Anterior Bone Block Research Articles

Direct anterior bone block grafting for treatment of bone defects and dysplasia of the coronoid process

The aim of the surgery was to treat an elbow instability caused by critical coronoid bone loss (CCBL), lateral ulnar collateral ligament (LUCL) insufficiency,and general hyperlaxity by performing adirect anterior coronoid bone graft (CBG) and LUCL reconstruction in the same setting. In cases with CCBL isolated ligament reconstruction harbors ahigh failure rate, necessitating supplementary bony procedures. The diagnosis of CCBL is confirmed through lateral radiographs and further quantified through computed tomography (CT) imaging. Objective assessment of instability is conducted with standardized arthroscopic tests. Performing an anterior approach for CBG offers distinct advantages, notably in terms of achieving precise positioning of plates and screws and providing access to the proximal radioulnar joint. Usual contraindications to surgery, coronoid bone loss less than 40%. The surgical procedure is thoroughly illustrated with avideo of the operation that can be accessed online: reconstruction of the LUCL with asemitendinosus allograft, harvesting of the graft from the iliac crest, exposure of the coronoid process with adirect anterior approach, freshening up of the graft bed. Temporary fixation of the graft with aKirschner wire. Assessment of joint congruency, stability and range of motion (ROM) prior to definitive fixation with a2.4 mm buttress plate and screws. Nonsteroidal anti-inflammatory drugs (NSAID) to prevent heterotopic ossification. Elbow mobilization in pronation from day1 with an overhead motion protocol. Removable splint for 4weeks, free mobilization at 6weeks, return to sport at 3months. Durable elbow stability was achieved along with free ROM and high patient satisfaction.

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

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. 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. Cohort study; Level of evidence, 3. 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. 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). 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.

Direct Anterior Bone Block Grafting for Coronoid Bone Loss and Dysplasia

Background: Critical coronoid bone loss (CCBL) can be the key factor of elbow instability, making bony reconstruction essential. Coronoid bone grafting (CBG) is challenging, with a paucity of descriptions in the literature. We present direct anterior CBG in a patient with instability, CCBL (&gt;40%), lateral ulnar collateral ligament (LUCL) insufficiency, and ligamentous laxity who underwent LUCL reconstruction in the same setting. Indications: Isolated ligament reconstruction has a high failure rate in cases with CCBL and therefore requires additional bone grafting. The diagnosis of CCBL is made with lateral radiographs and further quantified by computed tomography imaging. Instability can be best assessed objectively during arthroscopy with a switching stick. CBG performed with an anterior approach facilitates direct access with advantages for plate and screw positioning and access to the proximal radio-ulnar joint. Technique Description: First, LUCL reconstruction was performed. After harvesting of the graft from the iliac crest, the coronoid was exposed with a direct anterior approach. The incision starts centrally medial to the biceps tendon (BT) in the flexion crease extending distally (9 cm). Ligation of multiple vessels (leash of Henry) is required. The deep dissection is continued between the bicipital aponeurosis and BT. Blunt and flat Langenbeck-type retractors are used with care, laterally (BT/radial nerve) and medially (aponeurosis/median nerve). The brachialis muscle is exposed and longitudinally split in line with its fibers, gaining access to the capsule. Harmful retraction on either side of the split has to be avoided. The capsule is incised as a Z-plasty, the coronoid exposed from the joint in the distal direction prior to freshening up the graft bed. The graft is held in place with a wire joystick, sculpted, and temporarily fixed. Joint congruency, stability, and a range of motion (ROM) are checked prior to definitive fixation with a 2.4-mm buttress plate and screws. Results: The coronoid process height was successfully reconstructed from &lt;60% to 100% with durable elbow stability (&gt;1 year), free ROM, and high patient satisfaction. Conclusion: CBG can be standardized and facilitated with a direct anterior approach as a key element for successful elbow stabilization in the setting of CCBL. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Risk factors for unexpected readmission and reoperation following open procedures for shoulder instability: a national database study of 1,942 cases.

