Treatment Of Glenoid Bone Loss 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.

Arthroscopic Remnant Coracoid Autograft for Revision of the Failed Latarjet Procedure With Persistent Glenoid Bone Loss

Recurrence of anterior instability after a Latarjet procedure with persistent glenoid bone loss can be related to coracoid bone block resorption, migration, or malposition. Multiple options are available to address anterior glenoid bone loss, including autograft bone transfers (such as iliac crest graft, distal clavicle autograft) or allografts (distal tibia allograft). Here, we present the use of the remnant coracoid process as an option for consideration in the treatment of glenoid bone loss after failed Latarjet procedure with persistent glenoid bone loss. The remnant coracoid autograft is harvested and transferred inside the glenohumeral joint, through the rotator interval, and fixed using cortical buttons. This arthroscopic procedure includes using 1) glenoid and coracoid drilling guides to optimize graft positioning and making the procedure more reproducible and safer and 2) a suture tensioning device to provide intraoperative graft compression and ensure bone graft healing.

The Anatomy of Glenoid Concavity-Bony and Osteochondral Assessment of a Stability-Related Parameter.

Glenoid concavity is a crucial factor for glenohumeral stability. However, the distribution of this stability-related parameter has not been focused on in anatomical studies. In this retrospective study, computed tomography (CT) data and tactile measurements of n = 27 human cadaveric glenoids were analyzed with respect to concavity. For this purpose, the bony and osteochondral shoulder stability ratio (BSSR/OSSR) were determined based on the radius and depth of the glenoid shape in eight directions. Various statistical tests were performed for the comparison of directional concavity and analysis of the relationship between superoinferior and anteroposterior concavity. The results proved that glenoid concavity is the least distinctive in anterior, posterior, and anterosuperior direction but increases significantly toward the superior, anteroinferior, and posteroinferior glenoid. The OSSR showed significantly higher concavity than the BSSR for most of the directions considered. Moreover, the anteroposterior concavity is linearly correlated with superoinferior concavity. The nonuniform distribution of concavity indicates directions with higher stability provided by the anatomy. The linear relationship between anteroposterior and superoinferior concavity may motivate future research using magnetic resonance imaging (MRI) data to optimize clinical decision-making toward more personalized treatment of glenoid bone loss.

Arthroscopic Distal Clavicle Glenoid Augmentation: Rationale and Surgical Technique

Glenoid bone loss remains an important determinant of outcome in the surgical management of anterior shoulder instability. Multiple options are available to address this bone loss including autograft bone transfers, such as coracoid or iliac crest grafts. Allograft options include both bone and osteochondral options, such as the distal tibial allograft. Each of these choices has potential advantages and disadvantages. An ideal approach would provide an autograft source of osteochondral material that is well-matched to the defect, readily available, cost effective, and with minimal morbidity. In this article, we present the distal clavicle autograft as an ideal option for consideration in the treatment of glenoid bone loss. The graft has a cortical and cancellous side for direct fixation and is amenable to arthroscopic techniques using standard portals and obviating the need to go near the neurovascular structures of the shoulder. Recent work has demonstrated the utility of this graft in providing an anatomic restoration of the glenoid articular surface with a cartilage cap comparable in thickness to that of the native glenoid. Along with a summary of the pertinent literature, this article outlines the rationale, indications, and technical evolution for this procedure.

Distal clavicle autograft augmentation for glenoid bone loss in revision shoulder arthroplasty: results and technique

Structural bone graft for reconstruction of glenoid bone stock is often necessary in the setting of revision shoulder arthroplasty. This study introduces a new structural autograft technique using the distal clavicle for treatment of glenoid bone loss in the setting of revision shoulder arthroplasty. This is a retrospective, single-surgeonstudy of patients with significant glenoid bone loss requiring revision shoulder arthroplasty with autologous distal clavicle bone grafting to the glenoid. Twenty patients with failed shoulder arthroplasty who underwent revisions of their glenoid components between 2015 and 2019 were retrospectively identified. Sixteen patients were available with follow-up of greater than 1 year. Patient records and radiographs were reviewed for intraoperative and postoperative complications. Preoperative and postoperative function were evaluated by physical examination and patient-reported outcome surveys. There were no observed intraoperative complications relating to the distal clavicle autograft harvest or placement. There were no iatrogenic nerve injuriesor intraoperative instability. One of the 16 patients developed postoperative loosening and subsequent failure of the glenoid baseplate, requiring revision. One additional patient demonstrated increased elevation of the coracoclavicular interval postoperatively, likely related to the distal clavicle autograft harvest. At a mean follow-up of 25 months, 15 of 16 glenoid implants remained well fixed (93.4%), with no evidence of infection, or impingement demonstrated radiographically or clinically. Average patient age was 69 years at the time of surgery. Forward elevation improved from 76° to 123° at final follow-up (P = .0002). The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score improved from an average of 35.8 to 67.8 at mean follow-up (P = .001). The visual analog scale score improved from an average of 5.9 to 2 at mean follow-up, though not statistically significant (P = .068). There was no significant change in external rotation following surgery (P = .319). Osteolysis and bone loss of the glenoid poses a challenging problem in revision shoulder arthroplasty. Distal clavicle autograft augmentation is a viable and reproducible technique to manage structural glenoid defects.

