Arthroscopic Anatomic Glenoid Reconstruction Research Articles

Surgical considerations for glenoid bone loss in anterior glenohumeral instability: a narrative review.

Treatment algorithms may consider many factors like glenoid and humeral bone loss, or scores such as the instability severity index score (ISIS). As most studies only evaluate a part of these factors, there is still no evidence-based consensus estalished. Our study aims to summarize the surgical options for treatment of glenoid bone loss (GBL) in anterior shoulder instability. Based on the current available literature, surgical options including Bankart repair and glenoid bone augmentation should be considered while taking into consideration the degree of bone loss which has been divided into < 10%, 10-20% and > 20%. There are many new techniques evolving including arthroscopic anatomic glenoid reconstruction with bone blocks. Future long-term outcome studies and randomized controlled trials comparing established techniques will be needed for new evidence-based treatment algorithms.

Poster 160: Arthroscopic Anatomic Glenoid Reconstruction Does Not Affect Subscapularis Muscle Compared To Latarjet

Objectives: The Latarjet technique has been the gold standard treatment for glenoid bone loss following anterior shoulder instability due to its low recurrence rate, but other techniques including arthroscopic anatomic glenoid reconstruction (AAGR) have shown similar outcomes with fewer complications. The Latarjet requires a subscapularis split or take-down for placement of the coracoid, which may compromise post-operative subscapularis quality and strength. The AAGR is a subscapularis-sparing technique that obviates the need for a subscapularis split by using a far medial (Halifax) portal for graft placement. The purpose of this study was to compare subscapularis muscle changes before and after surgery between Latarjet and AAGR patients. Methods: This study was a retrospective analysis of patients treated surgically with AAGR and Latarjet that had pre- and post-operative CT scans. Patients’ charts were reviewed to obtain demographic information, as well as CT scan cross-sectional area measurements of the subscapularis muscle on pre- and post-surgery scans. We used a pre-existing validated formula (volume=[0.06(A+C)]-13.02) for calculating the volume of the subscapularis pre- and post-operatively based on the cross-sectional area of the muscle. Results: Our cohort included 40 patients in each group with pre- and post-operative CT scans. On average, patients had a CT scan one year post-operatively. Pre-operatively, patients were estimated to have similar subscapularis volumes (p&gt;0.05). We found that the change in medial area of the subscapularis muscle was significantly higher in the Latarjet group (-325.8 mm2) compared to the AAGR group (-73.2 mm2) (p&lt;0.05). We found that AAGR patients had a 3% increase in subscapularis volume post-operatively, while the Latarjet patients had 3% decrease in volume (p&lt;0.05) Conclusions: The AAGR technique is subscapularis-sparing both in surgical technique and structural outcomes, resulting in comparable subscapularis cross-sectional area and volume pre- and post- operatively. Latarjet using a subscapularis split results in lower subscapularis medial volumetric area.

Poster 165: Non-Rigid Fixation Results in Higher Failure Rates Following Arthroscopic Glenoid Reconstruction

Objectives: It has previously been established that screw fixation results in better outcomes than button fixation for arthroscopic anatomic glenoid reconstruction (AAGR) with frozen allograft. There has been considerable debate on the causes for the higher dislocation rates with non-rigid fixation. The purpose of this study was to evaluate which factors may affect failure rates for AAGR with non-rigid fixation. Methods: This was a retrospective review of patients who had AAGR using non-rigid fixation that were age-, gender-, and followup-matched with screw fixation patients. Arthroscopic videos were used to evaluate surgical factors including graft placement, fixation quality, tensioning, graft contact, soft tissue quality, quality of soft tissue repair, presence of Hill-Sachs, and addition of Remplissage. Patient demographic factors (age, gender, medical history etc) were also assessed. XRays and CTs were used to evaluate graft union, screw and button angle, graft remodeling, and button pull through. Results: A total of 36 patients were included in our study who had AAGR between 2014 and 2019 (18 non-rigid fixation matched to 18 screw fixation). Seven patients who had non-rigid fixation had a dislocation requiring reoperation. Of these, 4/7 had poor anterior soft tissue. All but one patient had excellent soft tissue repair and balance at end of surgery. All seven patients had complete graft resorption compared with those did not fail who had a normal post-operative glenoid A-P dimension. Conclusions: In our case series, AAGR with non-rigid fixation had high rate of recurrent dislocation. These failed patients had appropriate surgical factors that were equivalent between dislocated patients and successful patients. The failure rate was not correlated with surgical technique, patient or radiographic factors but rather only fixation type. Further study is needed to evaluate fixation methods and to assess whether type of graft impacts these clinical outcomes.

