Glenoid Bone Defects Research Articles

Humeral Head Bone Grafting of a Large Off-Track Hill-Sachs Lesion Using Femoral Condyle Osteochondral Allograft Through a Percutaneous Posterior Approach

Hill-Sachs lesions (HSLs) are commonly associated with anterior shoulder instability with or without glenoid bone defects. Treatment decision mainly depends on the size and location of the defect on the humeral head. Osteochondral allograft transplantation has been described for the treatment of large off-track HSLs. However, concerns have been raised due to concerns accessing the HSL and associated complications, predominantly due to the anterior aspect of the deltopectoral approach and subscapularis tenotomy used to gain access to these lesions. In addition, most of the studies used a lemon-wedge-shaped allograft to restore the defect, which can be technically demanding and time-consuming. This Technical Note aims to describe a posterior approach to the humeral head through an infraspinatus split that allows for accurate humeral head reconstruction with cylindrical osteochondral allografts in the setting of primary or recurrent anterior shoulder instability with large, off-track HSLs.

Management of bone loss in anterior shoulder instability.

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

Arthroscopic subscapularis augmentation of the classic Bankart repair leads to satisfactory clinical and functional mid-term outcomes in patients with recurrent anterior shoulder instability and less than a subcritical glenoid bone loss.

The long-term failure rate of the arthroscopic Bankart repair may reach unacceptable values, raising the need to augment this classic procedure. Arthroscopic subscapularis augmentation is the tenodesis of the upper part of the subscapularis tendon to the anterior glenoid rim. The aim of the study was to evaluate the mid-term clinical and functional outcomes of patients operated with arthroscopic subscapularis augmentation of the classic Bankart repair due to recurrent anterior shoulder instability. This is a retrospective single-centre case series study with prospectively collected data. All patients suffered from recurrent anterior shoulder instability and had glenoid bone loss less than 13.5% of the inferior glenoid diameter (subcritical glenoid bone loss). Patients with greater anterior glenoid bone defect, engaging Hill-Sachs lesions, multidirectional instability or subscapularis insufficiency were excluded. Postoperatively, all patients were evaluated for recurrence and apprehension. The patient's shoulder range of motion and functional scores were recorded. The final study cohort included 34 patients with a mean age of 29.3 ± 10.2 years. The mean follow-up period was 42.4 ± 10.7 months (range, 24-62 months). Two out of 34 patients (5.8%) experienced a re-dislocation postoperatively, while one additional patient had a subjective feeling of apprehension. External rotation at the last follow-up was lower compared to preoperative values or the healthy side, but only one patient had restrictions in his sporting activities. The functional scores were significantly increased compared to the preoperative values. Twenty-two out of 26 patients (84.6%) returned to the same level of sporting activities, and 30/34 patients (88.2%) were highly satisfied with the results. Arthroscopic subscapularis augmentation of the classic Bankart repair reduces the dislocation recurrence rate and leads to satisfactory clinical and functional mid-term outcomes in patients with recurrent anterior shoulder instability and less than a subcritical glenoid bone loss. Level IV.

Posterior Glenoid Bone Grafting in the Setting of Excessive Glenoid Retroversion Does Not Provide Adequate Stability in a Cadaveric Posterior Instability Model

Background: Excessive glenoid retroversion is a known risk factor for posterior shoulder instability and failure after soft tissue stabilization procedures. Whether excessive glenoid retroversion is a risk factor for failure after posterior glenoid bone grafting is unknown. Purpose: To evaluate the biomechanical effectiveness of posterior iliac crest bone grafting (ICBG) for posterior shoulder instability with increasing glenoid retroversion. Study Design: Controlled laboratory study. Methods: Six fresh-frozen cadaveric shoulders had a posterior glenoid osteotomy allowing the glenoid retroversion to be set at 0°, 10°, and 20°. At these 3 preset angles, 4 conditions were simulated consecutively on the same specimen: (1) intact glenohumeral joint, (2) posterior Bankart lesion, (3) 20% posterior glenoid bone defect, and (4) posterior ICBG. Stability was evaluated in the jerk position (60° of glenohumeral anteflexion, 60° of internal rotation) by measuring (A) posterior humeral head (HH) translation (in mm) and (B) peak translational force (in N) necessary for translation of the HH over 25% of glenoid width. Results: At 0° of retroversion, the ICBG restored posterior HH translation and peak translational force to values comparable with those of the intact condition (P = .649 and P = .979, respectively). At 10° of retroversion, the ICBG restored the peak translational force to a value comparable with that of the intact condition (22.3 vs 24.7 N, respectively; P = .418) but showed a significant difference in posterior HH translation in comparison to the intact condition (4.5 vs 2.0 mm, respectively; P = .026). There was a significant increase in posterior HH translation and significant decrease in peak translational force with the ICBG at 20° of glenoid retroversion compared with the intact condition (posterior HH translation: 7.9 vs 2.0 mm, respectively; P < .006; peak translational force: 15.3 vs 24.7 N, respectively; P = .014). Conclusion: In this cadaveric study, posterior ICBG was able to restore stability to a level comparable to that of the native condition at 0° and to some extent at 10° of retroversion. However, posterior ICBG was not able to provide adequate stability at 20° of glenoid retroversion. Clinical Relevance: Posterior glenoid bone grafting with ICBG should be used with caution when performed in isolation in the setting of posterior instability associated with glenoid bone loss and combined glenoid retroversion of >10°.

