lateral position of bone block on bone remodeling.

METHODS

Patients who underwent the modified Eden-Hybinette procedure for the treatment of recurrent anterior shoulder instability between May 2017 and July 2022 were included. Follow-up of at least 2 years and CT scans of preoperative, immediately after surgery and a minimum of 12 months after surgery were necessary. The medial-lateral as well as the superior-inferior position of bone block after surgery, and diameter, depth, version, surface area of the glenoid at the three time points were measured. Bivariate analyses and multivariate logistic regression analyses were used to determine variables on excessive bone resorption, which was defined as a final glenoid ratio less than 100%. The cutoff value was confirmed using receiver operating characteristic curve.

RESULTS

Excessive bone resorption was detected in 17.7% (11/62) of patients. Medial-lateral position of the bone block, glenoid depth and its increment immediate after surgery differed significantly between patients with and without excessive bone resorption. Multivariate logistic regression analyses revealed that excessive bone resorption was significantly correlated with medial-lateral position of bone block (Odd ratio, 0.191; P=0.002). The cutoff value was -0.5 mm (area under the curve, 0.934; 95% CI, 0.870-0.998; P<0.001; sensitivity, 84%; specificity, 100%). 81.8% (9/11) of cases with excessive bone resorption were detected with graft surfaces distant from the extrapolated glenoid curvature.

CONCLUSION

Medial-lateral position of bone block was a critical determinant for bone remodeling after glenoid reconstruction and excessive bone resorption was associated with too medially placed graft. To achieve a more stable glenohumeral joint with physiologically pear-shaped glenoid surface after remodeling, the graft placing at no more than 0.5 mm medial to bony surface of the glenoid as well as with a well-matched articular surface to the extrapolated glenoid curvature was proved to be preferred.

LEVEL OF EVIDENCE

IV, Retrospective case series.

Allograft Resorption Following Arthroscopic Anatomic Glenoid Reconstruction Is Part of Remodeling to Restore the Native Glenoid Size and Shape 6.9 Months Postoperatively

PURPOSE

To determine if the distal tibia allograft (DTA) remodels after arthroscopic anatomic glenoid reconstruction (AAGR) to restore the native glenoid size and shape postoperatively.

METHODS

This is a retrospective study on patients who underwent AAGR with DTA between 2013 and 2022 using screw fixation who have completed postoperative clinical follow-up for a minimum of 2 years and have an available postoperative computed tomography (CT) scan. Glenoid width (anterior-posterior) and height (superior-inferior) were measured using Horos and Meshmixer on an en face view. The measured glenoid width was compared to the predicted glenoid width based on height using the following equation: Width(mm) = 2.53mm + 0.71 ∗ Height(mm), and the difference between the 2 variables was calculated. Data analysis used a paired t test, Pearson correlation, and receiver operating characteristic curve at a .05 significance level.

RESULTS

In 109 patients included in this study, the mean ± SD age at surgery was 28.2 ± 9.6 years, mean ± SD body mass index was 26.1 ± 5.0, and mean ± SD CT follow-up was 1.0 ± 1.1 years, including 73 primary surgeries (67%), 81 men (74%), and 52 right-sided operative shoulders (48%). In all 109 patients, the predicted glenoid width (28.5 ± 2.5 mm) was significantly smaller than the measured glenoid width (30.7 ± 4.2 mm) (P < .001). A significant negative correlation was found between CT follow-up time and the difference between measured and predicted glenoid width (i.e., measured and predicted glenoid width became more similar as time passed postoperatively). A cutoff time of 6.9 months was identified for graft remodeling (area under the curve, 0.759; P < .001). In patients with ≥6.9 months between surgery and postoperative CT (n = 65), there was no difference between predicted and measured postoperative glenoid width (28.6 ± 2.6 mm, 29.4 ± 3.7 mm, respectively; P = .099). In patients with <6.9 months between surgery and postoperative CT (n = 44), the predicted glenoid width was significantly smaller than the measured glenoid width (28.4 ± 2.3 mm, 32.7 ± 3.9 mm, respectively; P < .001).

CONCLUSIONS

Predicted and measured postoperative glenoid width did not differ significantly in patients who had undergone AAGR with at least 6.9 months between surgery and postoperative CT. These findings support the hypothesis that the allograft remodels following AAGR with DTA to restore the native glenoid size and architecture.

CLINICAL RELEVANCE

These findings will help direct the size of bone blocks used in AAGR with DTA in the future to optimize surgical outcomes.

The scapula spine may not be a suitable source of bone graft for glenoid reconstruction in critical bone loss

BACKGROUND

The hypothesis is that the scapula spine can provide a graft of suitable dimensions for use in cases of shoulder instability with critical bone loss. We aimed to investigate its utility with grafts of differing sizes.

METHODS

The scapula spine was measured on computed tomography scans of 50 patients who had undergone anterior stabilization. The theoretical ability to harvest a graft of either 2 × 1 × 1 cm or 2 × 0.8 × 0.8 cm was analyzed.

RESULTS

Using the 2 × 1 × 1 cm threshold, 36% of the scapulae had at least 1 zone from which a suitable graft could be obtained. 61% had only 1 zone from which a suitable graft could be obtained. Using the 2 × 0.8 × 0.8 cm threshold, 72% had at least 1 zone from which a graft could be obtained. A total of 47% met the threshold in 1 zone only.

CONCLUSION

The scapula spine can be used as a source of autograft. Grafts up to 2 x 1 × 1 cm can be harvested in some individuals; however, the anatomy is very variable.