The purpose of this study was to identify demographics and risk factors associated with unplanned 30-day readmission and reoperation following open procedures for shoulder instability and examine recent trends in open shoulder instability procedures. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using current procedural terminology (CPT) codes 23455, 23460, and 23462 to find patients who underwent shoulder instability surgery from 2015 to 2019. Independent sample Student t-tests and chi-square tests were used in univariate analyses to identify demographic, lifestyle, and perioperative variables related to 30-day readmission following repair for shoulder instability. Multivariate logistic regression modeling was subsequently performed. In total, 1,942 cases of open surgical procedures for shoulder instability were identified. Within our study sample, 1.27% of patients were readmitted within 30 days of surgery, and 0.85% required reoperation. Multivariate logistic regression modeling confirmed that the following patient variables were associated with a statistically significant increase in the odds of readmission: open anterior bone block/Latarjet-Bristow procedure, being a current smoker, and a long hospital stay (all P<0.05). Multivariate logistic regression modeling confirmed statistically significant increased odds of reoperation with an open anterior bone block or Latarjet-Bristow procedure (P<0.05). Unplanned 30-day readmission and reoperation after open shoulder instability surgery is infrequent. Patients who are current smokers, have an open anterior bone block or Latarjet-Bristow procedure, or a longer than average hospital stay have higher odds of readmission than others. Patients who undergo an open anterior bone block or Latarjet-Bristow procedure have higher odds of reoperation than those who undergo an open soft-tissue procedure. Level of evidence: III.

Trends and projections in surgical stabilization of glenohumeral instability in the United States from 2009 to 2030: rise of the Latarjet procedure and fall of open Bankart repair.

Advances in surgical techniques have improved the ability to address recurrent glenohumeral instability via arthroscopic capsulolabral repair and bone-restoring procedures such as the Latarjet procedure. Given the paucity of studies analyzing temporal trends in the surgical management of glenohumeral instability, the purpose of this study was to assess trends in the treatment of anterior, posterior, and multidirectional instability over a 10-year period and model projections to 2030. Using the IBM Watson MarketScan national database, we identified all patients who underwent glenohumeral instability procedures from 2009 to 2018. Procedures were identified using Current Procedural Terminology codes for open Bankart, Latarjet, anterior bone block, posterior bone block, multidirectional capsular shift, and arthroscopic Bankart procedures. Sample weights provided by the database were used to calculate national estimates. US Census Bureau annual population data were used to calculate incidence. Future projections to 2030 were modeled using Poisson and linear regression. There were an estimated 446,072 glenohumeral instability cases from 2009 to 2018. The per capita incidence (per 100,000) remained constant, from 14.8 in 2009 to 14.5 in 2018. Arthroscopic Bankart procedures comprised the highest number of procedures throughout the study period, accounting for 89% of all procedures in 2009 and 93% in 2018. The number of open Bankart procedures decreased by 65% from 2009 to 2018, whereas the number of Latarjet procedures showed a 250% increase over the same period. Patient demographics did not change over the study period, and male patients aged 18-25 years comprised the largest demographic group undergoing anterior instability procedures. Multidirectional instability procedures exhibited the least pronounced sex differences. Future modeling from 2018 to 2030 projected a continued steady rise in arthroscopic Bankart procedures (from 40,000 to 49,000 cases/yr), rapid growth in Latarjet procedures (from 1370 to 4300 cases/yr), and continued decline in open Bankart procedures (from 1000 to 250 cases/yr). Arthroscopic Bankart repair continues to be the most common glenohumeral instability procedure in the United States. From 2009 to 2018, the incidence of open Bankart procedures declined whereas the incidence of Latarjet procedures markedly increased. Future projections to 2030 mirrored these findings. These data may provide an enhanced understanding of the evolution of surgical treatment of glenohumeral instability within the United States, laying the foundation for continued prospective studies into the appropriate indications and advancements in surgical techniques.

