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Gao R, Fleet CT, Jin W, Johnson JA, Faber KJ, Athwal GS. The Kouvalchouk procedure vs. distal tibial allograft for treatment of posterior shoulder instability: the deltoid "hammock" effect exists. J Shoulder Elbow Surg 2024; 33:e537-e546. [PMID: 38750787 DOI: 10.1016/j.jse.2024.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 03/10/2024] [Accepted: 03/25/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND In 1993, Kouvalchouk described an acromial bone block with a pedicled deltoid flap for the treatment of posterior shoulder instability. This procedure provides a "double blocking" effect in that the acromial autograft restores posterior glenoid bone loss and the deltoid flap functions as a muscular "hammock" resembling the sling effect of the conjoint in the Latarjet procedure. The primary aim of this study was to compare the Kouvalchouk procedure to distal tibial allograft (DTA) reconstruction for the management of posterior shoulder instability with associated bone loss, while the secondary aim was to evaluate the deltoid hammock effect. METHODS Ten upper extremity cadavers were evaluated using a validated shoulder testing apparatus in 0° and 60° of glenohumeral abduction in the scapular plane. Testing was first performed on the normal shoulder state and was followed by the creation of a 20% posterior glenoid defect. Subsequently, the Kouvalchouk and DTA procedures were conducted. Forces of 0N, 5N, 10N, and 15N were applied to the posterior deltoid tendinous insertion on the Kouvalchouk graft along the physiological muscle line-of-action to evaluate the 'hammock" effect of this procedure. Testing was additionally performed on the Kouvalchouk bone graft with the deltoid muscle sectioned from its bony attachment. For all test states, a posteriorly directed force was applied to the humeral head perpendicular to the direction of the glenoid bone defect, with the associated translation quantified using an optical tracking system. The outcome variable was posterior translation of the humeral head at an applied force magnitude of 30N. RESULTS The Kouvalchouk procedure with the loaded deltoid flap (10N: P = .039 and 15N: P < .001) was significantly better at reducing posterior humeral head translation than the DTA. Overall, increased glenohumeral stability was observed with increased force applied to the posterior deltoid flap in the Kouvalchouk procedure. The 15 N Kouvalchouk was most effective at preventing posterior humeral translation, and the difference was statistically significant compared with the 20% glenoid defect (P = .003), detached Kouvalchouk (P < .001), and 0N Kouvalchouk (P < .001). The 15 N Kouvalchouk procedure restored posterior shoulder joint stability to near normal levels, such that it was not significantly different from the intact state (P = .203). CONCLUSIONS The Kouvalchouk procedure with load applied to the deltoid was found to be biomechanically superior to the DTA for the management of posterior shoulder instability with associated bone loss. Additionally, the results confirmed the presence and effectiveness of the deltoid "hammock" effect.
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Affiliation(s)
- Ryan Gao
- Roth | McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Canada.
| | - Cole T Fleet
- Roth | McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Canada; Department of Mechanical and Materials Engineering, Western University, London, Canada
| | - Winston Jin
- Roth | McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Canada
| | - James A Johnson
- Roth | McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Canada; Department of Mechanical and Materials Engineering, Western University, London, Canada
| | - Kenneth J Faber
- Roth | McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Canada; Department of Surgery, Western University, London, Canada
| | - George S Athwal
- Roth | McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, London, Canada; Department of Surgery, Western University, London, Canada
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Karwandyar A, Sumpter AE, LeClere LE. Current Concepts in Assessment and Management of Failed Posterior Labral Repair. Clin Sports Med 2024; 43:755-767. [PMID: 39232578 DOI: 10.1016/j.csm.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Recurrent posterior shoulder instability after primary repair is uncommon, but presents a challenging clinical scenario. Most revisions in failed labral repair were associated with glenoid bone morphology related to critical bone loss, retroversion, or dysplasia. A variety of treatment options exist which include revision labral repair with or without capsular plication, glenoid osteotomy, humeral rotational osteotomy, or glenoid bone augmentation. No single technique has been shown to be superior and each technique has strengths and limitations. Therefore, thoughtful evaluation and planning is critical to address each patient's individual pathology to maximize success after revision surgery.
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Affiliation(s)
- Ayub Karwandyar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anna E Sumpter
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Lance E LeClere
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Ganokroj P, Adriani M, Whalen RJ, Provencher MT. Treatment of Shoulder Cartilage Defects in Athletes. Sports Med Arthrosc Rev 2024; 32:87-94. [PMID: 38978202 DOI: 10.1097/jsa.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Articular cartilage defects in the glenohumeral joint may be found in laborers, the elderly, and young athletes, among others. Various factors can contribute to cartilage damage, including prior surgery, trauma, avascular necrosis, inflammatory arthritis, joint instability, and osteoarthritis. There is a wide variety of treatment options, from conservative treatment, injections, and surgical options, including arthroscopic debridement, microfracture, osteochondral autograft transfer, osteochondral graft transplantation, autologous chondrocyte implantation, and the newly emerging techniques such as biologic augmentation. There is a challenge to determine the optimal treatment options, especially for young athletes, due to limited outcomes in the literature. However, there are many options which are viable to address osteochondral defects of the glenohumeral joint.
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Affiliation(s)
- Phob Ganokroj
- Steadman Philippon Research Institute, Vail, CO
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
| | - Marco Adriani
- Steadman Philippon Research Institute, Vail, CO
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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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.