Arthroscopic, Implant-Free Bone-Grafting for Shoulder Instability with Glenoid Bone Loss

The major steps of the procedure, which are demonstrated in the present video article, include (1) detachment of the labrocapsular ligamentous complex and preparation of the anterior aspect of the glenoid, (2) establishment of a deep anterior-inferior portal and splitting of the subscapularis tendon, (3) introduction of the "waterslide," (4) osteotomy at the scapular neck 30° relative to the glenoid surface and trial impaction, (5 and 6) harvesting and preparation of a J-shaped bicortical iliac-crest bone graft, (7) press-fit impaction of the bone graft in the prepared osteotomy over the "waterslide", and (8) capsuloligamentous repair over the graft. Coracoid transfer (Latarjet-Bristow), iliac-crest bone-grafting, and distal tibial allograft. Although widely in use, nonanatomic coracoid transfer procedures or bone-block techniques relying on hardware fixation are associated with specific complications, including nonunion, osteolysis, coracoid fractures, hardware complications, and difficult revision1. Many of these disadvantages can be avoided by the use of anatomic implant-free glenoid reconstruction with a J-shaped iliac-crest bone graft. After press-fit fixation, the graft undergoes a physiological remodeling process that follows the law of bone adaptation to mechanical stresses described by Wolff, which ultimately results in the restoration of a nearly native anterior scapular neck morphology4. The open version of this technique has been successfully used for over 3 decades. The arthroscopic, minimally invasive variation of the J-bone-graft technique presented in this video article represents a further advancement of the anatomic nature of the procedure. The arthroscopic implant-free J-bone-graft technique is an alternative to other procedures widely used for the treatment of anterior glenoid bone defects. The main advantage of this technique is the avoidance of severe complications that arise from the nonanatomic reconstruction and fixation methods found with other procedures1. Early to midterm follow-up of the arthroscopic J-bone-graft technique has revealed excellent clinical results, and the traditional open technique has been in use successfully for over 3 decades2-5. Previous patients have been able to return to a variety of occupational and athletic activities including overhead, throwing, and contact sports. Return to daily living and to moderate athletic activities is usually possible within 3 months. Return to competition is allowed after 6 months2-5. •Avoid intraoperative graft fractures by applying strictly axial force during impaction.•Reduce the risk of glenoid fractures by performing an oblique osteotomy at an angle of 20° to 30° and 5 mm medial to the glenoid surface.•The postoperative physiological remodeling process determines ultimate graft fixation and glenohumeral stability. Keep this in mind when allowing return to activities.

Reverse Total Shoulder Arthroplasty: Biomechanics and Indications.

Over the past decade, our understanding of the biomechanics of the reverse total shoulder arthroplasty (RTSA) has advanced, resulting in design adjustments, improved outcomes, and expanding indications. The purpose of this review is to summarize recent literature regarding the biomechanics of RTSA and the evolving indications for its use. While Grammont's principles of RTSA biomechanics remain pillars of contemporary designs, a number of modifications have been proposed and trialed in later generations to address complications such as impingement and glenoid failure. Clinical and biomechanical literature suggest that less medialized, more inferior glenospheres result in less impingement and notching. On the humerus, a more vertical neck cut is associated with less impingement. Indications for RTSA continue to expand beyond the classic indication of cuff tear arthropathy (CTA). Patients without a functional cuff but no arthritis now have a reliable option in the RTSA. RTSA has also replaced hemiarthroplasty as the implant of choice for displaced three- and four-part proximal humerus fractures in the elderly. Finally, updated design options and modular components now allow for treatment of glenoid bone loss, failed arthroplasty, and proximal humerus tumors with RTSA implants. Reverse total shoulder arthroplasty design has been modernized on both the glenoid and humerus to address biomechanical challenges of early implants. As outcomes improve with these modifications, RTSA indications are growing to address complex bony pathologies such as tumor and bone loss. Longitudinal follow-up of patients with updated designs and novel indications is essential to judicious application of RTSA technology.