Additional Scapular Spine Bone Grafting Combined with Bankart and Remplissage for Off-Track Hill-Sachs Lesions with Subcritical Glenoid Bone Loss: Provides Better Stability.

Arthroscopic Bankart repair combined with remplissage and autologous scapular spine bone grafting have been described as a treatment for off-track Hill-Sachs lesions with subcritical glenoid bone defects in the anterior shoulder instability. However, whether these two techniques can achieve satisfactory postoperative outcomes is unclear, and there are few comparative studies between them. Therefore, this study compared the postoperative efficacy of the two techniques for off-track Hill-Sachs lesions with subcritical glenoid bone loss. Between June 2017 and December 2020, 62 patients with shoulder instability due to Off-Track Hill-Sachs lesions with subcritical glenoid bone loss underwent surgical treatment and were included in this regression study. Thirty-two patients underwent arthroscopic Bankart repair combined with remplissage (B + R group), and 30 patients underwent additional autologous scapular glenoid bone grafting (additional bone grafting group). The general information of the patients was recorded. The patient's activity before and after surgery was recorded. The DASH score and Constant-Murley (CM) score were used to assess the patient's functional status; the Rowe score was used to evaluate the patient's shoulder stability. The shoulder function and stability before and after surgery were analyzed and compared between the two groups. The final DASH scores of the B + R group and the additional bone grafting group were significantly lower than those before surgery, with a statistically significant difference (9.76 ± 4.32 vs. 27.89 ± 6.63, 8.50 ± 3.32 vs. 28.0 ± 4.27, p = 0.000); the final CM scores of the two groups were significantly higher than those before surgery (88.71 ± 3.74 vs. 73.68 ± 3.74, 87.16 ± 2.29 vs. 71.37 ± 2.68, p = 0.000). There was no statistical difference in the final DASH score and final CM score between the two groups (p > 0.05). In terms of postoperative stability, the final Rowe scores of the two groups were significantly higher than those before surgery, with a statistically significant difference (89.06 ± 9.19 vs. 41.71 ± 4.13; 93.16 ± 4.99 vs. 42.33 ± 2.53, p = 0.000). Compared with the control group, the additional bone graft group achieved higher final Rowe scores (93.16 ± 4.99 vs. 89.06 ± 9.19, p = 0.032). For patients with anterior shoulder instability due to off-track Hill-Sachs lesions with subcritical glenoid bone loss, although Bankart and remplissage can achieve satisfactory clinical results, additional autogenous scapular spine bone grafting can provide better stability of the shoulder, especially for patients with high sports demands.

Reverse Total Shoulder Arthroplasty in the Setting of an Intramuscular Lipoma With Extension Into the Glenoid: A Case Report.

Glenoid bone loss from an infiltrating intramuscular lipoma causing erosive changes is a rare occurrence. A 71-year-old woman with symptomatic rotator cuff arthropathy in the setting of an intramuscular infiltrating lipoma and secondary glenoid bone loss was treated with single-stage tumor excision and reverse total shoulder arthroplasty (rTSA) using an injectable, hard self-setting calcium phosphate as structural bone graft substitute. The patient demonstrated excellent clinical and radiographic outcomes at 2-year follow-up. Infiltrating lipomas resulting in functional rotator cuff arthropathy and erosive osseous glenoid changes are exceedingly rare, yet significant glenoid bony defects present a challenge in the setting of shoulder arthroplasty. This report describes the use of structural bone graft substitute for the management of a glenoid bone defect from a rare case of an intramuscular infiltrating lipoma, while maintaining excellent improvement in functional outcomes and pain after rTSA.