Podium Presentation Title: Arthroscopic Anatomic Glenoid Reconstruction has Excellent Outcomes at Mid-Term Follow-Up

Podium Presentation Title: Arthroscopic Anatomic Glenoid Reconstruction has Excellent Outcomes at Mid-Term Follow-Up

Arthroscopic Anatomic Glenoid Reconstruction in the Unstable Shoulder: Technique, Pearls, and Pitfalls

Background: Anterior shoulder instability with glenoid bone loss is a complex condition. Bankart repairs have higher failure rate in this population and the Latarjet procedure is associated with a high complication rate (15%-30%). A recent technique, the arthroscopic anatomic glenoid reconstruction, safely uses distal tibial allograft to augment the glenoid. Indications: Glenoid or bipolar bone loss in the setting of shoulder instability. Technique Description: A diagnostic shoulder arthroscopy is performed to assess bone loss and capsulolabral tissue. After the preparation of the anterior glenoid, a bone block harvested from a distal tibial allograft is prepared. This technique uses the Halifax portal, a safe, far medial portal to insert the graft, and compress it onto the anterior glenoid using screws. A Bankart repair is then performed, to reduce the capsulolabral complex onto the glenoid. Results: Results at 2 years show a 92% to 100% union of the graft, no recurrence of instability, and improved patient-reported outcome scores. Graft remodeling is regularly observed on postoperative imaging. This procedure may be faster to learn and to perform compared to an arthroscopic Latarjet. Discussion/Conclusion: Arthroscopic anatomic glenoid reconstruction is a safe, minimally invasive procedure to address shoulder instability. It has low complication rate and is associated with improved patient-reported outcomes. Patient Consent Disclosure Statement: The author(s) attest 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.

Arthroscopic anatomic glenoid reconstruction has a lower rate of recurrent instability compared to arthroscopic Bankart repair while otherwise maintaining a similar complication and safety profile

ObjectivesThe primary purpose of this study was to determine the frequency and type of complications, including subluxation, infection, hardware complication, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness following an Arthroscopic Bankart Repair (ABR) or an Arthroscopic Anatomic Glenoid Reconstruction (AAGR) using a distal tibia allograft for recurrent anterior shoulder instability. Secondary purposes were to determine the frank dislocation rate and the associations of post-operative complications with demographic patient factors. MethodsDemographic and clinical data were reviewed using means ± standard deviations or frequencies in patients with recurrent anterior shoulder instability who underwent either an ABR or an AAGR. Post-operative patient records were analysed to identify any post-operative complications. The numerical variables of the two groups were compared using the independent t-test or Mann–Whitney U test. Categorical variables and complications were tested using the chi-square test, Fisher’s exact test, or the two-sided Monte Carlo test with a significance level of 0.05. ResultsWe included 174 patients in this cohort, with 61.5% of patients receiving ABR and 38.5% receiving AAGR. Most of our patients were male (70.1%) with an average age of 23.41 ± 8.26 years in the ABR group and 29.37 ± 13.54 years in the AAGR group (p = 0.001). The two groups were similar with respect to their post-operative complication rates when excluding frank dislocation (ABR: 11%, AAGR: 12%). The AAGR group had statistically significantly higher rates of hardware removal compared to the ABR group (p = 0.004). The ABR group had 25 post-operative frank dislocations, with none reported in the AAGR cohort (p < 0.001). The total complication rate for each procedure was found to be 35% for ABR and 12% for AAGR. ConclusionAAGR has a comparable safety profile to the ABR when assessing post-operative complications such as subluxation, infection, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness. AAGR is superior to ABR with respect to rates of recurrent instability and should be considered as a first-line treatment in certain patients with specific risk factors such as younger age, competitive contact sports participation, and higher number of instability events pre-operatively. Level of evidenceLevel III.

Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibial Allograft and Hybrid Fixation

Glenoid grafting is the standard surgical treatment for recurrent shoulder instability with significant glenoid bone loss. Arthroscopic anatomic glenoid reconstruction using a distal tibial allograft for anatomic glenoid reconstruction has recently been gaining attention. This article describes the use of a hybrid graft fixation technique with 1 suture-EndoButton device and 1 compression screw in arthroscopic anatomic glenoid reconstruction using distal tibial allograft.

Fixation Type Does not Affect the Learning Curve and Short-Term Radiographic Outcomes for Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibia Allograft

PurposeThe purpose of this study was to compare the learning curves and radiographic variables between screw and suture button fixation of the allograft for surgeons learning the all-arthroscopic anatomic glenoid reconstruction (AAGR) technique for anterior shoulder instability. We compared the surgical times of these two fixation techniques, as well as the graft placement in the vertical and medial-lateral directions.MethodsThis was a retrospective review of patients who underwent AAGR for recurrent anterior shoulder instability. Start and end times were recorded for each procedure, and learning was assessed through the change in operative time over successive surgeries and by variability of operative time. Graft placement, in terms of vertical positioning, medial-lateral step formation, and obliquity of fixation (alpha angle), was evaluated using 3-dimensional CT scans at approximately 6 months postoperation.ResultsA total of 43 patients were included in our study. Twenty-seven had screw fixation, and 16 had suture button fixation. The surgical duration of the button fixation technique was comparable to that of screw fixation (P = .72), with no significant difference in the variability of surgical time in either cohort (P > .05). Both groups showed similarly optimal vertical positioning of the graft onto the lower third of the glenoid (P = .89). Desired obliquity of graft fixation was identified more frequently with button fixation (P < .001). Both fixation methods provided clinically acceptable medial-lateral step formations, with suture-button fixation being significantly larger (P = .03).ConclusionsSuture button fixation of the allograft is a potential alternative to screw fixation for the management of glenoid bone loss in recurrent anterior shoulder instability. The results of this study show that this method has a comparable learning curve, with a similar surgical duration, while not compromising the optimal accuracy of vertical and medial-lateral placement of the graft and achieves a superior alpha angle of fixation.Level of EvidenceLevel III, retrospective cohort study.

Treatment of Failed Latarjet With Arthroscopic Anatomic Glenoid Reconstruction

PurposeVarious methods have been described for the treatment of anterior shoulder instability with glenoid bone loss. The incidence of recurrent dislocations following surgical intervention is high and, therefore, necessitates a reliable and replicable revision procedure. The purpose of this Technical Note is to describe a method of arthroscopic anatomic glenoid reconstruction using a distal tibial allograft and screw fixation in the setting of a failed Latarjet procedure with significant glenoid bone loss.MethodsWe describe in detail patient positioning, portal placement, steps of the diagnostic arthroscopy, and graft preparation using imaging and a detailed intraoperative arthroscopic technique.Level of EvidenceLevel 1, Shoulder; Level 2, Instability.

Clinical Outcomes of Primary versus Revision Surgery using Arthroscopic Anatomic Glenoid Reconstruction for Anterior Shoulder Instability. (244)