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Affiliation(s)
| | - T. Bradley Edwards
- Fondren Orthopedic Group, Fondren Orthopedic Research Institute, Texas Orthopedic Hospital, Houston, TX 77030, USA;
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5
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Ruzbarsky JJ, Peebles AM, Watkins L, Kruse AR, Lilley BM, Eble SK, Denard PJ, Romeo AA, Provencher MT. Effect of osteophyte removal on simulated range of motion using 3-dimensional preoperative planning software for reverse total shoulder arthroplasty. JSES Int 2024; 8:104-110. [PMID: 38312277 PMCID: PMC10837730 DOI: 10.1016/j.jseint.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Glenohumeral osteophytes (OPs) can adversely influence postoperative range of motion (ROM) following shoulder arthroplasty due to mechanical impingement. Though commercial three-dimensional preoperative planning software (3D PPS) is available to simulate ROM before and after OP resection, little is known about the magnitude of effect OPs and their subsequent removal have on simulated glenohumeral ROM. Methods Included patients were 1) indicated for reverse total shoulder arthroplasty (rTSA) using 3D PPS and 2) presented with glenoid and/or humeral head OPs on preoperative two-dimensional computed tomography (2D-CT) imaging. Thirty patients met the inclusion criteria (9 females, 21 males; mean age 70.45 ± 4.99 years, range 63-80 years). All subjects (n = 30) presented with humeral OPs (mean volume: 2905.16 mm3, range 109.1-11,246 mm3), while 11 subjects also presented with glenoid OPs (mean volume 108.06 mm3, range 37.59-791.4 mm3). Preoperative CTs were used to calculate OP volume (mm3) and OP circumferential extent (clockface). Mean clockface position for circumferential humeral OPs originated at 6:09 (range 4:30-7:15) and extended to 8:51 (range 8:15-10:15). Mean clockface position for glenoid OPs originated at 3:00 (range 2:00-5:00) and extended to 6:16 (range 3:00-7:30). 3D implants on PPS were standardized to achieve 0° of version, 0° of inclination and 4 mm of net lateralization. Thirty-nine and thirty-six mm glenospheres were used for males and females, respectively. 3D PPS was used to evaluate simulated ROM differences before and after OP removal in the planes of adduction (ADD), abduction, internal rotation (IR), external rotation (ER), extension, and flexion. Impact of OP volume and circumferential extent on pre and postop removal ROM were also analyzed. Results Humeral OP removal significantly increased impingement-free ADD, IR, ER, extension, and flexion. Removal of larger (mm3) humeral OPs positively correlated with improvement in IR (R = 0.452, P = .011), ER (R = 0.394, P = .033), and flexion (R = 0.500, P < .01). Greater circumferential extent of humeral OPs correlated with worse preremoval ROM in the planes of ADD (R = 0.364, P = .02) and extension (R = 0.403, P = .04), and improvements in ER postop removal (R = 0.431, P = .03). Conclusion Humeral OP removal significantly increases impingement-free ADD, IR, ER, extension, and flexion in simulated 3D PPS models following rTSA. Magnitude of simulated ROM improvement is influenced by initial humeral OP volume and circumferential clockface extent. Surgeons should consider these effects when using 3D PPS for rTSA planning to optimize postoperative ROM prognostics.
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Affiliation(s)
- Joseph J Ruzbarsky
- The Steadman Clinic, Vail, CO, USA
- Steadman Philippon Research Institute, Vail, CO, USA
| | | | | | - Amelia R Kruse
- Steadman Philippon Research Institute, Vail, CO, USA
- William Beaumont School of Medicine, Rochester, MI, USA
| | | | - Stephanie K Eble
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Anthony A Romeo
- Department of Orthopaedic Surgery, DuPage Medical Group, Chicago, IL, USA
| | - Matthew T Provencher
- The Steadman Clinic, Vail, CO, USA
- Steadman Philippon Research Institute, Vail, CO, USA
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Arner JW, Nolte PC, Ruzbarsky JJ, Woolson T, Provencher MT, Bradley JP, Millett PJ. Correlation of Acromial Morphology With Risk and Direction of Shoulder Instability: An MRI Study. Am J Sports Med 2023; 51:3211-3216. [PMID: 37732534 DOI: 10.1177/03635465231197661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The influence of bony morphology on the development of posterior shoulder instability is not well known. PURPOSE To determine if acromial morphology, as measured on magnetic resonance imaging (MRI), is associated with posterior or anterior shoulder instability. DESIGN Cross-sectional study; Level of evidence, 3. METHODS MRI measurements of posterior acromial coverage (PAC), posterior acromial height (PAH), posterior acromial tilt (PAT), and anterior acromial coverage (AAC) were completed for 3 separate matched groups who underwent surgical intervention: posterior instability, anterior instability, and a comparison group of patients who underwent arthroscopic surgery for snapping scapula. Inclusion criteria were patients with recurrent instability <40 years of age without multidirectional instability, glenoid bone loss >13.5%, or glenoid retroversion >10%. RESULTS Overall, 37 patients were included in each group. PAC was significantly less in the posterior instability group than in the anterior instability and comparison groups (68.3° vs 88.7° vs 81.7°; P < .001). PAH was significantly greater in the posterior group than in the anterior instability group (11.0 mm vs -0.1 mm; P < .001) and comparison group (0.7 mm; P < .001). There was no difference between the posterior and anterior groups in terms of PAT or AAC (P = .45 and P = .05, respectively). PAT was significantly smaller in the posterior instability group than the comparison group (55.2° vs 62.2°; P = .026). The anterior and comparison groups were not significantly different in PAH or PAT (P = .874 and P = .067, respectively) but were significantly different in AAC (P = .026). CONCLUSION A higher and flatter posterior acromion, as measured on preoperative MRI, appears to be associated with patients who require arthroscopic capsulolabral repair due to posterior shoulder instability. This information may help clinicians to both diagnose and predict the need for operative intervention for patients with posterior labral tears.