The impact of glenohumeral bone loss on range of motion in patients with anterior shoulder instability.

Loss of shoulder range of motion (ROM) is common after surgical management of anterior shoulder instability; however, it remains unclear to what degree this is related to their injury. The purpose of this study was to compare passive shoulder ROM in patients with ASI to a normal contralateral shoulder. A total of 121 patients undergoing stabilization surgery were prospectively enrolled. Preoperative advanced imaging was used to assess for glenoid bone loss and the presence of off-track Hill-Sachs lesions. Passive ROM was measured in both shoulders while under anaesthesia prior to surgery. In all directions, there was a significant loss of ROM in shoulders with instability. Regression analysis showed that neither a glenoid bone defect nor greater glenoid bone loss were associated with a loss of ROM in any plane. The presence of a Hill-Sachs lesion was significantly associated with a loss of external rotation, while off-track lesions were associated with a loss of ROM in all planes (p < 0.05). Patients with anterior shoulder instability lost motion in all directions, with a profound loss of external rotation. The presence of a glenoid bone defect nor greater bone loss did not reliably predict a loss of range of motion. A Hill-Sachs lesion was predictive of a loss of external rotation, while an off-track lesion was predictive of a loss of range in all directions.

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

This study aims to evaluate the clinical and radiological outcomes of the arthroscopic autologous iliac crest grafting (AICG) procedure with an adjustable-loop suspensory fixation device in the treatment of anterior shoulder instability (ASI) with glenoid bone defects. A retrospective review was conducted on the patients who underwent arthroscopic AICG with an adjustable-loop suspensory fixation device from January 2017 to December 2020. Patients with traumatic ASI, significant glenoid bone defects, and a minimum follow-up of 24 months were included. Patient-reported outcomes (PROs), including the Oxford Shoulder Instability Score (OSIS), the Rowe score, the Walch-Duplay score, the Constant score, and the Visual Analogue Score (VAS), were compared preoperatively and postoperatively. Radiological assessments using computed tomography (CT) were performed before and after the procedure. Additional data on active range of motion, recurrence events, and complications were recorded. A total of 42 patients were included in the study, with a mean follow-up time of 35.2 months ranging from 25.1 to 55.9 months. Mean preoperative OSIS, Rowe score, Walch-Duplay score, and Constant score significantly improved from 24.4±7.2, 25.0±9.0, 25.2±9.8, 87.5±7.1 to 42.4±4.9, 92.4±8.1, 87.9±8.3, 93.6±4.5 at the last follow-up, respectively. All patients exceeded the minimal clinically important difference (MCID) for OSIS, Rowe, and Walch-Duplay scores. The graft union rate was 100%, and the glenoid area increased significantly from 82.5% preoperatively to 100.1% at the final follow-up. No patient experienced a recurrence of instability. Two recorded complications included one case of dysesthesia around the donor site and one case of postoperative shoulder stiffness. The outcomes of the arthroscopic AICG procedure, which utilizes an adjustable-loop suspensory fixation device, demonstrated stable bone graft fixation, high rates of graft integration, favorable clinical results, and a low incidence of complications. Moreover, the remodeling of the graft during the follow-up period significantly restored the width and concavity of the inferior glenoid, contributing to the overall recovery. Level IV, retrospective case series.

Effectiveness analysis of double EndoButton suture fixation Latarjet procedure for treatment of anterior shoulder dislocation with glenoid bone defect caused by military training injuries