Resident Involvement in Shoulder-Stabilization Procedures Is Not Associated With an Increased Risk of 30-Day Postoperative Complications

To examine the 30-day postoperative outcomes of resident involvement in shoulder-stabilization surgical procedures using the American College of Surgeons National Surgical Quality Improvement database. We conducted a retrospective review of the National Surgical Quality Improvement database for all shoulder-stabilization procedures from 2010 to 2018. Procedures included arthroscopic Bankart, arthroscopic Bankart with SLAP repair, arthroscopic Bankart with Remplissage, open Bankart, anterior bone block, posterior bone block, Latarjet coracoid process transfer, and capsular shift/capsulorrhaphy for multidirectional instability. Data included preoperative demographics, comorbidities, and 30-day postoperative outcomes. Cases were categorized into 2 groups: "attending alone" and "attending and resident." Statistical analysis comparing groups on demographics and comorbidities included independent t-test for continuous variables and Pearson χ2 or Fischer exact for categorical variables. A logistic regression model including propensity score was used to calculate adjusted odds ratio for outcomes. A total of 3,954 patients undergoing shoulder-stabilization procedures were included in the study and 28.8% of patients had a resident involved intheir procedure. Residents were more likely to be involved in procedure for patients who were of minority ethnicity (P<.001), a lower body mass index (P < .001) and less likely to have a history of chronic obstructive pulmonary disease (P= .029). Resident involvement resulted in statistically significant longer total operation time (91 vs 85 minutes, P < .001). In terms of postsurgical outcomes, complication rates were low for both groups (∼0.8%). Resident involvement was not associated with any significant increase in 30-day postsurgical complications. Our results show that resident involvement in shoulder-stabilization surgery is associated with a significant increase in operative time without any significant increase in 30-day postsurgical complications. Level III, retrospective comparative study.

Poster 201: Trends and Projections in Surgical Stabilization of Glenohumeral Instability in the United States from 2009 to 2030: Rise of the Latarjet and Fall of the Open Bankart

Objectives: Advances in surgical techniques have improved the ability to addressrecurrent glenohumeral instability via arthroscopic capsulolabral repair and bonerestoring procedures such as Latarjet. Given the paucity of studies analyzing temporaltrends in surgical management of glenohumeral instability, the purpose of this studywas to assess trends in treatment of anterior, posterior, and multidirectional instabilityover a 10-year period and model projections to 2030. Methods: Using IBM Watson Marketscan national database, all patients thatunderwent glenohumeral instability procedures from 2009 to 2018 were identified.Procedures were identified using common procedural terminology (CPT) codes foropen Bankart Repair, Latarjet, anterior bone block, posterior bone block,multidirectional capsular shift, and arthroscopic Bankart procedures. Sample weightsprovided by the database were utilized to calculate national estimates. The UnitedStates (U.S.) Census Bureau annual population data were utilized for calculatingincidence. Future projections to 2030 were modeled using Poisson and linearregression. Results: There were an estimated 446,072 glenohumeral instability cases from 2009-2018. Per capita (per 100,000) incidence remained constant, from 14.8 in 2009 to 14.5in 2018. Arthroscopic Bankart comprised the highest number of procedures throughoutthe study period, accounting for 89% of all procedures in 2009 and 93% in 2018. OpenBankart procedures decreased by 65% from 2009 to 2018, while there was a 250%increase in Latarjet procedures over the same period. Patient demographics did notchange over the study period, and males aged 18-25 comprised the largestdemographic group undergoing anterior instability procedures. Multidirectionalinstability procedures exhibited the least pronounced gender differences. Futuremodeling from 2018-2030 projected continued steady rise in arthroscopic Bankart(40,000-49,000 case/yr), rapid growth in Latarjet (1370-4300 cases/yr), and continueddecline in open Bankart (1000-250 cases/yr) procedures. Conclusions: Arthroscopic Bankart continues to be the most common glenohumeralinstability procedure in the U.S. From 2009 to 2018, incidence of open Bankartprocedures declined while Latarjet procedures markedly increased. Future projectionsto 2030 mirrored these findings. These data may provide an enhanced understandingof the evolution of surgical treatment of glenohumeral instability within the U.S. layingthe foundation for continued prospective studies into the appropriate indications andadvancements in surgical techniques. [Table: see text][Table: see text]

Partial Humeral Head Arthroplasty, Glenoid Allograft Augmentation, and Open Bankart Reconstruction for Critical Glenoid Bone Loss and Engaging Hill-Sachs Lesion