Osteochondral augmentation of glenoid bone loss—distal tibia allograft

The treatment of glenoid bone loss in the setting of recurrent anterior shoulder instability has been a point of debate in orthopaedic surgery. The decision of when to treat with soft tissue stabilization only versus augmenting the glenoid with a bone graft, and which bone graft to use, has provoked varying opinions. In this review, we explore the different treatment options for these patients, when bony augmentation should be implemented, and the benefits and drawbacks of several different graft options.

Clavicular Osteochondral Graft as a Treatment of a Glenoid Bone Deficiency, a Comparison of Glenoid Resurfacing Capability Versus Coracoid Latarjet Transfer

The clavicular osteochondral graft was able to augment 44% of glenoid radial bone loss, compared to 33% achieved from the Latarjet graft. The aim of this study is to evaluate a distal clavicle osteochondral autograft as a possible option for treating glenoid bone loss in patients with instability. We compared clavicular augmentation with the Latarjet technique as a gold standard in glenoid deficiency treatment. Further, we calculated differences in articular cartilage thickness between clavicular grafts and native glenoids. Twenty-seven fresh frozen cadaver shoulders were dissected and distal clavicle excision was performed, In addition, we performed coracoid harvesting and graft preparation according to the Latarjet technique. Articular cartilage was measured on the glenoid side by making a saw cut perpendicular to the articular surface along the long axis, and measuring the thinkness with a digital micrometer. The distal clavicular graft was similarly evaluated for cartilage thickness. The distal clavicular osteochondral autograft resulted in significantly greater glenoid radius restoration compared to a Latarjet graft, p<0.0001. The clavicular osteochondral graft was able to augment 44% of glenoid radial bone loss, compared to 33% achieved from the Latarjet graft. In all specimens articular cartilage was present at the clavicular grafts, but was 1,44 mm thinner than the native glenoids, p<0.0001. Distal clavicular osteochondral graft may resurface a greater amount of glenoid radius when compared to a Latarjet coracoid graft. It’s cartilage is of similar thickness to that of the native glenoid, and may provide a reasonable option for treatment of glenoid bone loss in the setting of anterior instability.

Classification and Analysis of Attritional Glenoid Bone Loss in Recurrent Anterior Shoulder Instability

Proper recognition and treatment of glenoid bone loss (GBL) is important for successful management of anterior shoulder instability. Although GBL has been thoroughly described in the literature, there is also a fragment of bone that is usually displaced and often undergoes attrition that has been little described. Thus, the purposes of this study include (1) to evaluate ABL of the glenoid fragment in recurrent anterior shoulder instability and (2) correlate ABL with clinical history, fragment size and radiographic findings. GBL was evaluated on 3-dimensional (3D) computed topography (CT) en face view, and measured as percent loss. The bone fragment size was measured and attrition of the fragment was determined by evaluating the amount remaining relative to the initial defect; patients were stratified into minimal (<34%), moderate (34-67%) and severe (>67%) attritional loss groups. Clinical history and demographics were correlated to ABL, and comparison of GBL and ABL was performed. The overall median percent GBL was 15.3% (IQR, 9.9% - 20.0%) with a mean (SD) percent GBL of 16.5% (9.0%). Study participants had a corresponding median percent ABL of 75.8% (IQR, 53.8% - 95.7%) and a mean (SD) percent ABL of 72.0% (24.4%). A total of 61.2% of patients (n=85) exhibited severe ABL, while 30% had moderate ABL and 8.6% had minimal ABL. The total time of instability was significantly associated with percent attritional bone loss (p<0.05). This study highlights that GBL, in most patients with recurrent anterior instability, presents with extensive attrition of the bone fragment independent of initial glenoid bone loss; therefore, surgeons should be cognizant that the remaining bone fragment is unable to reconstitute glenoid bone stock. In addition, there was more attritional bone loss in patients with a longer duration of instability symptoms, indicating need for incorporating symptom duration in determining proper management.

Use of a Cutting Instrument for Fresh Osteochondral Distal Tibia Allograft Preparation: Treatment of Glenoid Bone Loss

Glenoid bone loss presents a major risk for glenohumeral instability that has been well recognized as a cause of instability recurrence after attempted Bankart repair, and although most surgeons consider the Latarjet procedure as the gold standard, failures can occur with this technique as well and the search for alternative grafts to address glenoid bone loss is a major topic of ongoing research in the field. Of these techniques, the distal tibia allograft (DTA) has been shown to provide an excellent option to restore glenoid biomechanics, due to its congruency with the humeral head, dense bony quality, and the facility of harvest. The correct preparation of the DTA is essential to provide the most anatomic reconstruction possible and to avoid damage to the graft. The purpose of this Technical Note is to present our technique for cutting the DTA in detail, using a special workstation to optimize this procedure.