To investigate the effectiveness of double EndoButton suture fixation Latarjet procedure in the treatment of shoulder anterior dislocation with glenoid bone defect caused by military training injuries. The clinical data of 14 patients with anterior shoulder dislocation with glenoid bone defect due to military training injuries who met the selection criteria and admitted between August 2021 and December 2022 were retrospectively analyzed. All patients were male, the age ranged from 21 to 38 years, with an average of 26.8 years. The time from initial dislocation to operation was 6-15 months, with an average of 10.2 months. Anterior shoulder dislocation occurred 5-12 times, with an average of 8.2 times. All glenoid bone defects were more than 10%, including 5 cases of 10%-15%, 8 cases of 15%-20%, and 1 case of 24%. All patients were treated by double EndoButton suture fixation Latarjet procedure. The operation time and complications were recorded. The shoulder function and pain were evaluated by the American Association for Shoulder and Elbow Surgery (ASES) score, Rowe score, Instability Severity Index Score (ISIS), and visual analogue scale (VAS) score before and after operation. The range of motion of the shoulder was recorded, including forward flexion, 0° external rotation, and abduction 90° external rotation. The position, healing, and resorption of the bone mass were evaluated by three-dimensional CT of shoulder joint after operation. All patients successfully completed the operation, and the operation time was 100-150 minutes, with an average of 119.7 minutes. There was no complications such as infection, vascular and nerve injury. All patients were followed up 12-20 months, with an average of 15.6 months. During the follow-up, 4 patients had bone mass separation, absorption, and recurrent anterior dislocation, and the shoulder joint fear test was positive. Imaging of the remaining patients showed that the bone mass healed well, no anterior dislocation recurrence occurred, and the healing time was 3-7 months (mean, 4.7 months). At last follow-up, the range of motion, ASES score, Rowe score, ISIS score, and VAS score of the patients significantly improved when compared with those before operation ( P<0.05). The effectiveness of double EndoButton suture fixation Latarjet procedure for the treatment of anterior shoulder dislocation with glenoid bone defect caused by military training injury is satisfactory.

Suture button fixation Latarjet procedure under total arthroscopy for treatment of anterior shoulder instability with severe bone defect

To assess the effectiveness of suture button fixation Latarjet procedure under total arthroscopy for anterior shoulder instability with severe bone defects. The clinical data of 15 patients with severe bone defects and anterior shoulder instability treated with suture button fixation Latarjet procedure under total arthroscopy between June 2020 and February 2023 was retrospectively analyzed, including 11 males and 4 females, with an average age of 31.1 years (range, 20-54 years). Three-dimensional CT showed that the average glenoid bone defect was 24.4% (range, 16.3%-35.2%). The average number of shoulder dislocation was 4.2 times (range, 3-8 times). The disease duration ranged from 6 to 21 months with an average of 10.6 months. The operation time and intraoperative blood loss were recorded. The pain relief was evaluated by visual analogue scale (VAS) score, and the functional recovery of shoulder joint was evaluated by Rowe score, Walch-Duplay score, and American Association for Shoulder and Elbow Surgery (ASES) score before and after operation. The range of motion (ROM) of the shoulder joint was assessed, including active flexion, lateral external rotation, abduction 90° external rotation, and internal rotation. Three-dimensional CT was performed at 6 months after operation and at last follow-up to observe the absorption of bone graft, the position of bone graft and glenoid, and the healing of bone graft. The operation was successfully completed in all patients. The operation time was 85-195 minutes, with an average of 123.0 minutes. The intraoperative blood loss was 20-75 mL, with an average of 26.5 mL. All patients were followed up 13-32 months, with an average of 18.7 months. During the follow-up, there was no serious complication such as shoulder joint infection, joint stiffness, or vascular and nerve injury. One patient had partial absorption of the transplanted bone and bone nonunion at 3 months after operation, but the pain of the shoulder joint relieved at last follow-up, and no redislocation of the shoulder joint occurred; no obvious bone fracture or dislocation of the shoulder joint was found in the other patients. Bone union was achieved at 6 months during follow-up. At last follow-up, the VAS score, Rowe score, Walch-Duplay score, and ASES score significantly improved when compared with those before operation ( P<0.05), while the ROM of active flexion, lateral external rotation, abduction 90° external rotation, and internal rotation of the shoulder joint was not significantly different from those before operation ( P>0.05). Suture button fixation Latarjet procedure under total arthroscopy can improve shoulder joint function in patients with severe anterior shoulder instability caused by bone defects, and imaging also indicates satisfactory placement of transplanted bone blocks.