Latarjet procedure versus iliac crest autograft transfer for anterior shoulder instability: a systematic review and meta-analysis of comparative studies

BACKGROUND

Anterior shoulder instability with glenoid bone loss presents a challenge in orthopedic surgery. The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are commonly employed for its management, but direct comparative evidence is insufficient.

METHODS

Following PRISMA guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Randomized controlled trials (RCTs) and cohort studies directly comparing the Latarjet and ICBGT procedures were included. Primary outcomes included postoperative recurrent instability, apprehension test, and complications, while secondary outcomes comprised Rowe score, Subjective Shoulder Value (SSV), pain level assessed by visual analogue scale (VAS), range of motion (ROM), and radiologic outcomes. Quality assessment was performed using RoB2 and MINORS tools. The weighted mean difference (WMD) for continuous variables and odds ratio (OR) for dichotomous variables were calculated, along with 95% confidence intervals (CIs). Meta-analysis was performed using RevMan 5.4.1 software.

RESULTS

A total of 6 studies with 409 patients were included. There was no significant difference in postoperative recurrent instability (OR, 1.33; 95% CI, 0.44 to 4.03; P = 0.61), positive apprehension test (OR, 0.78; 95% CI, 0.20 to 3.10; P = 0.73), revision surgery (OR, 2.06; 95% CI, 0.74 to 5.71; P = 0.16), mild complications (OR, 0.49; 95% CI, 0.23 to 1.06; 0.07), SSV (WMD, -1.94; 95% CI, -3.94 to 0.06; P = 0.06) or VAS score (WMD, 0.15; 95% CI, -0.17 to 0.47; P = 0.36) between the two procedures. The ICBGT group exhibited statistically superior Rowe scores (WMD, -3.10; 95% CI, -5.10 to -1.10; P = 0.002), as well as improved external (WMD, -5.32; 95% CI, -7.30 to -3.30; P < 0.001) and internal rotation (WMD, -5.11; 95% CI, -6.76 to -3.45; P < 0.001). However, these differences did not surpass the minimal clinically important difference (MCID). Radiological evaluations showed that the ICBGT procedure had statistically better outcomes in immediate glenoid augmentation, preservation and reduced fatty degeneration of the subscapularis (SSC) tendon, and graft remodeling at short-term follow-up.

CONCLUSIONS

The ICBGT procedure showed statistically superior Rowe scores and range of motion, but these differences may not be clinically significant. Both procedures had comparable outcomes in recurrent instability, apprehension test results, revision surgery, mild complications, SSV, and pain levels. ICBGT appears to offer advantages in glenoid augmentation and SSC preservation at short-term follow-up.

PROSPERO REGISTRATION ID

CRD42024586157.

Arthroscopic Bankart repair augmented with glenoid bone dry allograft

Background

The recurrence rate of shoulder instability after arthroscopic isolated Bankart repair is up to 25% at long term, especially in case of bipolar bone loss. Bony augmentation with free bone dry allograft would be an option to reconstruct a glenoid subcritical bone defect and to minimize the failure rate.

Methods

This case series included patients with anterior shoulder instability treated by arthroscopic free bone dry allograft (Supercrit, BIOBank, Lieusaint, Ile-de-France, France), fixed with a cortical button as an augmentation of Bankart repair and reviewed with a minimum follow-up of 2 years. Clinical assessment was based on active range of motion, shoulder apprehension test, as well as Walch-Duplay Score, Rowe Score, and Subjective Shoulder Value. Radiological evaluation was based on postoperative and last follow-up computed tomography scan to assess bone block positioning, glenoid enlargement, allograft healing, and/or resorption.

Results

Five patients were included with a mean follow-up of 50 months (range 44-56). None of the patients reported a recurrence, but apprehension test was positive in one. Mean Walch-Duplay Score, Rowe Score, and Subjective Shoulder Value were 88 points (70-11), 93 points (75-100), and 89% (80-95), respectively. No surgical complications were recorded. The mean preoperative anterior glenoid bone loss was 13.8% (7-19). At last follow-up, graft resorption was observed in all patients, reaching 100% of the initial volume in 4 cases.

Conclusion

This study showed satisfactory clinical results of Bankart repair augmented with dry bone allograft in the treatment of anterior shoulder instability with glenoid subcritical bone loss. However, anatomical results were disappointing, with graft resorption that raises the question of going ahead with such a procedure.

Incidence of Complications With Precontoured Allograft Wedges in Foot and Ankle Surgery

BACKGROUND

Precontoured cancellous allograft wedges have gained popularity in foot and ankle procedures in recent years because of their ease of use and ability to decrease operative time. A high rate of resorption of such wedges was noted anecdotally by the senior authors, particularly in 2022. The purpose of this study was to identify the resorption and complication rates of precontoured allograft wedges over time.

METHODS

A retrospective review was performed of patients who had a precontoured allograft wedge from a single source implanted during foot and ankle surgery between 2017 and 2022 at a single institution. Patient demographics, indication for graft use, and fixation method were obtained from chart review, and differences between patients with and without nonunion were analyzed. Radiographic review was completed to identify patients with graft resorption and/or nonunion.

RESULTS

Of the 334 wedges implanted, 24 grafts (7.2%) resorbed and an additional 10 wedges (2.9%) developed a nonunion without resorption. Resorption was noted as early as 5.7 weeks postoperatively and as late as 36.6 weeks postoperatively. Older patient age, body mass index (BMI) >30, and the Lapidus graft type were significantly associated with greater risk of resorption or nonunion.