Classification and Analysis of Attritional Glenoid Bone Loss in Recurrent Anterior Shoulder Instability

Background: Recognition and proper treatment of glenoid bone loss (GBL) are important for successful management of anterior shoulder instability. Although GBL has been described as the amount of bony loss from the front of the glenoid, there is also a fragment of bone that is usually displaced and often undergoes attrition. Thus, due to attritional bone loss (ABL) of the fragment, insufficient bone is left to fully reconstruct the glenoid. Purpose: To (1) evaluate ABL of the glenoid fragment in recurrent anterior shoulder instability and (2) correlate ABL with clinical history, fragment size, and radiographic findings. Study Design: Cross-sectional study; Level of evidence, 3. Methods: GBL was evaluated on 3-dimensional computed tomography (3D CT) en-face view and was measured as percentage loss. The bone fragment size was measured, and attrition of the fragment was determined by evaluation of the amount remaining relative to the initial defect; patients were stratified into minimal (<34%), moderate (34% to <67%), and severe (≥67%) attritional loss groups. Clinical history and demographics were correlated to ABL, and GBL and ABL were compared. Results: The overall median percentage GBL was 15.3% (interquartile range [IQR], 9.9%-20.0%), with a mean (±SD) percentage GBL of 16.5% ± 9.0%. Study participants had a corresponding median percentage ABL of 75.8% (IQR, 53.8%-95.7%) and a mean percentage ABL of 72.0% ± 24.4%. A total of 61.2% of patients (n = 85) exhibited severe ABL, while 30.2% had moderate ABL and 8.6% had minimal ABL. The total time of instability was significantly associated with percentage of attritional bone loss (P < .05). In addition, the time of instability was greatest in patients in the third tertile of ABL (≥87.5%; P = .08). A significant difference was found in total time of instability among patients in the highest tertile of ABL (38.6 months) versus both the middle (26.7 months) and lowest (32.8 months) tertiles (P < .05). Conclusion: The study results indicate that in the majority of patients with recurrent anterior instability, GBL presents with extensive attrition of the bone fragment independent of initial glenoid bone loss; therefore, surgeons should be cognizant that the remaining bone fragment is unable to reconstitute glenoid bone stock. In addition, the results showed more attritional bone loss in patients with a longer duration of instability symptoms, indicating a role for incorporating symptom duration in determining proper management.

The Sheffield bone block procedure: a new operation for the treatment of glenoid bone loss in patients with anterior traumatic shoulder instability.

The purpose of the present study was to evaluate the results of the Sheffield bone block procedure for anteroinferior bone loss in traumatic shoulder instability. In this modified open technique, the medial half of coracoid process without its soft tissue attachments is used to provide congruent augmentation of the anteroinferior glenoid and secured with two screws. In this retrospective consecutive case series (2007-11), all patients having recurrent traumatic instability with glenoid bone loss > 20% and/or a large Hill-Sachs lesion were included. The shoulder function was evaluated clinically and by Oxford Shoulder Instability Score (OSIS; by post/telephone). There were 84 patients in this series with a large proportion engaged in contact sports. Mean (range) age was 33 years (16 years to 45 years); male : female, 59 : 8; mean (range) follow-up period was 48 months (36 months to 84 months) and the response rate 89% (75/84). Mean postoperative OSIS was 43 (33 to 46) and one patient had re-dislocation (1.3%). No neurovascular complications/hardware failure/non-union/infections were noted. By 6 months, 85% patients had returned to pre-injury sport and 93% had returned to pre-injury work. The Sheffield bone block procedure provides reliable and satisfactory results in patients having recurrent instability with glenoid bone loss and/or a large Hill-Sachs lesion with minimal complications and an excellent chance of returning to original sport and occupation.

Arthroscopic treatment of glenoid bone loss.

Recurrent anterior instability of the glenohumeral joint has long been an arduous problem to solve surgically, owing to its difficulty to the need to restore both osseous and dynamic constraints in the unstable shoulder. Biomechanical studies have indicated that glenoid bone loss shortens the safe arc through which the glenoid can resist axial forces; in these cases, a soft tissue repair alone may be insufficient to maintain stability. Clinical studies have confirmed that major bone loss is associated with an unfavourable outcome. The benefits of using arthroscopic procedures for surgical stabilization of the shoulder include smaller incisions and less soft tissue dissection, better access for repair and, potentially, the maximum respect for the undamaged anatomical structures. The biggest disadvantage of arthroscopic procedures until recently was the inability to successfully treat a significant bone defect. Over the last 10 years, several new arthroscopic techniques have been developed, providing new surgical options for successfully treating soft tissues and bony lesions in anterior-inferior glenohumeral instability. Level of evidence V.

