Anatomical glenoid reconstruction via a J-bone graft for recurrent posttraumatic anterior shoulder dislocation

Objective

To reconstruct the anatomical glenoid shape in cases of osseous glenoid rim defects after recurrent posttraumatic anterior shoulder dislocation to restore stability without severely compromising the range of motion.

Indications

Osseous glenoid defects after recurrent posttraumatic anterior shoulder dislocation. Suitable for primary stabilization as well as for revision surgery in cases previously operated on.

Contraindications

Recurrent anterior shoulder dislocations without glenoid rim defects. Hyperlax shoulders with multidirectional instability. Patients over 60?years of age due to compromised bone quality. Teenage patients due to incomplete apophyseal fusion at the iliac crest.

Surgical technique

The subscapularis tendon and capsule are split. The humeral head is retracted laterally, and the glenoid defect is prepared and abraded with a rasp. A bicortical iliac crest bone block including crest and outer cortex is harvested and molded in a J-shaped manner. To incorporate the graft, a crevice on the glenoid rim is produced using a chisel. The keel is fitted into the preformed crevice with a spiked impactor. The graft??s surface is contoured using a high-speed burr.

Results

A total of 47?shoulders were followed-up after an average of 90?months (range 25?C152?months). The mean Rowe scores were 94.3 for the affected shoulder and 96.8 for the uninjured shoulder. The Constant scores reached 93.5 and 95?points, respectively. Loss of external rotation was 4.4°. In addition, 24?shoulders were followed-up by computed tomography (CT). There were no recurrences, with the exception of one traumatic graft fracture. Of 19?patients with arthropathy at follow-up, 11?already had arthropathy prior to the procedure.     

Shoulder Instability in the Setting of Bipolar (Glenoid and Humeral Head) Bone Loss: The Glenoid Track Concept

Background

An assortment of variables has been used in predicting anterior shoulder instability resulting from pathologic engagement of Hill-Sachs lesions on the glenoid. The glenoid track is a unique biomechanical model that relates both Hill–Sachs and bony Bankart lesions to predict shoulder engagement. We examined the glenoid track concept to determine if it provides a model that unifies glenoid rim and humeral head bone loss in predicting engagement.

Questions/purposes

In this review we addressed two questions: (1) How are humeral head and glenoid rim bony defects and their interactions quantified? (2) Why is the concept of the glenoid track important?

Methods

We performed a systematic review of the literature using PubMed (MEDLINE) and OVID for biomechanical studies and peer-reviewed articles published until March 2013. Twenty-four studies fit the inclusion criteria. These were subdivided into four anatomic studies, four studies quantifying glenohumeral bone loss, nine studies biomechanically defining shoulder engagement, six studies analyzing current treatment models, and one clinical study to be included in the final review.

Results

Data demonstrate pathologic engagement is dependent on the medial margin of the Hill–Sachs lesion traveling outside the glenoid track. The width of the glenoid track decreases accordingly if there is a glenoid defect, making engagement more likely. Most treatment models focus on widening the glenoid track before addressing Hill–Sachs lesions.

Conclusions

The glenoid track uses both glenoid and humeral head bone loss to predict subsequent risk of humeral head engagement and possible dislocation. The glenoid track shows us that restoring the track to its natural width should be among the surgeon’s first priority in restoring shoulder stability. Humeral head lesions, also known as Hill–Sachs lesions, are surgically addressed when they cause clinical symptoms. Symptoms arise when the medial margin of the defect engages the glenoid track.     

Articular arc length mismatch as a cause of failed Bankart repair

Summary: The purpose of this article is to recognize an often overlooked cause of failed anterior stabilization procedures of the shoulder. Hill-Sachs lesions are common occurrences after anterior dislocation. But despite the frequency of occurrence, they are commonly not addressed in the treatment of recurrent anterior dislocation. The Hill-Sachs lesion produces a shortened rotational arc length of the humeral head on the glenoid; any engagement of the defect with the glenoid produces a sensation in the patient of subluxation/dislocation. However, instead of subluxation/dislocation, the sensation may be caused by mismatch between the articular arc length of the humeral head and the glenoid. The literature concerning the Hill-Sachs lesion and its association with recurrent dislocation has been reviewed. There is no recognition in the literature of this articular arc length mismatch as a cause of failed anterior stabilization procedures. We present a case in which a Hill-Sachs lesion was the cause of a perceived recurrent subluxation/dislocation of the shoulder.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 740–744     