Background: Shoulder instability with critical bipolar bone loss can be difficult to treat. Anterior glenoid bone block augmentation and partial humeral head resurfacing is a viable option. Indications: This procedure is indicated in patients with both critical anterior glenoid bone loss (≥20%) and an engaging Hill-Sachs lesion. Technique Description: A deltopectoral approach is performed, followed by a subscapularis tenotomy. The Hill-Sachs lesion is resurfaced with a partial humeral head arthroplasty. The anterior glenoid bone loss is replaced with a prefabricated allograft. An open Bankart repair is then performed. Results: Three case reports give evidence that this technique is a viable surgical option for patients with critical glenoid bone loss and an engaging Hill-Sachs lesion. Discussion/Conclusion: Partial humeral head resurfacing, glenoid allograft augmentation, and open Bankart is a viable surgical option for patients with critical anterior glenoid bone loss and an engaging Hill-Sachs lesion. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopically Assisted Anterior Bone Block for Shoulder Instability

Background: Shoulder instability is a common complaint, with treatment depending on the severity of the bony defect. Advancements in arthroscopic techniques have allowed for a less invasive surgery with decreased postoperative pain, improved graft placement, and better visualization. Indications: Large bony defects of the glenoid require bone block augmentation to reduce recurrent instability. In this presentation, arthroscopically assisted anterior bone block was performed with a distal tibial allograft to address recurrent anterior shoulder instability with a large glenoid defect. Technique Description: The patient is placed in a lateral decubitus position. Standard arthroscopic portals are made. The bone block is fashioned from a distal tibial allograft. Using a guide, drill holes are placed in the bone block. The guide is inserted from the posterior portal and placed parallel to the joint surface. Using drill sleeves, superior and inferior screw holes are drilled and a metal cannula is left in place to allow for shuttling of suture. Two anchors are placed on the glenoid to allow for capsule labral junction to be brought up to the graft once the graft is in place. The bone block is delivered through a dilated anterior portal and reduced. The sutures are tensioned. A button is placed on each set of looped sutures, a Nice knot is placed into each, and a tensioning device is tensioned. Once compression is achieved, knots are tied to perform final fixation over the buttons. A suture passing device is used to grab inferior capsule and labrum to the priorly placed anchor on the inferior glenoid and tied. Results: Arthroscopically assisted anterior bone block for shoulder instability has been demonstrated to have similar clinical and radiographic outcomes when compared with open treatment. However, arthroscopically assisted Latarjet has been shown to have decreased soft tissue disruption and possible improvements in graft placement. Discussion/Conclusion: Arthroscopically assisted anterior bone block is a technically demanding surgery but has been shown to have similar outcomes when compared with open treatment. In this video, we demonstrate an arthroscopically assisted anterior bone block for recurrent anterior shoulder instability. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Clinical outcomes of shoulder arthroplasty for post-instability arthropathy after open anterior bone block stabilization

BackgroundPost-instability glenohumeral arthropathy can occur after nonanatomic instability repairs. With advanced secondary arthritis, subsequent shoulder arthroplasty may be complicated by altered surgical anatomy, poor range of motion, subscapularis deficiency, unique glenoid wear patterns, and/or aberrant neurovascular anatomy. The purpose of this study was to evaluate the clinical outcomes of patients undergoing shoulder arthroplasty after previous open nonanatomic anterior shoulder stabilization, particularly glenoid bone block procedures. MethodsBetween 2008 and 2014, all patients with shoulder arthroplasty for symptomatic post-instability glenohumeral arthropathy after prior open stabilizations were identified from surgical case logs of two senior shoulder surgeons. Demographic variables were extracted from electronic medical records, operative reports, and preoperative and postoperative radiographs, and a minimum 24-month follow-up with completion of patient-reported questionnaires was required. Postoperative active forward elevation and active external rotation were recorded. The primary outcome measures were the visual analog scale for pain, American Shoulder and Elbow Surgeons Shoulder score, and the Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were extracted. ResultsA total of 12 patients were identified with an average age of 63 ± 12 years (range, 46-83), including 7 males and 5 females, and index surgery included open Bristow (n = 7), open Latarjet (n = 2), iliac crest bone graft (n = 1), and Putti-Platt procedure (n = 2). Seven patients underwent anatomic TSA, 4 reverse TSA, and 1 hemiarthroplasty. At an average of 44 ± 21 months follow-up, average active forward elevation and active external rotation improved from 100 ± 36 preoperatively to 132 ± 41 (P = .12) postoperatively and 19 ± 15 to 49 ± 11 (P < .01), respectively. The average visual analog scale decreased from 5 ± 3 to 1 ± 2 (P < .01) and mean American Shoulder and Elbow Surgeons improved from 44 ± 23 to 79 ± 17 (P < .01); and the average Simple Shoulder Test improved from 4 ± 2 to 9 ± 3 (P < .01). No perioperative complications or secondary reoperations were required, and only one patient experienced subsequent instability due to subsequent shoulder trauma. ConclusionDespite the surgical complexity and unique challenges associated with post-instability arthropathy, shoulder arthroplasty after prior open anterior bone block procedure or nonanatomic reconstruction is a safe procedure with low risk of perioperative complication, subsequent shoulder instability, or secondary revision surgery. All patients experienced significant improvements in pain, range of motion, and self-reported function at short- to mid-term follow-up.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs.