The Importance of the Recognition and Treatment of Glenoid Bone Loss in an Athletic Population

Context:Osseous injury to the glenoid is increasingly being recognized as one of the most important aspects in the successful management of recurrent shoulder instability. Proper early recognition of glenoid bone injury in the setting of recurrent instability will lead to successful nonoperative and operative decision making, particularly in the athletic patient.Evidence Acquisition:We conducted a MEDLINE search on shoulder instability from 2000 to 2010. The emphasis was placed on patient-oriented Level 1 literature from 2000 to 2010.Results:After a traumatic anterior dislocation of the shoulder, the most common structural injury is an avulsion of the anteroinferior capsulolabrum, which is also known as a Bankart lesion. If this specific injury is accompanied by an associated fracture in the glenoid rim, the term bony Bankart lesion is more applicable. With diminished articular constraints, the glenohumeral joint is subject to recurrent instability, thereby potentiating the bony injury cycle. Additionally, patients with osseous defects usually complain of instability within the midranges of motion, or they recall a progression of instability. If glenoid bone loss is present, the humeral head often easily subluxates over the glenoid in the midranges of abduction (30°-90°) and lower levels of external rotation. Imaging workup should begin with plain radiographs, but advanced imaging should be obtained if there is any suspicion of bone loss. Treatment includes both nonoperative and operative interventions.Conclusions:Estimation of the amount of glenoid bone loss and the failure of nonoperative care is essential for guiding management, patient expectations, and surgical decision making.

Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head

The treatment of extensive glenoid chondral defects in young, active patients remains a challenge. Chondrolysis and extensive chondral defects of the glenohumeral joint in young patients have been reported after shoulder surgery and have been associated with the use of thermal capsulorrhaphy, intra-articular pain pumps, and implanted fixation devices, such as suture anchors. Prominent glenohumeral anchors have been implicated in the early development of postoperative glenohumeral degenerative changes. A proud implant may cause local wear on the glenoid and the humerus, contributing to chondral loss, decreased range of motion, mechanical symptoms, and pain. Recently, a novel treatment of glenoid bone loss has been proposed that uses a distal tibia allograft. As our group described in a previous report, this technique was initially for the treatment of glenohumeral instability secondary to extensive glenoid bone loss. The lateral aspect of the distal tibia has excellent conformity to the radius of curvature of the humeral head and has been used as a fresh allograft for the treatment of glenoid bone loss. Given its successful early outcomes, this technique can potentially have broader applications in glenohumeral pathology. We present the case of a young, active patient with focal but extensive glenohumeral degenerative changes.

Anatomic Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability With Glenoid Deficiency Using a Distal Tibia Allograft

The treatment of glenoid bone loss in the setting of recurrent shoulder instability remains a challenge. This is because of the nonanatomic nature and resultant incongruous joint resulting from most bony augmentation procedures. We present a novel technique for the management of glenoid bone deficiency by using a fresh osteochondral distal tibial allograft. We have found that the distal tibia has excellent articular conformity to unmatched humeral heads, fits nearly anatomically on the distal two thirds of the glenoid, is composed of dense weight-bearing cortical and metaphyseal distal tibia bone, and provides for a cartilaginous surface for which the humeral head to articulate. This article describes the technique, initial results, and postoperative findings with the use of a distal tibia allograft (the lateral portion of the distal tibia) for the treatment of glenoid bone deficiency (mean loss of 30%) in a series of 3 patients.

Glenoid bone grafting with a reverse design prosthesis

The purpose of this study was to evaluate the outcome of patients who underwent glenoid bone grafting and implantation of a reverse design prosthesis in 1 or 2 stages for the treatment of glenoid bone loss and rotator cuff insufficiency. Indications for the reverse prosthesis in this series included cuff tear arthropathy and revision arthroplasty. Nine patients were reviewed clinically and radiographically with a minimum 2-year follow-up (range, 24-41 months). Despite a low postoperative functional score (mean Constant score, 53 points [range, 22-79 points]), most patients were satisfied with their results primarily because of pain relief. (The mean pain score increased from 3 points preoperatively to 12.5 points postoperatively.) Radiographic evaluation did not demonstrate component loosening or evidence of graft failure. Six patients had radiographic evidence of an inferior scapular notch, which may be of concern in the future. Early results of this procedure are encouraging, but further clinical and radiologic assessment is necessary.