Latarjet procedure: biomechanical evaluation of 2-screw coracoid fixation

Coracoid nonunion is a relevant complication following the Latarjet procedure and is influenced by multiple factors, including the method of graft fixation. The purpose of this study was to evaluate and characterize the biomechanical properties of various two-screw fixation constructs used for coracoid graft fixation in the Latarjet procedure. Forty model scapulae (Sawbones Inc., Vashon, WA, USA) were used for this study. A 15% anterior inferior glenoid bone defect was created. The coracoid was osteotomized at the juncture of the vertical and horizontal aspects, transferred to the anterior-inferior edge of the glenoid, and fixed with either two 3.5mm fully threaded cannulated cortical screws, two 3.5mm fully threaded solid cortical screws, two 3.5mm partially threaded cannulated screws, or two 4.5mm partially threaded malleolar screws (MS). Biomechanical testing was performed with an Instron material testing machine (Instron Corp., Norwood, MA, USA) by applying loads to the lateral aspect of the transferred coracoid graft. The constructs were preconditioned with nondestructive cyclical loading (0N-20N) to determine construct stiffness. After 100 cycles of dynamic loading, the construct was loaded to failure to determine ultimate failure load, yield displacement, and mode of failure. All failures were associated with plastic deformation of the screws and coracoid graft fracture. There was a significantly lower initial stiffness for partially threaded cannulated screws compared to MS (186±49.3N/mm vs. 280±65.5N/mm, P=.01) but no significant differences among the other constructs. There was no difference in ultimate failure load (P=.18) or yield displacement (P=.05) among constructs. Two screw coracoid fixation of the coracoid in a simulated classic Latarjet procedure with 3.5mm fully threaded cortical and cannulated screws is comparable to 4.5mm MS in strength, stiffness, and displacement at failure. On the other hand, partially threaded 3.5mm cannulated screws provide inferior fixation stiffness and could potentially affect clinical outcomes.

The Kouvalchouk procedure vs. distal tibial allograft for treatment of posterior shoulder instability: the deltoid “hammock” effect exists

BackgroundIn 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. s MethodsTen 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. ResultsThe Kouvalchouk procedure with the loaded deltoid flap (10N: P=0.039 and 15N: P<0.001) 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 15N Kouvalchouk was most effective at preventing posterior humeral translation, and the difference was statistically significant compared with the 20% glenoid defect (P=0.003), detached Kouvalchouk (P<0.001), and 0N Kouvalchouk (P<0.001). The 15N Kouvalchouk procedure restored posterior shoulder joint stability to near normal levels, such that it was not significantly different from the intact state (P=0.203). ConclusionsThe 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.

Biomechanical study of 3D-printed titanium alloy pad for repairing glenoid bone defect.

Background: The purpose of this study was to investigate the effect of 3D-printed technology to repair glenoid bone defect on shoulder joint stability. Methods: The shoulder joints of 25 male cadavers were tested. The 3D-printed glenoid pad was designed and fabricated. The specimens were divided into 5 groups. Group A: no bone defect and the structure of the glenoid labrum and joint capsule was intact; Group B: Anterior inferior bone defect of the shoulder glenoid; Group C: a pad with a width of 2mm was installed; Group D: a pad with a width of 4mm was installed; Group E: a pad with a width of 6mm was installed. This study measured the distance the humeral head moved forward at the time of glenohumeral dislocation and the maximum load required to dislocate the shoulder. Results: The shoulder joint stability and humerus displacement was significantly lower in groups B and C compared with group A (p < .05). Compared with group A, the stability of the shoulder joint of group D was significantly improved (p < .05). However, there was no significant difference in humerus displacement between groups D and A (p > .05). In addition, compared with group A, shoulder joint stability was significantly increased and humerus displacement was significantly decreased in group E (p < .05). Conclusion: The 3D-printed technology can be used to make the shoulder glenoid pad to perfectly restore the geometric shape of the shoulder glenoid articular surface. Moreover, the 3D-printed pad is 2mm larger than the normal glenoid width to restore the initial stability of the shoulder joint.

The Use of Glenoid Structural Allografts for Glenoid Bone Defects in Reverse Shoulder Arthroplasty.

Background: The use of reverse shoulder arthroplasty as a primary and revision implant is increasing. Advances in implant design and preoperative surgical planning allow the management of complex glenoid defects. As the demand for treating severe bone loss increases, custom allograft composites are needed to match the premorbid anatomy. Baseplate composite structural allografts are used in patients with eccentric and centric defects to restore the glenoid joint line. Preserving bone stock is important in younger patients where a revision surgery is expected. The aim of this article is to present the assessment, planning, and indications of femoral head allografting for bony defects of the glenoid. Methods: The preoperative surgical planning and the surgical technique to execute the plan with a baseplate composite graft are detailed. The preliminary clinical and radiological results of 29 shoulders which have undergone this graft planning and surgical technique are discussed. Clinical outcomes included visual analogue score of pain (VAS), American Shoulder and Elbow Surgeons score (ASES), Constant-Murley score (CS), satisfaction before and after operation, and active range of motion. Radiological outcomes included graft healing and presence of osteolysis or loosening. Results: The use of composite grafts in this series has shown excellent clinical outcomes, with an overall graft complication rate in complex bone loss cases of 8%. Conclusion: Femoral head structural allografting is a valid and viable surgical option for glenoid bone defects in reverse shoulder arthroplasty.