Objectives:Revision surgeries after prior shoulder stabilization are known to have worse outcomes as compared to their primary counterparts. To date, no studies have looked at the utility of arthroscopic anatomic glenoid reconstruction (AAGR) as a revision surgery. The purpose of this study was to assess the clinical outcomes of primary versus revision AAGR for anterior shoulder instability with bone loss.Methods:We performed a retrospective review on consecutive patients with prospectively collected data who underwent AAGR from 2012 to 2018. Patients who received AAGR for anterior shoulder instability with bone loss and had a minimum follow-up of two years were included. Exclusion criteria included patients with rotator cuff pathology, multidirectional instability and glenoid fractures. There were 68 patients (48 primary and 20 revision) who met inclusion/exclusion criteria. Our primary outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) and Disabilities of Arm, Shoulder, Hand (DASH) scores. Secondary outcomes included post-operative complications and post-operative recurrent instability.Results:The primary group showed a significant improvement in most-recent post-operative WOSI from 62.7 to 20.7 (P<0.001, α=0.05) and in DASH from 26.89 to 6.7 (p<0.001, α=0.05). The revision group also showed a significant improvement in WOSI from 71.5 to 34.6 (p<0.001, α=0.05) and in DASH from 39.5 to 17.0 (p<0.05, α=0.05). When comparing between groups, the revision group had worse WOSI scores (34.6) at most recent follow-up compared to the primary group (20.7); p<0.05. The most-recent DASH scores also showed the revision group (17.0) having worse outcomes than the primary group (6.7); p<0.05. Important to note that the minimal clinically important difference (MCID) was met for WOSI (MCID=10.4) but not DASH (MCID=10.83). There were no post-operative reports of instability in either group. For complications, one hardware failure (suture anchor) was seen in the primary group, and two hardware removals were seen in the revision group.Conclusions:While patient reported scores indicated worse outcomes in the revision group, the significant clinical improvement in DASH and WOSI, along with the lack of recurrent instability provides evidence that AAGR is a suitable option for revision patients.

Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Is Safe and Effective for Anterior Shoulder Instability With Bone Loss

PurposeTo establish a safety profile for an arthroscopic anatomic glenoid reconstruction using autologous iliac crest bone graft to treat shoulder instability with significant bone loss and to evaluate short-term clinical and radiological outcomes.MethodsA retrospective analysis of prospectively collected data was conducted for the patients who were treated for shoulder instability with bone loss using arthroscopic autologous iliac crest bone graft between November 2014 and June 2018. The safety profile was established by detective intraoperative or postoperative complications such as neurovascular injuries, infections, major bleeding, and subluxations. Short-term clinical and radiologic outcomes also were evaluated.ResultsThirteen patients were included in the study. A safety profile was observed, with no occurrence of intraoperative complications, neurovascular injuries, infection, or major bleeding. There were no dislocations or positive apprehension tests on clinical examination postoperatively. Postoperative Western Ontario Shoulder Instability (WOSI) scores were significantly greater than preoperative WOSI scores, with a mean improvement of 35.0 ± 20.2 (P < .001). Twelve patients (92.3%) received postoperative computed tomography scans, with 11 of 12 patients (91.7%) displaying complete graft union.ConclusionsArthroscopic treatment of shoulder instability with bone loss via autologous iliac crest bone graft is shown to be a safe operative procedure that results in favourable short-term clinical and radiologic outcomes, with a significant improvement in WOSI scores and high rates of graft union. Although graft resorption was seen in most patients who had postoperative computed tomography imaging, there were no instances of clinical graft failure.Level of EvidenceLevel IV, therapeutic case series.

Primary Bankart Repair Versus Arthroscopic Anatomic Glenoid Reconstruction in Patients with Subcritical Bone Loss: A Cost-Utility Analysis.