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Affiliation(s)
- Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Joseph J Ruzbarsky
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Thomas Woolson
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Matthew T Provencher
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter J Millett
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
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Livesey MG, Bedrin MD, Baird MD, Tran A, Weir TB, Hasan SA, Gilotra MN, Kilcoyne KG, Dickens JF. Acromion morphology is associated with glenoid bone loss in posterior glenohumeral instability. J Shoulder Elbow Surg 2023; 32:1850-1856. [PMID: 37003427 DOI: 10.1016/j.jse.2023.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND The acromion morphology in a shoulder with posterior instability differs from that of a shoulder without glenohumeral instability. Specifically, the acromion with a flatter sagittal tilt, greater posterior acromial height, and less posterior coverage is associated with posterior instability. However, the association between acromion morphology and glenoid bone loss (GBL) in the setting of posterior glenohumeral instability has not previously been investigated. The purpose of this study was to determine whether acromial morphology influences the extent or pattern of posterior GBL in a cohort of patients with posterior glenohumeral instability. METHODS This multicenter retrospective study identified 89 shoulders with unidirectional posterior glenohumeral instability. Total area GBL was measured using the best-fit circle method on magnetic resonance imaging (MRI). Shoulders were divided into 3 groups: (1) no GBL (n = 30), (2) GBL 0%-13.5% (n = 45), or (3) GBL ≥13.5% (n = 14). Acromion measurements were performed on MRI and included acromial tilt, posterior acromial height, anterior acromial coverage, and posterior acromial coverage. RESULTS Patients without GBL had a steeper acromial tilt (58.5° ± 1.4°) compared with those with 0%-13.5% GBL (64.3° ± 1.5°) or GBL ≥13.5% (67.7° ± 1.8°) (P = .004). Patients without GBL also had greater posterior coverage (65.4° ± 1.7°) compared with those with GBL (60.3° ± 1.4°) (P = .015). Posterior acromion height was not significantly different among groups. CONCLUSION The results demonstrate that an acromion with a flatter sagittal tilt and less posterior coverage is associated with GBL in the setting of posterior glenohumeral instability. This is important to consider as posterior GBL has been identified as a risk factor for failure of posterior soft tissue-stabilizing procedures.
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Affiliation(s)
| | - Michael D Bedrin
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Michael D Baird
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Andrew Tran
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Tristan B Weir
- University of Maryland Medical Center, Baltimore, MD, USA
| | - S Ashfaq Hasan
- University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Kelly G Kilcoyne
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center Uniformed Services University of Health Sciences, Bethesda, MD, USA; Department of Orthopaedics, Duke University, Durham, NC, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
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Waltz RA, Brown J, Brady AW, Bartolomei C, Dornan GJ, Miles JW, Arner JW, Millett PJ, Provencher MT. Biomechanical Evaluation of Posterior Shoulder Instability With a Clinically Relevant Posterior Glenoid Bone Loss Model. Am J Sports Med 2023; 51:2443-2453. [PMID: 37350387 DOI: 10.1177/03635465231177957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Existing biomechanical studies of posterior glenoid bone loss and labral pathology are limited by their use of anterior instability models, which differ in both orientation and morphology and have been performed in only a single, neutral arm position. PURPOSE To evaluate the biomechanical effectiveness of a posterior labral repair in the setting of a clinically relevant posterior bone loss model in various at-risk arm positions. STUDY DESIGN Controlled laboratory study. METHODS Ten fresh-frozen cadaveric shoulders were tested in 7 consecutive states using a 6 degrees of freedom robotic arm: (1) native, (2) posterior labral tear (6-9 o'clock), (3) posterior labral repair, (4) mean posterior glenoid bone loss (7%) with labral tear, (5) mean posterior glenoid bone loss with labral repair, (6) large posterior glenoid bone loss (28%) with labral tear, and (7) large posterior glenoid bone loss with labral repair. Bone loss was created using 3-dimensional printed computed tomography model templates. Biomechanical testing consisted of 75 N of posterior-inferior force and 75 N of compression at 60° and 90° of flexion and scaption. Posterior-inferior translation, lateral translation, and peak dislocation force were measured for each condition. RESULTS Labral repair significantly increased dislocation force independent of bone loss state between 10.1 and 14.8 N depending on arm position. Dislocation force significantly decreased between no bone loss and small bone loss (11.9-13.5 N), small bone loss and large bone loss (9.4-14.3 N), and no bone loss and large bone loss (21.2-26.5 N). Labral repair significantly decreased posterior-inferior translation compared with labral tear states by a range of 1.0 to 2.3 mm. In the native state, the shoulder was most unstable in 60° of scaption, with 29.9 ± 6.1-mm posterior-inferior translation. CONCLUSION Posterior labral repair improved stability of the glenohumeral joint, and even in smaller to medium amounts of posterior glenoid bone loss the glenohumeral stability was maintained with labral repair in this cadaveric model. However, a labral repair with large bone loss could not improve stability to the native state. CLINICAL RELEVANCE This study shows that larger amounts of posterior glenoid bone loss (>25%) may require bony augmentation for adequate stability.