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability. Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure. The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures. Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

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

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR). We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR). Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men. ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Satisfactory functional results and complication rates after anterior glenoid bone block reconstruction in recurrent shoulder dislocation: a mean 4-year follow-up comparative study

BackgroundAnterior recurrent instability of the glenohumeral joint is a common clinical problem among the young population. Glenoid reconstruction with bone graft has become the treatment of choice, particularly in significant deficiency (˃20%). This study aims to assess the functional results of glenoid reconstruction using Latarjet and iliac bone graft in the management of glenoid insufficiency associated with recurrent anterior dislocation of the glenohumeral joint. MethodsPatients suffering from anterior shoulder instability with glenoid defect >20% were included in this study between 2016 and 2021. The university of California at Los Angeles (UCLA) shoulder scale and Constant score were used to assess the functional improvement. Preoperative and final postoperative continuous outcomes were compared with a one-tailed paired t-test and the outcomes across groups were compared using a two-tailed independent t-test. A P-value of <0.05 was considered statistically significant for both tests. ResultsThis trial included 50 patients; twenty-five underwent mini-open Latarjet, and 25 underwent arthroscopic tricortical iliac crest bone grafting (ICBG). The mean follow-up durations were 50.1 ± 5.9 months for Laterjet and 51.6 ± 6.8 months for ICBG. Both techniques showed statistically significant improvement in the final UCLA (31.1 ± 2.1 in Laterjet and 30.2 ± 2.2 in ICBG) and Constant (90.2 ± 4.6 in Laterjet and 89 ± 5.01 in ICBG) scores. There was no statistically significant difference regarding mean age, sex, side of injury, mechanism of injury, follow-up period and clinical outcome between both surgical treatments. At the end of the study, both groups demonstrated statistically significant improvement in the range of motion (p ˂ 0.00001). Only one, non-adherent patient in Laterjet group had post-operative dislocation. In ICBG group, two patients had partial bone graft resorption, 3 graft site morbidities and 1 hardware prominence. ConclusionBoth Laterjet and iliac bone graft procedures had satisfactory functional results in reconstruction of glenoid defect >20% in unstable shoulders with a mean 4-year follow-up. No statistically significant difference was reported in the last postoperative Constant and UCLA scores between both techniques, but Latarjet procedure had fewer complications (4%) than ICBG (24%).Level of evidence: Prospective non-randomized comparative study; level II

Arthroscopic Iliac Bone Block Augmentation for Glenoid Reconstruction: Transglenoid Fixation Technique Using an All-Suture Anchor

Arthroscopic Bankart repair of anterior instability has shown relatively good results, but its effectiveness is unclear in cases wherein there is a bone defect in the glenoid bone. The surgical management of recurrent anterior shoulder instability with severe glenoid bone loss has been challenging until now. Therefore the Latarjet procedure was introduced as an alternative that provided good results in cases of full instability with a bone defect. In cases of recurrent anterior shoulder instability, bone defects are often present within the glenoid. To restore glenohumeral stability, a bone augmentation procedure is required, and the Latarjet procedure to use bony transfer from the coracoid is the most popular technique. However, resorption of the bone graft with metal screw protrusion is a serious concern, whereas the relative contribution of the dynamic sling effect of the Latarjet procedure remains controversial. The Latarjet procedure also destroys the normal kinematics, resulting in side effects such as scapular dyskinesia. Here we introduce an arthroscopic anterior bone block procedure for reconstructing anterior glenoid bone defects using an autologous iliac crest graft. This technique enables precise bone block placement and fixation using one all-suture anchor instead of screw fixation.