Background:Anterior shoulder instability and its treatment is a quickly evolving field of interest in orthopaedics, both for patients and for health-care systems. In this study, we aimed to evaluate the cost-effectiveness of arthroscopic anatomic glenoid reconstruction (AAGR) compared with Bankart repair in the treatment of anterior shoulder instability in patients with subcritical glenoid bone loss.Methods:A cost-utility analysis was performed from the perspective of Canada’s publicly funded health-care system. A decision-tree model was created to simulate the progression of patients undergoing either a primary Bankart repair or AAGR. Recently published data were used to determine the recurrence rate and level of glenoid bone loss for the AAGR procedure; the recurrence rate was 1.4% in a cohort with a mean glenoid bone loss of 25.3%. A literature review on the primary Bankart procedure in patients with at least subcritical levels of glenoid bone loss yielded a recurrence rate of 22.9% in patients with a mean glenoid bone loss of 17.5%. AAGR served as the revision surgery for both primary procedures. Health utility scores for anterior shoulder instability were obtained from published literature. Total procedure costs, including costs of operating-room consumables, anesthesia, diagnostic imaging, and rehabilitation, were sourced from a hospital database. A probabilistic sensitivity analysis using 5,000 Monte Carlo simulations was performed, and results were used to create a cost-effectiveness acceptability curve.Results:The AAGR procedure was less costly and led to an improvement in quality-adjusted life years (QALYs) when compared with the arthroscopic Bankart repair in the treatment of patients with anterior shoulder instability with subcritical glenoid bone loss (AAGR, cost = $16,682.77 [Canadian dollars] and QALYs = 5.76; Bankart, cost = $16,720.29 and QALYs = 5.46), suggesting that the AAGR is dominant, i.e., lower costs with higher QALYs. Applying a commonly used willingness-to-pay threshold of $50,000 per QALY gained, the probability that the primary AAGR was more cost-effective was 85.8%.Conclusions:This study showed that, from the perspective of a publicly funded health-care system, AAGR was the economical treatment option when compared with Bankart repair in anterior shoulder instability with subcritical glenoid bone loss.Level of Evidence:Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Chapter 6: Attritional Glenoid Bone Loss in the Shoulder: Operative Considerations.

Patients with recurrent anterior shoulder instability often have glenoid bone loss present in addition to soft tissue pathologies. It is known that patients with significant glenoid bone loss are best treated with a boney augmentation procedure as opposed to a soft tissue Bankart repair because of the high rate of recurrent instability that results from a Bankart repair. Although the Latarjet technique has been the gold-standard treatment for patients with glenoid bone loss because of the low incidence of recurrent instability, it has a high complication rate and a steep learning curve. Herein, the authors present the technique and outcomes for arthroscopic anatomic glenoid reconstruction that has a similar complication rate to the Bankart repair but with a low recurrence rate similar to the Latarjet. This procedure is safe, has a short learning curve, low recurrence rate, and positive patient-reported outcomes.

Arthroscopic Anatomic Glenoid Reconstruction Using Distal Tibial Allograft for Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes

Background: The all-arthroscopic anatomic glenoid reconstruction technique using a distal tibial allograft avoids damage to the subscapularis muscle and allows repair of the capsulolabral tissue. Purpose: To analyze the clinicoradiologic outcomes of patients who underwent this procedure to treat anterior shoulder instability with glenoid bone loss with a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Over 6 years, 73 patients (52 male and 21 female; mean age, 28.8 years) under the care of the same surgeon underwent arthroscopic stabilization with capsulolabral Bankart repair and bony allograft augmentation of the glenoid for recurrent shoulder instability with significant bone loss. Pre- and postoperative patient-reported functional assessment was performed using 2 questionnaires, the Western Ontario Shoulder Instability Index (WOSI) and the Disabilities of the Arm, Shoulder and Hand, and radiological assessment was performed using radiographs and computed tomography scans obtained preoperatively and approximately 1 year later (mean ± SD, 0.9 ± 1.1 years). Results: The mean follow-up was 4.7 ± 1.1 years. The mean pre- and postoperative WOSI scores were 71.1 ± 17.5 and 25.6 ± 21.9, respectively (P < .001). There were no recurrences of dislocation, although 1 patient had symptoms of subluxation; however, 5 patients had hardware complications that required screw removal. There were no cases of nerve injury. Postoperative computed tomography scans were available for 66 patients. Seven patients were lost to follow-up. The graft union rate was 100%. Overall, graft resorption was <50% in 86% of patients (57/66). Eighteen patients (27%) had no resorption (grade 0), 39 (59%) had <50% (grades 1 and 2), and 9 (14%) had ≥50% (grade 3); however, none had symptoms of instability. The mean alpha angle of the screw between the screw shaft axis and the native glenoid axis was 18.3°± 5.7°. Graft positioning was flush with the glenoid in 61 of 66 patients (92.4%), and vertical positioning was excellent in 64 of 66 patients (97.0%) (3- to 5-o’clock position). Conclusion: Arthroscopic stabilization using distal tibial allograft augmentation resulted in excellent clinicoradiologic outcomes at a 2-year follow-up. This procedure has the advantages of being an anatomic reconstruction that addresses bony and soft tissue instability. However, long-term follow-up studies are necessary for better assessment of outcomes.