CONCLUSION

We observed an overall radiographic complication rate of 10% with the use of precontoured cancellous wedges. Older age, BMI >30, and Lapidus wedge type were associated with increased risk of radiographic complication. Patients should be counseled on the risk of resorption and nonunion, and caution should be exercised when contemplating the use of precontoured allograft cancellous wedges in foot and ankle surgery.

Current Evidence and Techniques for Arthroscopic Bone Augmentation

The indications for bone block augmentation of the glenoid following recurrent anterior shoulder instability are expanding. Arthroscopic anatomic glenoid reconstruction (AAGR) is an evolving technique with similar clinical results to the Latarjet procedure and other open bone block procedures. Multiple types of bone grafts and fixation techniques have been described, with varying results on bony integration, resorption, articular congruity, and recurrence rates. This review focuses on biomechanics, patient workup, indications, current evidence, and the authors' preferred surgical technique for AAGR.

Management of bone loss in anterior shoulder instability

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Arthroscopic Autologous Iliac Crest Grafting With an Adjustable-Loop Suspensory Device Yields Favorable Outcomes for Anterior Shoulder Instability With Glenoid Defects

PURPOSE

To evaluate the clinical and radiologic outcomes of the arthroscopic autologous iliac crest grafting (AICG) procedure with an adjustable-loop suspensory fixation device in the treatment of anterior shoulder instability with glenoid bone defects.

METHODS

A retrospective review was conducted on the patients who underwent arthroscopic AICG with an adjustable-loop suspensory fixation device from January 2017 to December 2020. Patients with traumatic anterior shoulder instability, significant glenoid bone defects, and a minimum follow-up of 24 months were included. Patient-reported outcomes, including the Oxford Shoulder Instability Score (OSIS), the Rowe score, the Walch-Duplay score, the Constant score, and the visual analog scale score, were compared preoperatively and postoperatively. Radiologic assessments using computed tomography were performed before and after the procedure. Additional data on active range of motion, recurrence events, and complications were recorded.

RESULTS

A total of 42 patients were included in the study, with a mean follow-up time of 35.2 months, ranging from 25.1 to 55.9 months. Mean preoperative OSIS, Rowe score, Walch-Duplay score, and Constant score significantly improved from 24.4 ± 7.2, 25.0 ± 9.0, 25.2 ± 9.8, 87.5 ± 7.1 to 42.4 ± 4.9, 92.4 ± 8.1, 87.9 ± 8.3, and 93.6 ± 4.5 at the last follow-up, respectively. All patients exceeded the minimal clinically important difference for OSIS, Rowe, and Walch-Duplay scores. The graft union rate was 100%, and the glenoid area increased significantly from 82.5% preoperatively to 100.1% at the final follow-up. No patient experienced a recurrence of instability. Two recorded complications included one case of dysesthesia around the donor site and one case of postoperative shoulder stiffness.

CONCLUSIONS

The outcomes of the arthroscopic AICG procedure, which uses an adjustable-loop suspensory fixation device, demonstrated stable bone graft fixation, high rates of graft integration, favorable clinical results, and a low incidence of complications. Moreover, the remodeling of the graft during the follow-up period significantly restored the width and concavity of the inferior glenoid, contributing to the overall recovery.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

iPhone-Based Cartilage Topography Scanning Yields Similar Results to Computed Tomography Scanning

Purpose

To investigate the feasibility and accuracy of 3-dimensional (3D) iPhone scans using commercially available applications compared with computed tomography (CT) for mapping chondral surface topography of the knee.

Methods

Ten cadaveric dysplastic trochleae, 16 patellae, and 24 distal femoral condyles (DFCs) underwent CT scans and 3D scans using 3 separate optical scanning applications on an iPhone X. The 3D surface models were compared by measuring surface-to-surface least distance distribution of overlapped models using a validated 3D-3D registration volume merge method. The absolute least mean square distances for the iPhone-generated models from each scanning application were calculated in comparison to CT models using a point-to-surface distance algorithm allowing regional "inside/outside" measurement of the absolute distance between models.

Results

Only 1 of the 3 scanning applications created models usable for quantitative analysis. Overall, there was a median absolute least mean square distance between the usable model and CT-generated models of 0.18 mm. The trochlea group had a significantly lower median absolute least mean square distance compared with the DFC group (0.14 mm [interquartile range, 0.13-0.17] vs 0.19 mm [0.17-0.25], P = .002). iPhone models were smaller compared with CT models (negative signed distances) for all trochleae, 83% of DFCs, and 69% of patellae.

Conclusions

In this study, we found minimal differences between a 3D iPhone scanning application and conventional CT scanning when analyzing surface topography.

Clinical Relevance

Emerging 3D iPhone scanning technology can create accurate, inexpensive, real-time 3D models of the intended target. Surface topography evaluation may be useful in graft selection during surgical procedures such as osteochondral allograft transplantation.

Biomechanical Analysis Reveals Shoulder Instability With Bipolar Bone Loss Is Best Treated With Dynamic Anterior Stabilization for On-Track Lesions and With Remplissage for Off-Track Lesions

PURPOSE

To compare the biomechanical effects of augmenting Bankart repair (BR) with either remplissage or dynamic anterior stabilization (DAS) in the treatment of anterior shoulder instability with on-track or off-track bipolar bone loss.