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Affiliation(s)
- Robert A Waltz
- Naval Health Clinic Annapolis, United States Naval Academy, Annapolis, MD, USA
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Justin Brown
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jon W Miles
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter J Millett
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
| | - Matthew T Provencher
- Steadman Philippon Research Institute, Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado, USA
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Livesey MG, Bedrin MD, Kolevar MP, Lundy AE, Weir TB, Kaveeshwar S, Kilcoyne KG, Dickens JF, Hasan SA, Gilotra MN. Glenoid Bone Loss Pattern in Patients With Posterior Instability Versus Anterior Instability: A Matched Cohort Study. Orthop J Sports Med 2023; 11:23259671221146559. [PMID: 36874054 PMCID: PMC9974616 DOI: 10.1177/23259671221146559] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 03/03/2023] Open
Abstract
Background The pattern of glenoid bone loss (GBL) in anterior glenohumeral instability is well described. It was recognized recently that posterior GBL after instability has a posteroinferior pattern. Purpose/Hypothesis The purpose of this study was to compare GBL patterns in a matched cohort of patients with anterior versus posterior glenohumeral instability. The hypothesis was that the GBL pattern in posterior instability would be more inferior than the GBL pattern in anterior instability. Study Design Cohort study; Level of evidence, 3. Methods In this multicenter retrospective study, 28 patients with posterior instability were matched with 28 patients with anterior instability by age, sex and number of instability events. GBL location was defined using a clockface model. Obliquity was defined as the angle between the long axis of the glenoid and a line tangent to the GBL. Superior and inferior GBL were measured as areas and defined relative to the equator. The primary outcome was the 2-dimensional characterization of posterior versus anterior GBL. The secondary outcome was a comparison of the posterior GBL patterns in traumatic and atraumatic instability mechanisms in an expanded cohort of 42 patients. Results The mean age of the matched cohorts (n = 56) was 25.2 ± 9.87 years. The median obliquity of GBL was 27.53° (interquartile range [IQR], 18.83°-47.38°) in the posterior cohort and 9.28° (IQR, 6.68°-15.75°) in the anterior cohort (P < .001). The mean superior-to-inferior bone loss ratio was 0.48 ± 0.51 in the posterior cohort and 0.80 ± 0.55 (P = .032) in the anterior cohort. In the expanded posterior instability cohort (n = 42), patients with traumatic injury mechanism (n = 22), had a similar GBL obliquity compared to patients with an atraumatic injury mechanism (n = 20) (mean, 27.73° [95% CI, 20.26°-35.20°] vs 32.20° [95% CI, 21.27°-43.14°], respectively) (P = .49). Conclusion Posterior GBL occurred more inferiorly and at an increased obliquity compared with anterior GBL. This pattern is consistent for traumatic and atraumatic posterior GBL. Bone loss along the equator may not be the most reliable predictor of posterior instability, and critical bone loss may be reached more rapidly than a model of loss along the equator may predict.
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Affiliation(s)
| | - Michael D Bedrin
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Alexander E Lundy
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Tristan B Weir
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samir Kaveeshwar
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kelly G Kilcoyne
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - S Ashfaq Hasan
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mohit N Gilotra
- University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ernat JJ, Jildeh TR, Peebles AM, Hanson JA, Mologne MS, Golijanin P, Provencher MT. How to Fashion the Bone Block for Reconstruction of the Glenoid in Anterior and Posterior Instability. Am J Sports Med 2022; 50:3333-3340. [PMID: 36122346 DOI: 10.1177/03635465221121583] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Glenoid restoration techniques to address glenohumeral instability-induced anterior and posterior glenoid bone loss (AGBL and PGBL) often require reconstruction, but best-fit bone block (BFBB) modeling has not been developed. PURPOSE To provide glenoid bony reconstruction models for anterior and posterior instability of the shoulder using a bone loss instability cohort with high-fidelity 3-dimensional (3D) imaging. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We reviewed consecutive patients indicated for operative stabilization who had posterior glenohumeral instability and suspected GBL who underwent 2-dimensional (2D) computed tomography (CT). Patients were matched by sex, laterality, and age to patients who underwent operative stabilization of anterior glenohumeral instability. Mimics software was used to convert all 2D CT scans into 3D models of the scapula. A BFBB model was designed to digitally reconstruct GBL and was used to predict the amount, anatomic configuration, and fixation configuration of bony reconstruction required in AGBL and PGBL. RESULTS The study included 30 patients with posterior instability and 30 patients with anterior instability; the participants' mean ± SD age was 28.8 ± 8.15 years (range, 16.0-51.0 years). Mean surface area of AGBL was 24.9% ± 7.7% (range, 14.7%-39.1%). Mean BFBB dimensions to reconstruct the anterior glenoid were determined to be a superior-inferior length of 23.9 ± 4.2 mm, anterior-posterior width of 6.4 ± 2.4 mm, and height of 1 cm. Mean angle of AGBL bone block interface relative to glenoid to reconstruct the native concavity was 79.4°± 5.9°. For PGBL, the mean surface area was 9.2% ± 5.6% (range, 3.0%-26.3%). Mean BFBB dimensions to reconstruct the posterior glenoid were a superior-inferior length of 21.9 ± 3.4 mm, width of 4.5 ± 2.3 mm, and height of 1 cm. The mean angle of PGBL bone block interface relative to the glenoid to reconstruct the native concavity was 38.6°± 14.3°. Orientation relative to the vertical glenoid axis was 77.2°± 13.8° in anterior reconstructions versus 105.9°± 10.9° in posterior reconstructions. CONCLUSION Patients with anterior instability required a more rectangular BFBB with a bone block-glenoid interface angle of 79°, whereas patients with posterior instability required a more trapezoidal, obtusely oriented BFBB with a bone block-glenoid interface angle of 39°. BFBBs for either AGBL or PGBL can be effectively designed, and their size and/or shape can be predicted based on approximate percentage of GBL.