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

Donor site morbidity constitutes the most prevalent source of complications during anatomic glenoid reconstruction. Therefore, the aim of this study was to evaluate the clinical and radiologic results of arthroscopic anatomic glenoid reconstruction using an allogenic, tricortical iliac crest bone graft for glenoid bone loss in recurrent anterior shoulder instability. Ten patients [one female/nine male, mean age 31.9years (range, 26-40)] underwent allogenic iliac crest bone grafting and were evaluated clinically [range of motion, subscapularis tests, apprehension sign, Constant score (CS), Rowe score (RS), Walch-Duplay score (WD), Western Ontario Shoulder Instability Index (WOSI), Subjective Shoulder Value (SSV)] and radiographically [3-dimensional computed tomography (CT) scans]. After 23.2months, the CS averaged 90 points (range, 84-98), RS 83 points (range, 50-100), WD 81 points (range, 50-100), WOSI 72% (range, 41-86) and the SSV 83% (range, 70-95). All patients showed a free range of motion and intact subscapularis muscle function. The apprehension sign was positive in three patients (30%) with a recurrent subluxation in one patient (10%). The glenoid surface area increased significantly from 84.4% (range, 73.5-92.1) preoperatively to 118.4% (range, 105.6-131.2) after surgery, while the glenoid defect was significantly reduced from 16.2% (range, 9.2-26.5) to 0.6% (range, 0-1.6). One year postoperative, total resorption of the allografts was observed with a glenoid surface area of 86.6% (range, 76.4-98.0) and corresponding increase of the glenoid defect to 14.0% (range, 2.9-23.6). Arthroscopic glenoid reconstruction using an iliac crest bone allograft achieves satisfactory clinical results and glenohumeral stability during a short-term follow-up. However, this procedure was not observed to accomplish an anatomic reconstruction of the glenoid concavity due to excessive graft resorption. Level IV, case series, therapeutic study.

Arthroscopic Anatomic Glenoid Reconstruction in the Setting of a Failed Latarjet Using Distal Tibial Allograft

Treatment of traumatic anterior glenohumeral dislocation has evolved over the years in terms of surgical approaches and methods of repair. Recurrence of instability following surgical repair remains challenging with conventional methods of open reconstruction. We describe the utilization of arthroscopic anatomic glenoid reconstruction using a distal tibial allograft after a failed Latarjet procedure. Preoperative and operative methodology are described with relevant imaging investigations and a detailed intraoperative arthroscopic technique.

Arthroscopic Revision with Autologous Iliac Crest Bone Graft for Failed Anatomic Glenoid Reconstruction Using Distal Tibia Allograft

Recurrent instability after anterior shoulder stabilization surgery is not an uncommon complication, with variable rates of recurrences associated with different surgical procedures. The Latarjet procedure continues to be the gold standard in the management of anterior instability with significant glenoid bone loss, although a recent trend toward arthroscopic anatomic glenoid reconstruction (AAGR) with distal tibial allograft has been noted, with excellent short-term results and minimal complication rates. Arthroscopic revision stabilization for failed stabilization procedures is increasingly being performed, although it is technically more challenging than the primary stabilization procedure because of the anatomic rearrangements of the index surgery. In this article, we describe a revision arthroscopic technique for anatomic glenoid reconstruction using iliac crest autograft for a previous failed AAGR procedure secondary to nonunion of the graft. The graft is passed through the Halifax far-medial portal without splitting the subscapularis. Arthroscopic revision in the setting of a failed AAGR procedure is technically easier than after a Latarjet procedure, as the anatomy is relatively undisturbed in the former, facilitating easier identification of anatomic landmarks, accurate graft positioning, and decreased risk of neurovascular injuries. A Bankart capsulolabral repair is performed after graft fixation, making the graft extra-articular and providing additional stability.