METHODS

Eight fresh-frozen cadaveric shoulders were tested at 60° of glenohumeral abduction in the intact, injury, and repair conditions. Injury conditions included 15% glenoid bone loss with an on-track or off-track Hill-Sachs lesion as previously recommended. Repair conditions included isolated BR, BR with remplissage, and BR with DAS (long head of biceps transfer). The glenohumeral stability was assessed by measuring the anterior translation under 0, 10, 20, 30, 40, 50 N load and maximum load without causing instability at mid-range (60°) and end-range (90°) external rotation (ER). Maximum range of motion (ROM) was measured by applying a 2.2-N·m torque in passive ER and internal rotation.

RESULTS

Isolated BR failed to restore native glenohumeral stability in both on-track and off-track bipolar bone loss models. Both remplissage and DAS significantly decreased the anterior instability in the bipolar bone loss models, showing better restoration than the isolated BR. In the on-track lesions, DAS successfully restored native glenohumeral stability and mobility, whereas remplissage significantly decreased anterior translation without load (-2.12 ± 1.07 mm at 90° ER, P = .003; -1.98 ± 1.23 mm at 60° ER, P = .015). In the off-track lesions, remplissage restored native glenohumeral stability but led to significant ROM limitation (-8.6° ± 2.3° for internal rotation, P < .001; -13.9° ± 6.2° for ER, P = .003), whereas DAS failed to restore native stability at 90° ER regarding the increased anterior translation under 50 N (4.10 ± 1.53 mm, P < .001) and decreased maximum load (-13.8 ± 9.2 N, P = .021).

CONCLUSIONS

At time-zero, both remplissage and DAS significantly reduced residual anterior instability compared with isolated BR in the bipolar bone loss models and restored the native glenohumeral stability under most translational loads. However, remplissage could decrease the anterior translation without load for on-track lesions and may restrict ROM for off-track lesions, whereas DAS failed to restore native stability under high translational loads for off-track lesions.

CLINICAL RELEVANCE

DAS could be recommended to treat on-track bipolar bone loss with less biomechanical adverse effects, whereas remplissage might be the preferred procedure to address off-track bipolar bone loss for better stability.

Graft Position, Healing, and Resorption in Anterior Glenohumeral Instability: A Comparison of 4 Glenoid Augmentation Techniques

Background

The success of glenoid augmentation procedures depends on accurate placement and healing of the graft to the glenoid. Different glenoid augmentation techniques have been described, but no comparative studies between them exist.

Purpose

To assess the bone graft position, healing, and resorption in a group of patients treated with 1 of 4 procedures: arthroscopic anterior bone-block procedure using either (1) fresh-frozen iliac crest allograft or (2) iliac crest autograft, (3) open Latarjet, or (4) arthroscopic Latarjet.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 40 patients (87.5% men; mean age, 29.5 ± 7.9 years) were included, with 10 patients in each of the procedure groups. The graft position in the axial and sagittal planes was assessed on postoperative computed tomography (CT). Graft healing and resorption were assessed in a second CT scan performed 1 year postoperatively. Qualitative variables were compared between the 4 procedures using the chi-square test, and quantitative variables were compared with the Student t test or Mann-Whitney U test.

Results

No differences were found between the procedures in the axial or sagittal position. The healing rate was significantly lower in the allograft bone-block group (20%) compared with the autograft bone-block (80%), open Latarjet (90%), and arthroscopic Latarjet (90%) groups (P < .001). Graft resorption developed in 17 of 40 (42.5%) cases overall. Osteolysis occurred in 100% of cases in the allograft bone-block group compared with 50% in the autograft group, 20% in the open Latarjet group, and 0% in the arthroscopic Latarjet group (P < .001). The glenoid surface area on 1-year CT scan was significantly lower in the allograft bone-block group compared with the autograft bone-block, open Latarjet, and arthroscopic Latarjet groups (P < .001).

Conclusion

Arthroscopic bone-block, open Latarjet, and arthroscopic Latarjet procedures provided accurate bone graft positioning. However, very high rates of osteolysis and nonunion were observed in the iliac crest fresh-frozen allograft bone-block procedure when compared with the other procedures.

Arthroscopic Latarjet Versus Arthroscopic Free Bone Block Procedures for Anterior Shoulder Instability: A Proportional Meta-analysis Comparing Recurrence, Complication, and Reoperation Rates

BACKGROUND

Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet.

PURPOSE

To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: "Arthroscopic" AND "Bone Block" OR "Bone Graft," and "Arthroscopic" AND "Glenoid Augmentation" OR "Glenoid Reconstruction," and "Arthroscopic" AND "Latarjet" OR "Coracoid Graft" OR "Coracoid Transfer." Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias.

RESULTS

Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age (P = .07), sex (P = .14), glenoid bone loss (P = .14), number of preoperative dislocations (P = .62), proportion of primary and revision procedures (P = .95), length of follow-up (P = .81), modified Coleman Methodology Score (P = .21), and level of evidence (P = .49). There was no difference in the recurrence (P = .88), reoperation (P = .79), and complication (P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation (P = .01).

CONCLUSION

The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation.

REGISTRATION

CRD42022368153 (PROSPERO).

Clinical Outcomes and Graft Resorption After Metal-Free Bone Block Suture Tape Cerclage Fixation for Recurrent Anterior Shoulder Instability: A Computed Tomography Analysis

BACKGROUND

Glenoid reconstruction with a bone block for anterior glenoid bone loss (GBL) has shown excellent outcomes. However, fixation techniques that require metal implants are associated with metal-related complications and bone graft resorption.