Evaluation of glenoid morphology and bony Bankart lesion in shoulders with traumatic anterior instability using zero echo time magnetic resonance imaging

BackgroundPreoperative computed tomography (CT) evaluation of bone morphometry aids in determining treatment strategies for shoulder instability. The use of zero echo time (ZTE) sequence in magnetic resonance imaging (MRI), a new bone cortex imaging technique, may help reduce radiation exposure and medical costs. Therefore, this study aimed to evaluate the glenoid morphology and detect the presence of bony Bankart lesion using ZTE MRI in shoulders with anterior instability and compare its diagnostic accuracy with that of CT. MethodsThirty-six patients (36 shoulders) with anterior instability who underwent preoperative CT and MRI examinations between April 2019 and October 2021 were retrospectively analyzed. The percentages of glenoid bone defects on three-dimensional (3D) CT and ZTE images were determined, and the correlation between these percentages was evaluated. The number of cases with bony Bankart lesion on CT and two types of ZTE (3D and CT-like) images was determined, and the diagnostic accuracy of ZTE for detecting bony Bankart lesion was assessed, with CT as the gold standard. Patients with bony Bankart lesion on CT images were divided into two groups based on whether the lesion was detectable on 3D ZTE or CT-like images. The longer diameters of bony Bankart lesion were compared between the groups. ResultsThe median percentage of glenoid bone loss was 12.1% (range, 1.3%–45.9%) and 12.3% (range, 0%–46.6%) on 3D CT and 3D ZTE images, respectively. The Spearman’s rank correlation coefficient was 0.89. Bony Bankart lesion was detected in 18, 13, and eight shoulders of the 36 patients on CT, 3D ZTE, and CT-like images, respectively. The overall diagnostic accuracy of the CT-like and 3D ZTE images for detecting bony Bankart lesion was 86.1% and 72.2%, respectively. A significant difference was observed between the groups with and without bony Bankart lesion on CT-like images in terms of the long diameter of the bone fragments on CT (p < 0.01). ConclusionsZTE MRI demonstrated high reproducibility for the evaluation of glenoid bone defect in shoulders with anterior instability. Although no significant difference in the measurement was observed compared with that on CT, the ability of ZTE MRI to delineate bone Bankart lesion remains limited.

Distal clavicle autograft for large glenoid defects during revision reverse total shoulder arthroplasty

IntroductionRevision reverse total shoulder arthroplasty (rTSA) can be complicated by significant glenoid bone loss and require augmented baseplates or structural bone grafts to fill the defect while optimizing glenosphere lateralization. Distal clavicle autografting is a newly described type of structural graft that has shown promising outcomes in revision reverse rTSA to address severe glenoid bone loss. Additionally, distal clavicle autografts are an option that is proposed to be more cost effective and have low morbidity in addressing glenoid bone defects. The technique for distal clavicle autografting during revision rTSA and the outcomes of a series of cases are contained within this report. Materials and MethodsA retrospective chart review was conducted for 9 patients who underwent revision rTSA with a distal clavicle autograft for glenoid bone loss between January 2013 to January 2022. The primary outcome was component survivorship at two years postoperatively. Patient charts were reviewed for clinical and radiographic information, and any complications were recorded. Postoperative radiographs were assessed for evidence of component loosening or failure. Distal clavicle and glenoid defect dimensions were measured using preoperative CT scans and compared. Results9 patients were identified who underwent revision rTSA with distal clavicle autograft to address glenoid bone loss. All patients had clinical and radiographic data available two years postoperatively. There was significant improvement in active forward flexion and abduction, and no-significant change in external rotation compared to preoperative measurements. Patient-reported QuickDASH score improved significantly with non-significant improvements in VAS function, SANE, and ASES scores. 8 of 9 (88.9%) of patients had stable prostheses with no evidence of loosening or failure at two years. One patient experienced component failure and graft osteolysis requiring conversion to hemiarthroplasty. No other complications were noted. Dimensions of the distal clavicle are similar to the dimensions of contained glenoid vault defects and glenoid defects with minimal loss of containment. ConclusionUsing a distal clavicle autograft during revision rTSA is an effective technique that can address severe glenoid bone loss. This technique has excellent radiographic outcomes at short-term follow-up and is a fortuitous autograft option in revision rTSA due to its location, dimensions, and low cost.