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Affiliation(s)
- Justin J Ernat
- The Steadman Clinic, Vail, Colorado, USA.,University of Utah Health, Salt Lake City, Utah, USA
| | | | | | - Jared A Hanson
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Matthew T Provencher
- The Steadman Clinic, Vail, Colorado, USA.,Steadman Philippon Research Institute, Vail, Colorado, USA
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Bedrin MD, Owens BD, Slaven SE, LeClere LE, Donohue MA, Tennent DJ, Goodlett RP, Cameron KL, Posner MA, Dickens JF. Prospective Evaluation of Posterior Glenoid Bone Loss After First-time and Recurrent Posterior Glenohumeral Instability Events. Am J Sports Med 2022; 50:3028-3035. [PMID: 35983958 DOI: 10.1177/03635465221115828] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although posterior glenohumeral instability is becoming an increasingly recognized cause of shoulder pain, the role of posterior glenoid bone loss on outcomes remains incompletely understood. PURPOSES To prospectively determine the amount of bone loss associated with posterior instability events and to determine predisposing factors based on preinstability imaging. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 1428 shoulders were evaluated prospectively for ≥4 years. At baseline, a subjective history of shoulder instability was ascertained for each patient, and bilateral noncontrast magnetic resonance imaging (MRI) scans of the shoulders were obtained regardless of any reported history of shoulder instability. The cohort was prospectively followed during the study period, and those who were diagnosed with posterior glenohumeral instability were identified. Postinjury MRI scans were obtained and compared with the screening MRI scans. Glenoid version, perfect-circle-based bone loss was measured for each patient's pre- and postinjury MRI scans using previously described methods. RESULTS Of the 1428 shoulders that were prospectively followed, 10 shoulders sustained a first-time posterior instability event and 3 shoulders sustained a recurrent posterior instability event. At baseline, 11 of 13 shoulders had some amount of glenoid dysplasia and/or bone loss. The change in glenoid bone loss was 5.4% along the axis of greatest loss (95% CI, 3.8%-7.0%; P = .009), 4.4% at the glenoid equator (95% CI, 2.7%-6.2%; P = .016), and 4.2% of total glenoid area (95% CI, 2.9%-5.3%; P = .002). Recurrent glenoid instability was associated with a greater amount of absolute bone loss along the axis of greatest loss compared with first-time instability (recurrent: 16.8% ± 1.1%; 95% CI, 14.6%-18.9%; first-time: 10.0% ± 1.5%; 95% CI, 7.0%-13.0%; P = .005). Baseline glenoid retroversion ≥10° was associated with a significantly greater percentage of bone loss along the axis of greatest loss (≥10° of retroversion: 13.5% ± 2.0%; 95% CI, 9.6%-17.4%; <10° of retroversion: 8.5% ± 0.8%; 95% CI, 7.0%-10.0%; P = .045). CONCLUSIONS Posterior glenohumeral instability events were associated with glenoid bone loss of 5%. The amount of glenoid bone loss after a recurrent posterior glenohumeral instability event was greater than that after first-time instability. Glenoid retroversion ≥10° was associated with a greater amount of posterior glenoid bone loss after a posterior instability event.
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Affiliation(s)
- Michael D Bedrin
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, Maryland, USA
| | - Brett D Owens
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Brown University Alpert Medical School, Providence, Rhode Island, USA
| | - Sean E Slaven
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, Maryland, USA
| | - Lance E LeClere
- United States Naval Academy, Department of Orthopaedic Surgery, Annapolis, Maryland, USA.,Vanderbilt Orthopaedics, Nashville, Tennessee, USA
| | - Michael A Donohue
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - David J Tennent
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopaedic Surgery, Evans Army Community Hospital, Fort Carson, Colorado, USA
| | - Ronald P Goodlett
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Kenneth L Cameron
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - Matthew A Posner
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.,Department of Orthopedic Surgery, Keller Army Community Hospital, West Point, New York, USA
| | - Jonathan F Dickens
- Uniformed Services University of the Health Sciences, Department of Surgery, Bethesda, Maryland, USA.,Duke University, Department of Orthopaedic Surgery, Durham, North Carolina, USA.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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12
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Dey Hazra ME, Dey Hazra RO, Hanson JA, Millett PJ. Arthroscopic Posterior Labral Repair and Capsular Closure via Single Working Portal for Posterior Shoulder Instability. Arthrosc Tech 2022; 11:e1557-e1561. [PMID: 36185126 PMCID: PMC9519942 DOI: 10.1016/j.eats.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/26/2022] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder instability (PSI) is a relatively less common form of instability that frequently affects young overhead or contact athletes. The etiology of PSI may be traumatic or atraumatic, with establishment of the diagnosis being more difficult in cases of atraumatic instability. Surgical management of PSI has evolved from open techniques to arthroscopic techniques. Posterior stabilization has commonly been performed with 2 posterior working portals with the patient in the lateral decubitus position. The objective of this Technical Note is to describe a technique for posterior labral repair using all-suture anchors with the patient in the beach-chair position via 1 working portal with capsular closure.