HYPOTHESIS

Arthroscopic glenoid reconstruction using a tricortical iliac crest bone graft (ICBG) and metal-free suture tape cerclage fixation can safely and effectively restore the glenoid surface area in patients with recurrent anterior shoulder instability and anterior GBL.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Adult patients (≥18 years) of both sexes with recurrent anterior shoulder instability and anterior GBL ≥15% were enrolled. These patients underwent arthroscopic glenoid reconstruction with ICBGs and metal-free suture tape cerclage fixation. The effectiveness and clinical outcomes with this technique were evaluated at 24 months using functional scores. Resorption of the graft articular surface was assessed by computed tomography, with the graft surface divided into 6 square areas aligned in 2 columns. Descriptive analysis was conducted.

RESULTS

A total of 23 consecutive patients met inclusion criteria (22 male, 1 female; mean age, 30.5 ± 7.9 years). The mean preoperative GBL was 19.7% ± 3.4%, and there were 15 allograft and 8 autograft ICBGs. All patients exhibited graft union at 3 months. The median follow-up was 38.5 months (interquartile range, 24-45 months). The Western Ontario Shoulder Instability Index, Rowe, Constant-Murley, and Subjective Shoulder Value scores improved from preoperatively (35.1%, 24.8, 83.1, and 30.9, respectively) to postoperatively (84.7%, 91.1, 96.0, and 90.9, respectively) (P < .001). No differences in clinical scores were observed between the graft types. One surgical wound infection was reported, and 2 patients (8.7% [95% CI, 2.4%-26.8%]) required a reoperation. The mean overall glenoid surface area increased from 80.3% ± 3.5% to 117.0% ± 8.3% immediately after surgery before subsequently reducing to 98.7% ± 6.2% and 95.0% ± 5.7% at 12 and 24 months, respectively (P < .001). The mean graft resorption rate was 18.1% ± 7.9% in the inner column and 80.3% ± 22.4% in the outer column. Additionally, 3 patients treated with an allograft (20.0% [95% CI, 7.1%-45.2%]), including the 2 with clinical failures, exhibited complete graft resorption at the last follow-up.

CONCLUSION

Arthroscopic glenoid reconstruction using an ICBG and metal-free suture tape cerclage fixation was safe and effective, yielding excellent clinical outcomes. Resorption of the graft articular surface predominantly affected the nonloaded areas beyond the best-fit circle perimeter.

Controversies in surgical management of anterior shoulder instability. State of the Art

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report

CASE

A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal.

CONCLUSION

Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer

PURPOSE

Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts.

METHODS

A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded.

RESULTS

177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.).

CONCLUSION

The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates.

LEVEL OF EVIDENCE

Level II.

Open Latarjet with Metal-Free Cerclage Fixation

Despite multiple modifications, the Latarjet is still the most popular procedure for recurrent anterior shoulder instability with glenoid bone loss. Partial or subtotal resorption of the graft is common, potentially leading to hardware prominence and risk of anterior soft-tissue impingement. To minimize the technical difficulties and morbidity associated with metallic implants, a coracoid and conjoint tendon transfer with a mini-open approach using Cerclage tape suture is described, as an alternative for the Latarjet procedure typically performed with metal screws and plates.

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.

Radiological and Histological Analyses of Nonrigid Versus Rigid Fixation for Free Bone Block Procedures in a Rabbit Model of Glenoid Defects

BACKGROUND

Nonrigid fixation techniques have been recently introduced in free bone block (FBB) procedures to treat substantial glenoid bone loss in patients with anterior shoulder instability. However, the radiological and histological effectiveness of nonrigid fixation versus conventional rigid fixation have not been comprehensively understood in vivo.

PURPOSE

To (1) explore the radiological and histological characteristics of nonrigid fixation for FBB procedures in a rabbit model of glenoid defects and (2) further compare them with those of conventional rigid fixation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Unilateral shoulder glenoid defects were created in 36 mature New Zealand White rabbits, of which 24 underwent FBB procedures using allogenic iliac crest bone and were randomly divided into rigid fixation (RF) and nonrigid fixation (N-RF) groups, with the remaining divided into 2 control groups: 6 with sham surgery for glenoid defects (GD group) and 6 native glenoids (normal group). In the RF and N-RF groups, 6 rabbits were sacrificed at 6 or 12 weeks postoperatively for radiological and histological analyses of the reconstructed glenoid, and all rabbits in the GD and normal groups were sacrificed at 12 weeks. The radiological glenoid morphology was evaluated via micro-computed tomography. Moreover, the graft-glenoid healing and graft remodeling processes were determined using histological staining.

RESULTS

At 6 weeks, both the N-RF and RF groups had similarly improved radiological axial radian and en face area of the glenoid compared with the GD group, but the N-RF group showed superiority in restoration of the glenoid radian and area compared with the RF group at 12 weeks, with the native glenoid as the baseline. Histologically, the bone graft in both groups was substantively integrated into the deficient glenoid neck at 6 and 12 weeks, showing similar osseous healing processes at the graft-glenoid junction. Moreover, the bone graft histologically presented similar regenerated vascular density, total graft bone, and integrated graft bone in both groups. In contrast, the N-RF group had a different remodeling profile on radiological and histological analyses regarding regional bone resorption, mineralization, and fibrous tissue replacement during osseointegration.