Multilevel spinal reconstruction in pediatric patients under 4years old with non-congenital pathology (10-year single-center cohort study).

To evaluate the influence of anterior fusion option on the short- and long-time outcomes on multilevel spinal reconstructions in young children. Forty-five patients aged under 4years old (2years 2months ± 11months in average) underwent spinal reconstruction due to tuberculosis spondylitis (35), pyogenic spondylitis (9) and spinal tumors (1) complicated by angular kyphosis exceeded 20° (49.2° ± 14.3° in average). All lesions involved two or more spinal motion segments. Clinical and radiographic data were compared in two groups depended on the types of anterior fusion: titanium mesh cage with bone graft (TMC + BG) (19 patients) and cortical BG only (26). The average follow-up was 5years 10months ± 2years 8months (min=3years; max = 12years). The deformity correction was similar in groups. The operation time and blood loss were less in TMC + BG group (p = 0.001) as a times for anterior bone block formation (p < 0.001) and posterior instrumentation removal (p = 0.003). Ten late post-op complications registered include disease's recurrence (1), pseudoarthrosis (6), deformity progression (1) and graft resorption (1). The complication rate was less in TMC + BG than in BG group: two and eight cases consequently, p = 0.024. Multilevel spinal reconstruction in early aged patients is safe and effective procedure. The anterior fusion by TMC with bone autograft has advantages of reducing blood loss, operation time, time for anterior block formation and complications rate compared with bone autograft only. These slides can be retrieved under Electronic Supplementary Material.

Arthroscopic double bone block augmentation is a salvage procedure for anterior and posterior shoulder instability secondary to glenoid bone loss.

The aim of this study was to describe a one-step arthroscopic anterior and posterior bone block augmentation technique for bidirectional shoulder instability and to present preliminary results. Seven consecutive patients who underwent a concomitant anterior and posterior bone block procedure between 2007 and 2015 were retrospectively reviewed. Clinical scores, return to sport rate, and complications were assessed. Radiological outcome, with CT scan at 6months and plain radiographs at final follow-up were reviewed. Patient reported functional outcomes were also assessed via phone or email interview. Seven consecutive patients were included in the study with a median age at surgery of 27years. Median clinical and radiological follow-up was 7months (4-72months). Walch-Duplay score and Rowe scores were improved. Four patients were able to return to sport. One patient experienced recurrent dislocation, and one subjective instability/subluxation without confirmed recurrence. CT scan showed union in all cases, with one case of anterior bone block osteolysis and one case of partial posterior bone block osteolysis. Radiographs showed no detectable progression of osteoarthritis using the Samilson and Prieto classification. At final follow-up the median WOSI score was 187 (100-1140). An all-arthroscopic technique for the treatment of combined anterior and posterior glenoid bone loss as a cause of shoulder instability can provide fair to good clinical outcomes, with a low incidence of intra-operative complications. The rate of failure in our series remains higher than that seen in primary stabilization procedures. As such we consider this largely as a salvage procedure for cases in which alternative treatments have failed or are unlikely to succeed. IV.

Risk factors of recurrence after an arthroscopic stabilisation procedure performed for traumatic anterior shoulder instability in pediatric population