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Affiliation(s)
| | | | - Jared A. Hanson
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Peter J. Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A,The Steadman Clinic, Vail, Colorado, U.S.A,Address correspondence to Peter J. Millett, M.D., M.Sc., The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.
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13
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Evaluation and Management of the Contact Athlete's Shoulder. J Am Acad Orthop Surg 2022; 30:e584-e594. [PMID: 35171860 DOI: 10.5435/jaaos-d-20-01374] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 12/10/2021] [Indexed: 02/01/2023] Open
Abstract
Shoulder injuries are common in contact athletes and vary in severity because of the required complex interplay of shoulder stability and range of motion for proper function. Pathology varies based on sport but most commonly includes shoulder instability, acromioclavicular injuries, traumatic rotator cuff tears, and brachial plexus injuries. Acute management ranges from reduction of shoulder dislocations to physical examination to determine the severity of injury. Appropriate radiographs should be obtained to evaluate for alignment and fracture, with magnetic resonance imaging commonly being necessary for accurate diagnosis and management. Treatments range from surgical stabilization in shoulder instability to repeat examinations and physical therapy. Return-to-play decision making can be complex with avoidance of reinjury and player safety being of utmost concern. Appropriate evaluation and treatment are vital because repeat injury can lead to long-term effects due to the relatively high effectsometimes seen in contact sports.
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14
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Marcaccio SE, O’Donnel RM, Schilkowsky R, Owens MBD, Bokshan SL. Posterior Glenoid Osteotomy With Capsulolabral Repair Improves Resistance Forces in a Critical Glenoid Bone Loss Model. Orthop J Sports Med 2022; 10:23259671221083579. [PMID: 35309235 PMCID: PMC8928394 DOI: 10.1177/23259671221083579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background: There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss. Hypothesis: That opening posterior glenoid wedge osteotomy with soft tissue repair would improve the resistance forces of instability when compared with soft tissue repair alone in the setting of 20% critical bone lose. Study Design: Controlled laboratory study. Methods: Native glenoid retroversion was measured on 9 shoulders using computed tomography (CT) scans. The humerus was potted in 90° of forward flexion and 30° of internal rotation relative to the scapula, and a posterior dislocation was performed to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, and (4) 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. Bone loss was created using a sagittal saw. The resultant peak forces with 1 cm of posterior translation were measured. A 1-way repeated-measures analysis of variance was used to compare mean force values. Results: After the initial dislocation event, all shoulders had a resultant posterior capsulolabral injury. The resulting labral injury was extended from 6- to 9-o’clock in all specimens to homogenize the extent of injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared with the labral deficient group (34.1 vs 22.2 N; P = .068). When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger (43.8 N) than the posterior repair alone both with (34.1 N) and without (31.8 N) bone loss (P = .008 and .045, respectively). Conclusion: In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair improved resistance to posterior humeral translation significantly compared with capsulolabral repair alone. Clinical Relevance: The results of this biomechanical cadaveric study may aid in surgical planning for this complex patient population.
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Affiliation(s)
- Stephen E. Marcaccio
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Ryan M. O’Donnel
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Rachel Schilkowsky
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Meng Brett D. Owens
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
| | - Steven L. Bokshan
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA
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15
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Bone Block Augmentation of the Posterior Glenoid for Recurrent Posterior Shoulder Instability Is Associated With High Rates of Clinical Failure: A Systematic Review. Arthroscopy 2022; 38:551-563.e5. [PMID: 34332053 DOI: 10.1016/j.arthro.2021.07.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 07/06/2021] [Accepted: 07/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether posterior glenoid bone block augmentation performed for the treatment of recurrent posterior shoulder instability succeeds in restoring stability and is associated with rates of complications or clinical failures comparable to other glenoid bone augmentation procedures. METHODS A comprehensive search of PubMed, MEDLINE, and EMBASE databases was performed. Level of evidence studies I to IV pertaining to posterior bone block augmentation reporting on outcomes or complications were included. The search was carried out in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. RESULTS Screening of titles, abstracts, and manuscripts with application of inclusion and exclusion criteria yielded 17 full-text articles reporting on 269 shoulders undergoing bone block augmentation. Surgical technique varied between studies with regard to graft type (iliac crest, 13 studies; scapular spine, 2; acromion, 1; distal tibia allograft, 1), graft positioning (medial to 1.5 cm lateral to glenoid surface, equatorial to subequatorial), and open versus arthroscopic technique (open, 10 studies; arthroscopic, 4; both, 3). Four of the 8 studies with pre- and postoperative patient-reported outcomes (PROs) showed significant improvements in these outcomes at final follow-up. The postoperative outcomes ranged from 60 to 90 for Rowe scores (n = 7 studies) and 79 to 90 for Walch-Duplay scores (n = 7 studies). Complications were commonly encountered, with high rates of recurrent instability (0% to 73%) and revision procedures (0% to 67%) across different studies. CONCLUSION Posterior bone block augmentation for recurrent posterior shoulder instability does not reliably yield substantial improvements in PROs, and complications are frequently observed. The substantial heterogeneity across studies and the small number of patients precludes any substantive judgements as to the superiority of one surgical technique over another. LEVEL OF EVIDENCE IV, systematic review of level III and IV studies.