CONCLUSION

Compared with rigid fixation, nonrigid fixation resulted in superior reconstructed glenoid morphology radiologically and similar graft-glenoid osseous healing histologically, showing different graft remodeling profiles of regional bone resorption, mineralization, and fibrous tissue replacement.

CLINICAL RELEVANCE

The nonrigid fixation technique can be feasible for FBB procedures to treat glenoid bone loss in anterior shoulder instability. More clinical evidence is required to determine its pros and cons compared with conventional rigid fixation.

Clinical and Radiological Outcomes in Patients With Anterior Shoulder Instability and Glenoid Bone Loss after Arthroscopic Free Bone Block Combined With Dynamic Anterior Stabilization

BACKGROUND

As an alternative to the Latarjet procedure, the arthroscopic free bone block (FBB) procedure combined with dynamic anterior stabilization (DAS) has been recently proposed to provide both glenoid augmentation and a tendon sling effect for treating anterior shoulder instability (ASI) with glenoid bone loss.

PURPOSE

To evaluate the clinical and radiological outcomes of FBB-DAS for ASI with glenoid bone loss.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent arthroscopic FBB-DAS for ASI with >15% glenoid bone loss between February 2017 and March 2020 were screened and enrolled in this study. Clinical outcome measures were assessed preoperatively and at a minimum 2-year follow-up, including recurrence, complications, shoulder functional scores, range of motion, and return to sports. Postoperative computed tomography and magnetic resonance imaging were also performed.

RESULTS

Of a total of 65 patients with a mean follow-up of 46.1 ± 13.1 months, no patients experienced a recurrent dislocation or subluxation postoperatively, while 2 had a positive anterior apprehension test (3.1%). Additionally, 2 patients (3.1%) experienced complications of hematoma and shoulder stiffness, respectively. The mean visual analog scale score, American Shoulder and Elbow Surgeons score, Rowe score, and Oxford Shoulder Instability Score all improved significantly from 3.2 ± 2.4, 75.0 ± 18.9, 43.6 ± 27.3, and 33.8 ± 9.0 preoperatively to 1.3 ± 0.8, 95.1 ± 8.0, 95.5 ± 7.8, and 14.8 ± 3.5 at final follow-up, respectively (all P < .001). No difference was detected in range of motion except for 8.1° and 7.5° external rotation limitations in adduction and abduction, respectively. There were 62 patients (95.4%) who returned to sports, and 54 patients (83.1%) returned to the preinjury level. The transferred biceps tendon was intact in all 59 patients who completed radiological examination at the latest follow-up. Good bone healing was achieved in 98.3% of patients, and the glenoid bone defect decreased from 18.1% to 4.9%. Osseous and labral glenoids were significantly enlarged in width and depth on the latest magnetic resonance imaging (all P < .001).

CONCLUSION

Arthroscopic FBB-DAS provided satisfactory clinical and radiological outcomes for ASI with glenoid bone loss. Despite slight external rotation restrictions, it achieved low recurrence and complication rates, excellent shoulder functional scores, a high return-to-sports rate, and favorable graft healing and remodeling.

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.

High resorption rates following glenoid augmentation procedures do not seem to lead to higher recurrence rates or worse clinical outcomes: a systematic review and meta-analysis

PURPOSE

Bone augmentation techniques show a relatively high complication rate, which might be due to graft non-union and resorption. It is unclear which augmentation techniques demonstrate the highest amount of non-union and resorption and whether this leads to worse clinical or functional outcomes. Therefore, the aim of this review was (i) to compare non-union and resorption rates between surgical approaches, procedures, graft types, donor sites and fixation methods regarding clinical and functional outcomes and (ii) determine whether high non-union or resorption rates lead to less favorable clinical or functional outcomes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements were followed. PubMed, EMBASE (Ovid) and Cochrane Library were searched on December 15th 2021 for studies examining bone graft non-union or resorption using radiograph or CT following glenoid augmentation to treat anterior shoulder dislocation.

RESULTS

The search resulted in 103 inclusions, comprising 5,128 glenoid augmentations. When comparing pooled proportions of bony union, graft fracture rate, hardware failure rate, recurrence rate, return to sports and Rowe score, most results were similar between approaches, procedures, graft types, donor sites and fixation methods. High resorption rates were seen for allograft augmentation (74.3; 95% CI: 39.8-92.7) compared to autograft augmentation (15.5; 95% CI 10.1-23.2), but this was not associated with higher recurrence rates or worse clinical outcomes. Meta-analyses (8 studies; 494 patients) demonstrated no difference in incomplete and complete non-union rates between arthroscopic and open procedures; however, both analyses showed substantial heterogeneity. Higher partial resorption rates were observed on CT (48.0; 95% CI 43.3-52.7) compared to radiograph (14.1; 95% CI 10.9-18.1). Three studies comprising 267 shoulders demonstrated a higher rate of non-union and recurrence in smokers, whereas one study comprising 38 shoulders did not.

CONCLUSION

Non-union and resorption rates were similar among procedures, grafts and fixation methods. Higher resorption rates were observed in allografts, but this was not associated with higher recurrence rates or worse clinical outcomes. Pooling data demonstrated substantial heterogeneity and definitions varied among studies, warranting more standardized measuring.

LEVEL OF EVIDENCE

IV.

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.

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.