Innovative Approaches in the Management of Shoulder Instability: Current Concept Review.

This article summarises the latest innovations and concepts in the management of shoulder instability associated with glenoid bone loss. The management of shoulder instability has undergone significant evolution in the last century with rapid strides being made in the last few decades due to the transition from open to arthroscopic techniques allowing management of pathological entities which were previously untreatable. However, there is no consensus on treatment methods, especially in the presence of glenoid bone loss. The complication profile associated with non-anatomic glenoid bony reconstruction procedures has triggered research for alternate techniques using free bone grafts. Open Latarjet procedure continues to be the gold standard in the face of glenoid bone loss; however, arthroscopic anatomic glenoid reconstruction with bone block grafts is gaining in popularity and is associated with excellent short-term clinico-radiologic outcomes. Arthroscopic anatomic glenoid reconstruction using bone grafts has been proposed as an alternative to the complex all-arthroscopic Latarjet procedure with excellent short-term results, minimal complications and a relatively easier learning curve. Capsular reconstruction has emerged as option for the management of instability with poor quality or absent capsular tissue. Future long-term outcome studies and randomised comparative trials will determine if these innovations stand the test of time.

Arthroscopic Glenoid Bone Grafting: Preserving the Subscapularis—A Reproducible Technique

The ideal technique for the treatment of anterior shoulder instability with glenoid bone loss is a topic of debate. Several techniques have been described by the orthopaedic surgeons including bony reconstruction as well as soft tissue repair. The clinical outcomes and complication rate (recurrent instability and graft failure) of these procedures vary significantly. It is believed that arthroscopic anatomic bony reconstruction might be a suitable option for the treatment of anterior shoulder instability with significant glenoid bone loss. We have discussed the technique of arthroscopic anatomic glenoid reconstruction using distal tibial allograft preserving the subscapularis muscle which seems to be very safe with excellent outcome.

Arthroscopic Anatomic Glenoid Reconstruction: Analysis of the Learning Curve.

Background:Anatomic glenoid reconstruction involves the use of distal tibial allograft for bony augmentation of the glenoid surface. An all-arthroscopic approach was recently described to avoid damage to the subscapularis tendon and preserve the capsule and labrum.Purpose:To explore and compare change in surgical time between 2 proposed methods used for the treatment of anterior shoulder instability—arthroscopic anatomic glenoid reconstruction (AAGR) and arthroscopic Latarjet (AL)—over successive procedures. We also compared graft positioning on the anterior glenoid surface between the 2 methods.Study Design:Cohort study; Level of evidence, 3.Methods:This was a single-surgeon retrospective review of 54 cases of surgically treated recurrent anterior shoulder instability: 27 had AAGR with distal tibial allograft, while the other 27 had AL. AAGR with the distal tibial allograft was the primary choice for the treatment of anterior shoulder instability; however, AL was performed when tibial allograft was not available from the bone bank. Thus, there was an overlapping period for those 2 procedures. Procedure start and end times were recorded, and duration was calculated. Postoperative 3-dimensional computed tomography scans were reviewed, and graft position was judged to be in the lower third (desired position), middle third, or upper third of the anterior glenoid surface. To assess learning, these data were organized in chronological order of surgery, and each surgical cohort was divided into 3 chronological clusters of 9 patients each. Learning was assessed through change in operative time over successive clusters, change in variability of operative time among clusters, and change in graft positioning among clusters. Statistical analysis comprised a 2-tailed independent-sample t test and the Levene test for equality of variance.Results:Our study found that AAGR was significantly faster to perform than AL in the early (P = .001), middle (P = .001), and late (P = .05) clusters of each cohort. Duration of surgery did not significantly improve across clusters within each cohort (P = .15-.79). There were no significant changes in the variability of surgical time in the AAGR group (P = .09) or the AL group (P = .13). Desired positioning of the bone graft on the anterior glenoid surface (lower third) was identified more commonly in the AAGR cohort.Conclusion:AAGR is faster to learn and perform than AL for the treatment of recurrent anterior shoulder instability with significant glenoid bone loss. The current study found higher rates of desired graft positioning for AAGR clusters.