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16
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Arner JW, Ruzbarsky JJ, Midtgaard K, Peebles L, Bradley JP, Provencher MT. Defining Critical Glenoid Bone Loss in Posterior Shoulder Capsulolabral Repair. Am J Sports Med 2021; 49:2013-2019. [PMID: 34081559 DOI: 10.1177/03635465211016804] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although critical bone loss for anterior instability is well defined, a clinically significant threshold of posterior bone loss has not been elucidated. HYPOTHESIS Patients with failed arthroscopic posterior shoulder capsulolabral repair will have increased posterior glenoid bone loss with a defined critical threshold. STUDY DESIGN Case control study; Level of evidence, 3. METHODS Athletes older than 18 years with unidirectional posterior instability treated with arthroscopic repair were evaluated at 2-year minimum follow-up. Failure was defined as revision surgery, American Shoulder and Elbow Surgeons (ASES) score of <60, or subjective stability score of >5. Magnetic resonance imaging (MRI) measurements from 19 patients with failed arthroscopic posterior shoulder capsulolabral repair were compared with 56 patients whose surgery was successful. MRI measures included glenoid version, labral version, glenoid width, labral width, percentage bone loss using the circle technique, labral height, percent subluxation, and recently described measures of defect slope, bone loss angle, and defect length. The P value threshold was set at .05, and a multivariable logistic regression analysis was performed for evaluation of risk of surgical failure. RESULTS Smaller glenoid width and greater percentage glenoid bone loss (25.5 ± 0.68 mm vs 28.8 ± 0.47 mm; P < .001; 6.8% ± 0.64% vs 4.6% ± 0.43%; P = .008) were seen in those patients with failed surgery. There was no difference in glenoid version or other measurements between the failures and nonfailures. A cutoff of 11% glenoid bone loss resulted in a 10.4 times statistically higher surgical failure rate, while a 15% bone loss resulted in a 24.4 times statistically higher failure rate. Six patients had >11% bone loss (range, 11.1 to 19.3) and 1 patient had >15% bone loss. CONCLUSION Risk factors for failure of arthroscopic posterior shoulder capsulolabral repair include smaller glenoid bone width and greater percentage of glenoid bone loss. A threshold of 11% posterior glenoid bone loss implicated a 10 times higher surgical failure rate, while a threshold of 15% led to a 25 times higher surgical failure rate. Surgical failure of posterior capsulolabral repair, however, is relatively rare as it is an overall successful intervention.
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Affiliation(s)
- Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Liam Peebles
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew T Provencher
- The Steadman Clinic, Vail, Colorado, USA.,The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
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17
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Posterior Glenoid Reconstruction Using a Distal Tibial Allograft. Arthrosc Tech 2021; 10:e1227-e1232. [PMID: 34141536 PMCID: PMC8185618 DOI: 10.1016/j.eats.2021.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder instability is increasingly recognized and diagnosed in young athletes. These patients often present with vague shoulder pain rather than the frank instability commonly seen with anterior instability. Three common causes of posterior shoulder instability are congenital retroversion, a single traumatic event, or repetitive microtrauma with erosive effects. The critical determination when deciding on the appropriate treatment of posterior shoulder instability is the presence and degree of glenoid bone loss. In patients without bone loss, arthroscopic procedures have a high success rate with a failure rate of less than 10% and an 89% return-to-sport rate. The determination of the critical amount of bone loss that would permit an arthroscopic procedure is controversial, but recent reports that attempt to quantify the critical bone loss value posteriorly have ranged from 13.5% to 20%. This Technical Note describes our preferred method of open surgical treatment of posterior shoulder instability with posterior glenoid bone loss using an intra-articular distal tibial allograft.
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18
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Weber AE, Bolia IK, Horn A, Villacis D, Omid R, Tibone JE, White E, Hatch GF. Glenoid Bone Loss in Shoulder Instability: Superiority of Three-Dimensional Computed Tomography over Two-Dimensional Magnetic Resonance Imaging Using Established Methodology. Clin Orthop Surg 2021; 13:223-228. [PMID: 34094013 PMCID: PMC8173237 DOI: 10.4055/cios20097] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022] Open
Abstract
Backgroud Recent literature suggests that three-dimensional magnetic resonance imaging (3D MRI) can replace 3D computed tomography (3D CT) when evaluating glenoid bone loss in patients with shoulder instability. We aimed to examine if 2D MRI in conjunction with a validated predictive formula for assessment of glenoid height is equivalent to the gold standard 3D CT scans for patients with recurrent glenohumeral instability. Methods Patients with recurrent shoulder instability and available imaging were retrospectively reviewed. Glenoid height on 3D CT and 2D MRI was measured by two blinded raters. Difference and equivalence testing were performed using a paired t-test and two one-sided tests, respectively. The interclass correlation coefficient (ICC) was used to test for interrater reliability, and percent agreement between the measurements of one reviewer was used to assess intrarater reliability. Results Using an equivalence margin of 1 mm, 3D CT and 2D MRI were found to be different (p = 0.123). The mean glenoid height was significantly different when measured on 2D MRI (39.09 ± 2.93 mm) compared to 3D CT (38.71 ± 2.89 mm) (p = 0.032). The mean glenoid width was significantly different between 3D CT (30.13 ± 2.43 mm) and 2D MRI (27.45 ± 1.72 mm) (p < 0.001). The 3D CT measurements had better interrater agreement (ICC, 0.91) than 2D MRI measurements (ICC, 0.8). intrarater agreement was also higher on CT. Conclusions Measurements of glenoid height using 3D CT and 2D MRI with subsequent calculation of the glenoid width using a validated methodology were not equivalent, and 3D CT was superior. Based on the validated methods for the measurement of glenoid bone loss on advanced imaging studies, 3D CT study must be preferred over 2D MRI in order to estimate the amount of glenoid bone loss in candidates for shoulder stabilization surgery and to assist in surgical decision-making.