Fresh Distal Tibial Allograft: An Updated Graft Preparation Technique for Anterior Shoulder Instability

Fresh distal tibia allograft (DTA) has been gaining popularity among surgeons as an anatomic reconstruction option for the treatment of significant glenoid bone loss. Fresh DTA results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption, and it has similar outcomes as the Latarjet procedure. Proper graft preparation and fixation are critical to ensuring optimal outcomes. The purpose of this Technical Note is, therefore, to describe our updated technique for DTA preparation that highlights precise cutting anatomy, sizing options, and use of orthobiologics to optimize distal tibia graft union to the native glenoid surface.

A review of bone grafting techniques for glenoid reconstruction

BACKGROUND

Traumatic anterior shoulder dislocations can cause bony defects of the anterior glenoid rim and are often associated with recurrent shoulder instability. For large glenoid defects of 20-30% without a mobile bony fragment, glenoid reconstruction with bone grafts is often recommended. This review describes two broad categories of glenoid reconstruction procedures found in literature: coracoid transfers involving the Bristow and Latarjet procedures, and free bone grafting techniques.

METHODS

An electronic search of MEDLINE and PubMed was conducted to find original articles that described glenoid reconstruction techniques or modifications to existing techniques.

RESULTS

Coracoid transfers involve the Bristow and Latarjet procedures. Modifications to these procedures such as arthroscopic execution, method of graft attachment and orientation have been described. Free bone grafts have been obtained from the iliac crest, distal tibia, acromion, distal clavicle and femoral condyle.

CONCLUSION

Both coracoid transfers and free bone grafting procedures are options for reconstructing large bony defects of the anterior glenoid rim and have had similar clinical outcomes. Free bone grafts may offer greater flexibility in graft shaping and choice of graft size depending on the bone stock chosen. Novel developments tend towards minimising invasiveness using arthroscopic approaches and examining alternative non-rigid graft fixation techniques.

Free bone grafting improves clinical outcomes in anterior shoulder instability with bone defect: a systematic review and meta-analysis of studies with a minimum of 1-year follow-up

BACKGROUND

Evidence on the efficacy and safety of the free bone grafting in treating anterior shoulder instability is limited. The purpose of this study was to systematically evaluate the clinical and imaging results of free bone grafting in treating anterior shoulder instability with glenoid bone defect and to explore the incidence of complications in clinically relevant subgroups.

METHODS

This systematic review was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched up to January 29, 2021, for studies that had reported on free bone grafting in treating anterior shoulder instability with glenoid bone defect with a minimum of 1-year follow-up. Two researchers independently screened studies and extracted data. A random-effects model was used to pool data on clinical function scores, imaging results, and incidence of complications (recurrent instability and non-instability-related complications). Meta-regression analysis was used to evaluate the incidence of complications in different subgroups and investigate the sources of heterogeneity.

RESULTS

A total of 29 studies were included in the meta-analysis, comprising 840 patients (845 shoulders) with average ages ranging from 21 to 34.6 years. Compared with preoperatively, free bone grafting increased the postoperative Rowe score, American Shoulder and Elbow Surgeons score, Constant score, Subjective Shoulder Value, and Oxford Shoulder Instability Score by 53.16, 31.80, 20.81, 38.63, and 4.07 points, respectively, and reduced the visual analog scale pain score by 3 points on average. During the postoperative follow-up period, the rates of return to sport and return to preoperative levels were 84.2% and 73.1%, respectively. The imaging results showed that the free bone healing rate was 98.9% and the incidence of osteoarthritis was 10.9%. The incidence rates of recurrent instability and non-instability-related complications were 3.4% and 5.6%, respectively. Meta-regression analysis showed no evidence of effect modification by the year, follow-up time, proportion of male patients, autograft or allograft, and arthroscopy or open surgery on the incidence of complications. Subgroup analysis showed that the incidence rates of recurrent instability for open surgery, arthroscopy, allograft, autograft, Latarjet revision, and non-bone block revision were 4.1%, 2.3%, 1.5%, 4.4%, 10.3%, and 3.5%, respectively.

CONCLUSION

The application of free bone grafting in treating anterior shoulder instability with glenoid bone defect can effectively improve shoulder joint function and is associated with a high return-to-sport rate and a low overall recurrence rate, but there were some differences in the complications of recurrent instability and non-instability-related complications among the subgroups. Given that these results need to be confirmed via head-to-head comparisons, we recommend that future clinical and biomechanical studies focus on comparing and investigating the advantages and disadvantages of different surgical approaches, thus providing a basis for orthopedic surgeons to make reliable choices.

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement

PURPOSE

The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability.

METHODS

A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

RESULTS

The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation.

CONCLUSION

Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage.

LEVEL OF EVIDENCE

Level V, expert opinion.

Arthroscopic Autologous Scapular Spine Bone Graft Combined With Bankart Repair for Anterior Shoulder Instability With Subcritical (10%-15%) Glenoid Bone Loss

PURPOSE

The purpose of our study is to prove that the autologous scapular spine bone graft is an alternative for the treatment of anterior shoulder instability and the clinical and radiological results are promising.