Arthroscopic stabilisation of traumatic anterior shoulder instability is being performed also in pediatric age group, and reports associated with risks of recurrent instability have been presented. The aim of the current study was determining the risk factors of recurrence after the arthroscopic anatomic repair preformed in pediatric age group. 46 patients who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability with the mean age of 17 ±0.8 (15-18) were included in this study. After an average follow-up time of 40.4± 22.7(24-155) months age, gender, dominant side, number of dislocations before surgery, participation in contact sports, Rowe and Oxford shoulder scores, labral lesion type, number of anchor used, and capsular laxity were assessed, and their correlation with recurrence were investigated. Recurrence was encountered in 9 (19,5%) patients, on average, 16.1 ±13.43 months after surgery. The only risk factor of recurrence was found to be the history of five or more times of dislocation before surgery (p=0,006). Although statistically insignificant, when evaluated separately, it was found that patients with contact sports history had double times of recurrence rate if they had ALPSA or SLAP lesion and triple times of recurrence rate if they had capsular laxity. The recurrence rate was found to be 38,4% when accompained by capsular laxity, 50% when accompained by both capsular laxity and ALPSA lesion, and 100% when accompanied by all capsular laxity, ALPSA lesion and contact sports history. Arthroscopic stabilisation of traumatic anterior shoulder instability in pediatric population is an appropriate technique, especially in those with less than five times of dislocation because of the low recurrence rate (3.4%). Surgical procedures that are non-anotomic, such as coracoid transfer or anterior glenoid bone block, should be considered in patients with high risk of recurrence rate after an arthroscopic anatomic repair because of the risk factors like history of five or more times of dislocation, being accompanied by an ALPSA, SLAP lesion, or a capsular laxity and participation in contact sports.

Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique)

In comminuted fractures of the intercondyloid eminence of the tibial spine, the quality of the reduction and the arthroscopic fixation, notably adjustable suture button fixation, is sometimes disappointing with reduction defects of the anterior bone block. In the Speed-Bridge technique, the two traction sutures of the adjustable button fixation are replaced with two braided sutures of different colors. After the button is placed above the eminence, reduction is obtained by tightening the loop of the button. The accessory communitive fragments are then packed in the depression around the main fragment. A second row provides bone suturing for these accessory fragments; traction sutures of the button are attached anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-type inverted-V bone suture. The Speed-Bridge arthroscopic reinsertion technique of the tibial eminence effectively completes the adjustable button bone suture technique for communitive fractures to obtain better reduction and good stability.

Arthroscopic Iliac Crest Bone Block for Reconstruction of the Glenoid: A Fixation Technique Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

Recurrent anterior shoulder instability with significant bone loss represents a surgical challenge. Anterior bone block procedures including variations of the Latarjet coracoid transfer have been used in this setting. Bone graft resorption with prominence of the metalwork is a serious concern, whereas the relative contribution of the dynamic sling effect of a Latarjet procedure is still controversial. We describe an arthroscopic technique for anatomic reconstruction of anterior glenoid bone defects using autologous iliac crest graft. This technique allows accurate placement of the bone block; fixation with 2 knotless TightRope devices (Arthrex, Naples, FL), avoiding the use of screws; and a final labral repair.

Is anterior glenoid bone block position reliably assessed by standard radiography? A cadaver study

BackgroundStandard radiography with an antero-posterior view and Bernageau's glenoid profile view is the method most widely reported in the literature to assess coracoid bone block position and fusion. ObjectiveThe aim of this cadaver study was to determine whether the antero-posterior and Bernageau's radiographs provide a reliable and reproducible evaluation of the position of a coracoid bone block and its fixation screws. MethodAn isolated scapula showing no evidence of osteoarthritis or other abnormalities was used. The coracoid process was transferred to the anterior glenoid rim. Fixation was with two slightly diverging malleolar screws, chosen of different sizes for ease of identification. Computed tomography (CT) was performed as the reference imaging technique. The standard radiographs were then obtained, using fluoroscopy to accurately position the scapula for the antero-posterior and Bernageau's views. This position was defined as 0°, and radiographs were taken at angles of 5°, 10°, and 15° in all three planes. All radiographs were taken during a single session to ensure that the distance separating the tube from the scapula remained unchanged. The images were exported to OsiriX for analysis. We measured the angles formed by the screws and the glenoid surface, as well as bone block position and overhang. Finally, we used 1-mm thick disks to evaluate bone-to-bone contact. ResultsNo correlations were found between values by CT and by standard radiography (both views) for the screw angles or overhang. A space≤1mm between the neck of the scapula and the bone block was not visible on the standard radiographs in any of the positions. ConclusionStandard radiography does not provide an accurate analysis of bone block position or bone-to-bone contact. CT is needed to assess bone block and screw position and bone-to-bone contact. Level of evidenceLevel III.