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Affiliation(s)
- Alexander E Weber
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
| | - Andrew Horn
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
| | - Diego Villacis
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
| | - Reza Omid
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
| | - James E Tibone
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric White
- Department of Radiology, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - George F Hatch
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA, USA
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19
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Sheean AJ, Arner JW, Bradley JP. Posterior Glenohumeral Instability: Diagnosis and Management. Arthroscopy 2020; 36:2580-2582. [PMID: 32442706 DOI: 10.1016/j.arthro.2020.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/08/2020] [Indexed: 02/02/2023]
Abstract
Posterior glenohumeral instability can manifest as posterior shoulder pain and dysfunction, particularly among athletes. Repetitive, posteriorly-directed axial loads, as commonly encountered by contact athletes (American football linemen, rugby players), result in microtrauma that can induce posteroinferior labral tears. Alternatively, SLAP tears commonly seen in throwing athletes may propagate in a posteroinferior direction (i.e., a type VIII SLAP tear), owing to a complex pathologic cascade involving glenohumeral capsular contracture and imbalances among the dynamic stabilizing muscles of both the glenohumeral joint and shoulder girdle. The diagnosis of posterior glenohumeral instability is elucidated by a thorough history and physical examination. Posterior shoulder pain is oftentimes insidious in onset. The throwing athlete with posterior glenohumeral instability may complain of diminished control, accuracy, and generalized shoulder discomfort. A number of provocative physical examination maneuvers have been described (Kim test, Jerk test), which load the humeral head against the labral lesion and recreate patients' symptoms. Magnetic resonance imaging and magnetic resonance arthrography can be of value in demonstrating avulsions of the labrum from the posteroinferior glenoid, and computed tomography is useful for quantifying the location and amount of attritional glenoid bone loss, although in contradistinction to anterior glenohumeral instability, clearly defined thresholds that would otherwise guide treatment have not been established. In the absence of substantial bone loss, arthroscopic posterior capsulolabral repair remains the gold standard for the surgical management of symptoms refractory to nonoperative treatment, and excellent clinical outcomes have generally been reported. However, high rates of return to play at the previous level of participation, particularly among throwing athletes, have been less consistently observed. Risk factors for the need for revision stabilization include surgery on the dominant extremity, female sex, and capsulolabral repairs involving either anchorless techniques or the use of less than 4 anchors.
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Affiliation(s)
- Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, U.S.A..
| | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
| | - James P Bradley
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, U.S.A
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20
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Arner JW, Elrick BP, Nolte PC, Goldenberg B, Dekker TJ, Millett PJ. Posterior Glenoid Augmentation With Extra-articular Iliac Crest Autograft for Recurrent Posterior Shoulder Instability. Arthrosc Tech 2020; 9:e1227-e1233. [PMID: 33024660 PMCID: PMC7528205 DOI: 10.1016/j.eats.2020.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/29/2020] [Indexed: 02/03/2023] Open
Abstract
Several techniques have been described for bone block augmentation as a treatment for posterior shoulder instability, including intra-articular distal tibial allograft and extra-articular iliac crest autograft. Although indications are not yet well defined, these bone augmentation procedures are considered in patients with glenoid bone loss, increased glenoid retroversion, previous failed posterior soft-tissue repair, and insufficient posterior capsulolabral tissue. In patients with posterior glenoid bone loss, the senior author (P.J.M.) recommends intra-articular glenoid reconstruction with a fresh distal tibial osteoarticular allograft. In patients with insufficient posterior capsulolabral tissue, the senior author prefers an extra-articular iliac crest autograft to buttress the posterior soft-tissue restraints. This technique guide outlines extra-articular iliac crest autograft treatment for recurrent posterior shoulder instability in patients with insufficient posterior soft tissues due to prior failed surgery. After an open capsulolabral repair is performed using suture anchors, the bone block is placed extra-articularly on the posterior glenoid neck.
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Affiliation(s)
- Justin W. Arner
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A
| | | | - Philip-C. Nolte
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany (P-C.N.)
| | | | - Travis J. Dekker
- Eglin Air Force Base, 96th Medical Group, United States Air Force, Eglin, Florida, U.S.A
| | - Peter J. Millett
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Peter J. Millett, M.D., M.Sc., Steadman Philippon Research Institute, The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.
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