Outcomes of anatomic total shoulder arthroplasty revised to reverse shoulder arthroplasty in patients with contained central glenoid bone defects

BackgroundThe purpose of this study is to present the outcomes of patients with failed total shoulder arthroplasty (TSA) who were treated by conversion to reverse shoulder arthroplasty (RSA). MethodsThis retrospective cohort study investigates patients who underwent single-stage revision from TSA to RSA by one of three fellowship-trained orthopedic surgeons between 2012 and 2020. Patients with central bone defects in the glenoid were included, whereas those with uncontained peripheral or combined glenoid defects or with infections requiring a 2-stage revision were excluded. The glenoid baseplate size and use of bone graft augmentation were recorded. A minimum 2-year postsurgical follow-up was required to participate in the outcome evaluations. Primary outcome measures were shoulder pain on the visual analog scale and active shoulder forward flexion and abduction, while secondary outcome measures included patient satisfaction, procedure complications, and reoperations. The Wilcoxon signed rank exact test was used to compare preoperative and postoperative clinical data. ResultsData from 18 shoulders in 16 patients, average age 74 years, were analyzed. The standard 28-mm-sized baseplate with longer and wider central peg was implanted in 12 of 18 reconstructions. Bone graft augmentation of the glenoid was required in 4 of 6 cases when the 25-mm mini baseplate was used. Clinical evaluation of 13 patients (15 shoulders) with an average of 5 (range, 2-10) years after surgery showed statistically significant improvements in median visual analog scale shoulder pain score decreasing from 7 to 0 (P < .001), median active shoulder forward flexion increasing from 90° to 140° (P < .001), and median active shoulder abduction increasing from 60° to 125° (P < .001). In 14 of 15 cases, the patient was satisfied with the outcome. There were minor complications in 2 cases (13%), but there were no major complications or reoperations. ConclusionIn patients with symptomatic TSA from component failure, shoulder instability, or rotator cuff insufficiency, single-stage revision to RSA for those with contained glenoid bone defects is a reliable salvage option to reduce shoulder pain and improve shoulder motion. At a mean 5-year follow-up, we observed 100% implant survival in 15 cases.

Reliability of Manual Measurements Versus Semiautomated Software for Glenoid Bone Loss Quantification in Patients With Anterior Shoulder Instability.

The presence of glenoid bone defects is indicative in the choice of treatment for patients with anterior shoulder instability. In contrast to traditional linear- and area-based measurements, techniques such as the consideration of glenoid concavity have been proposed and validated. To compare the reliability of linear (1-dimensional [1D]), area (2-dimensional [2D]), and concavity (3-dimensional [3D]) measurements to quantify glenoid bone loss performed manually and to analyze how automated measurements affect reliability. Cohort study (diagnosis); Level of evidence, 3. Computed tomography images of 100 patients treated for anterior shoulder instability with differently sized glenoid defects were evaluated independently by 2 orthopaedic surgeons manually using conventional software (OsiriX; Pixmeo) as well as automatically with a dedicated prototype software program (ImFusion Suite; ImFusion). Parameters obtained included 1D (defect diameter, best-fit circle diameter), 2D (defect area, best-fit circle area), and 3D (bony shoulder stability ratio) measurements. Mean values and reliability as expressed by the intraclass correlation coefficient [ICC]) were compared between the manual and automated measurements. When manually obtained, the measurements showed almost perfect agreement for 1D parameters (ICC = 0.83), substantial agreement for 2D parameters (ICC = 0.79), and moderate agreement for the 3D parameter (ICC = 0.48). When measurements were aided by automated software, the agreement between raters was almost perfect for all parameters (ICC = 0.90 for 1D, 2D, and 3D). There was a significant difference in mean values between manually versus automatically obtained measurements for 1D, 2D, and 3D parameters (P < .001 for all). While more advanced measurement techniques that take glenoid concavity into account are more accurate in determining the biomechanical relevance of glenoid bone loss, our study showed that the reliability of manually performed, more complex measurements was moderate.