METHOD

From July 2016 to August 2018, patients who were diagnosed as having anterior shoulder instability with subcritical (10%-15%) glenoid bone loss were treated by arthroscopic repair with autologous scapular spine bone graft. The inclusion criteria were (1) anterior shoulder instability underwent arthroscopic autologous scapular spine bone graft; (2) glenoid bone loss was within 10% to 15% (measured by Sugaya's method); (3) three complete sets of computed tomography (CT) scans (preoperative, 1 week after surgery, and 1 year after surgery) available; and (4) clinical follow-up time was at least 2 years. The exclusion criteria were (1) concomitant rotator cuff tear; (2) concomitant remplissage or SLAP repair; (3) previous surgery of the affected shoulder; (4) open surgery; and (5) incomplete radiological or clinical follow-up. The preoperative and postoperative Constant-Murley score, dietary approaches to stop hypertension (DASH) score, visual analog scale (VAS) score, and range of motion (ROM) were recorded. CT scans with 3-dimensional reconstruction were obtained at the first week after operation and at 1 year after operation; the graft resorption rate was consequently calculated.

RESULTS

Twenty-seven patients were qualified and enrolled in the study. No severe complication was recorded during follow-up. No redislocation or subluxation was found, and the apprehension tests were all negative. At the last follow-up, the mean Constant-Murley score was 89.74 ± 3.71, the mean DASH score was 9.77 ± 5.31, the mean VAS score was 0.74 ± 0.64, which are all improved significantly compared with preoperative scores (P = .00,.00,.00, respectively). At the last follow-up, the ROM including anterior flexion, external rotation by side, and the internal rotation were well restored without significant difference compared with the contralateral shoulder (P =.48, .08, .47, respectively). At 1 year after operation, the resorption rate of the bone graft was 19.4%.

CONCLUSION

This study found that anterior shoulder instability with subcritical (10%-15%) glenoid bone loss treated with arthroscopic autologous scapular spine bone graft with suture anchor fixation is safe and could achieve satisfactory result at short-term follow-up.

LEVEL OF EVIDENCE

Therapeutic case series.

Autologous free iliac crest bone grafting of glenoid through the rotator interval using double-barrelled cannula

PURPOSE

The primary aim of this study is to prove that reconstructing the anterior glenoid defect with iliac crest graft arthroscopically using double-barrelled cannula through the rotator interval is safe and prevents both recurrence of instability and the neurovascular injury because subscapularis muscle is not split and procedure is far away from important structures.

METHODS

Thirteen patients with anterior shoulder instability and engaging Hill-Sachs lesion were reviewed after arthroscopic reconstruction of the anterior glenoid with iliac crest autogenous graft. Patient satisfaction and Western Ontario İnstability Score (WOSI) were evaluated on clinical examination. Computed tomography was used to analyse graft position on sagittal and axial planes.

RESULTS

The mean follow-up was 28.7 months (SD 7.1), and age at surgery was 31 years (21 to 64 years). Post-operatively there was only one dislocation due to trauma. There was statistically significant improvement of WOSI scores (p: 0.001). There was not any neurological injury. Graft position on the axial plane was described as flush in 5 cases (41%), lateral in 2 (16%), too lateral in one (8%) and medial in 4 of the cases (33%). Graft position could be accepted as high in only three patients (23%).

CONCLUSION

Arthroscopic reconstruction of glenoid defect using autogenous iliac bone graft, through rotator interval, without splitting subscapularis is safe and effective without any neurological injury, producing substantial graft position and good functional outcomes in patients.

Arthroscopic Iliac Crest Bone Allograft Combined With Subscapularis Upper-Third Tenodesis Shows a Low Recurrence Rate in the Treatment of Recurrent Anterior Shoulder Instability Associated With Critical Bone Loss

PURPOSE

To evaluate the clinical and radiologic outcomes of patients undergoing arthroscopic glenoid bone allograft combined with subscapularis upper-third tenodesis for anterior shoulder instability associated with clinically relevant bone loss and hyperlaxity.

METHODS

Between January 2016 and December 2017, patients with recurrent anterior shoulder instability associated with bone loss and hyperlaxity were selected and treated with arthroscopic iliac crest bone graft combined with subscapularis upper-third tenodesis. The selection criteria were as follows: more than 5 dislocations; positive apprehension, anterior drawer, and Coudane-Walch test results; glenoid bone defect between 15% and 30% and humeral bone defect with an engaging Hill-Sachs lesion; and no previous shoulder surgery. All patients were followed up with the Constant score, University of California-Los Angeles (UCLA) rating, Rowe score, and visual analog scale evaluation. Assessments were performed with plain radiographs and a PICO computed tomography scan before surgery and at 2 years of follow-up.

RESULTS

Nineteen patients were included in the study, with a mean follow-up duration of 34.6 months (range, 24-48 months). In 17 patients (89%), excellent clinical results were recorded according to the Rowe score. The Constant score improved from 82.9 (standard deviation [SD], 5.2) to 88.9 (SD, 4.3) (P = .002); Rowe score, from 25.3 (SD, 5.3) to 89.1 (SD, 21.8) (P < .001); UCLA score, from 23.7 (SD, 3) to 31.5 (SD, 4.8) (P < .001); and visual analog scale score, from 3.2 to 1.3 (P < .001). Patients met the minimal clinically important difference 94.7%, 89.5%, and 47.3% of the time for the Rowe score, UCLA score, and Constant score, respectively. Bone graft resorption was observed in all patients: partial in 9 and complete in 10. We recorded 2 recurrent traumatic dislocations (11%), with no case of persistent anterior apprehension or other complication.

CONCLUSIONS

An arthroscopic glenoid bone graft combined with subscapularis upper-third tenodesis may be a valid surgical option to treat recurrent anterior instability associated with both bone loss and hyperlaxity.

LEVEL OF EVIDENCE

Level IV, 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.

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.