Stabilizing Mechanisms in Patients Treated Using Hill-Sachs Remplissage With Bankart Repair in Abduction-External Rotation Position.

Hill-Sachs lesion (HSL) remplissage with Bankart repair (RMBR) provides a minimally invasive solution for treating HSLs and glenoid bone defects of <25%. The infraspinatus tendon is inserted into the HSL during the remplissage process, causing the infraspinatus to shift medially, leading to an unknown effect on glenohumeral alignment during the resting abduction-external rotation (ABER) and muscle-active states. The purpose of this study was to evaluate the possible check-rein effect and muscle-active control in stabilizing the glenohumeral joint after RMBR in vivo. We hypothesized that the check-rein effect and active control would stabilize the glenohumeral joint in the ABER position in patients after RMBR. Controlled laboratory study. We included 42 participants-22 patients in group A who met the inclusion criteria after RMBR and 20 healthy participants in group B without shoulder laxity. Three-dimensional magnetic resonance imaging was performed to analyze the alignment relationship of the glenohumeral joint with and without muscular activity. Ultrasonic shear wave elastography was used to evaluate the elastic properties of the anterior capsule covered with the anterior bands of the inferior glenohumeral ligament. Patients who underwent RMBR demonstrated more posterior (-1.81 ± 1.19 mm vs -0.76 ± 1.25 mm; P = .008) and inferior (-1.05 ± 0.62 mm vs -0.45 ± 0.48 mm; P = .001) shifts of the humeral head rotation center and less anterior capsular elasticity (70.07 ± 22.60 kPa vs 84.01 ± 14.08 kPa; P = .023) than healthy participants in the resting ABER state. More posterior (-3.17 ± 0.84 mm vs -1.81 ± 1.19 mm; P < .001) and less-inferior (-0.34 ± 0.56 mm vs -1.05 ± 0.62 mm; P < .001) shifts of the humeral head rotation center and less anterior capsular elasticity (36.57 ± 13.89 kPa vs 70.07 ± 22.60 kPa; P < .001) were observed in the operative shoulder during muscle-active ABER than in resting ABER states. The check-rein effect and muscle-active control act as stabilizing mechanisms in RMBR during the ABER position. Stabilizing mechanisms in RMBR during the ABER position include the check-rein effect and muscle-active control.

Reconstruction of recurrent shoulder dislocation with glenoid bone defect with 3D-printed titanium alloy pad: outcomes at 2-year minimum follow-up

BackgroundTo evaluate the outcome of shoulder arthroscopy-assisted implantation of three-dimensional (3D)-printed titanium pads for recurrent shoulder dislocation with glenoid bone defects.MethodsFrom June 2019 to May 2020, the clinical efficacy of 3D printed titanium pad implantation assisted by shoulder arthroscopy, for the treatment of recurrent shoulder dislocations with shoulder glenoid defects was retrospectively analyzed. The American Shoulder and Elbow Surgeons (ASES) shoulder, Rowe, and Constant scores were recorded before surgery and at 3 months, 6 months, 1 year, and 2 years after surgery. 3D computed tomography (CT) and magnetic resonance imaging were used to evaluate the location of the glenoid pad, bone ingrowth, joint degeneration, and osteochondral damage.ResultsThe mean age of the 12 patients was 21.4 (19–24) years and the mean follow-up time was 27.6 (24–35) months. The Visual Analog Scale score significantly improved from 5.67 ± 1.98 preoperatively to 0.83 ± 0.58 postoperatively (p = 0.012). The postoperative ASES score was significantly increased to 87.91 ± 3.47 compared with preoperative ASES score (46.79 ± 6.45) (p < 0.01). Rowe and Constant scores also improved from 22.5 ± 12.34 and 56.58 ± 7.59 preoperatively to 90.83 ± 4.69 and 90.17 ± 1.89 at 2 years postoperatively, respectively. CT performed 2 years after surgery showed that the pad perfectly replenished the bone-defective part of the shoulder glenoid and restored the articular surface curvature of the shoulder glenoid in the anterior-posterior direction, and the bone around the central riser of the pad was tightly united. Magnetic resonance imaging 2 years after surgery showed that the humeral head osteochondral bone was intact, and there was no obvious osteochondral damage.Conclusions3D printed titanium pads are a reliable, safe, and effective surgical procedure for treating recurrent shoulder dislocations with glenoid bone defects.