骨性缺损对肩关节稳定性影响的研究

目的探讨肩关节骨性缺损对关节稳定性的影响,为临床提供理论依据。方法分别制作肩胛盂及肱骨头缺损模型并逐渐增加缺损程度;以盂肱关节旋转中立位、60°外展位为起始位置,逐渐增加外旋角度至盂肱关节脱位,测量脱位发生前肱骨头前移距离;保持盂肱关节外展60°,分别在旋转中立位及外旋60°位时增加轴向应力,直至盂肱关节脱位,测量脱位前肱骨头的应力强度变化。结果随着肩胛盂及肱骨头缺损程度增加,外旋角度增加,肩关节稳定性下降,肱骨头位移不断增大,各组间呈显著性差异(P<0.01);盂肱关节外展60°、旋转中立位时,肱骨头应力强度随着骨缺损增大而不断增大,正常应力强度从1.68 Mpa迅速增加至4.62 Mpa,各组间呈显著性差异(P<0.01);盂肱关节外展60°、外旋60°时,正常应力强度为1.94 Mpa,骨缺损时迅速增加至6.65 Mpa,各组间呈显著性差异(P<0.01);肩关节不同缺损时,其接触力学特性证实了对肩关节稳定性有较大的影响,肩关节不稳定现象十分突出。结论随着肩胛盂及肱骨头缺损范围的增大,肩关节稳定性不断下降,肱骨头位移和应力强度不断增加,以致发生提前脱位。     

The two-step maneuver for closed reduction of inferior glenohumeral dislocation (luxatio erecta to anterior dislocation to reduction)

The 2-step closed reduction maneuver was developed to aid in the rarely encountered inferior shoulder dislocation. The maneuver converts the humeral head from an inferior dislocation to an anterior dislocation and then reduces the humeral head into the glenoid. The operator places one hand on the shaft of the humerus and the other hand on the medial condyle. The hand on the shaft initiates an anteriorly directed force rotating the humeral head from an inferior to an anterior position. Once this is accomplished, the humerus is adducted against the body. The humerus is then external rotated reducing the humeral head into the glenoid. Two cases of inferior shoulder dislocation were closed reduced by using the described technique with minimal analgesia and without a change in the postreduction neurovascular status.     

三维CT测量肩关节复发前脱位肩胛盂轨迹的可靠性研究

目的:本研究旨在评估三维CT测量肩盂轨迹的可靠性和可重复性.方法:由3位独立观察者(肩关节专科医生)通过三维CT评估60例单侧肩关节复发前脱位患者的肩胛盂及Hill-Sachs骨缺损情况,并按Di Giacomo等的方法,将损伤分类,制定手术方案.所有观察者在1周后重复测量.采用组内相关系数(intraclass co...     

Eine neue Repositionstechnik für die verhakte hintere Schulterluxation

The case of a 61-year-old male with posterior dislocation of the right shoulder joint is presented and a new technique for closed reduction of posterior locked shoulder dislocation is described. The technique involves four steps: in step 1 a constant traction is applied on the injured arm, in step 2 the arm is internally rotated and in steps 3 and 4 the second arm of the physician is used as a lever arm to lateralize and ventralize the shoulder. Lateralization and ventralization of the humeral head are essential to engage the humeral head and to pass it around the glenoid during reduction. Steps 3 and 4 are performed simultaneously. In the presented case the patient suffered a traumatic shoulder dislocation with a rim fracture of the glenoid. After reduction the shoulder was stable and conservative treatment was performed. A 2 year follow-up examination revealed a pain-free and stable shoulder with free range of motion and an Oxford instability score of 48 points. The described reduction technique for posterior locked shoulder dislocation is a simple and gentle technique, which can be performed easily by one person.Presentation of a reduction technique for locked posterior shoulder dislocation. Constant traction and internal rotation is performed for engaging the locked humeral head. After disengaging the humeral head the reduction is performed by using the arm of the physician as a lever arm.     

Locked posterior dislocation of the shoulder joint: Report of two cases

Posterior dislocation of the shoulder joint is very rare. Most cases are missed initially because it is difficult to diagnose using conventional radiographic images. Computed tomography (CT) is the best tool for diagnosis. We report two cases of posterior dislocation of the shoulder joint that were missed initially at another hospital. The patients presented with painful disability of the shoulder joint. Posterior dislocation of the shoulder joint was suspected after physical examination. Anteroposterior radiography was unable to confirm the diagnosis because an abnormal posterior relationship of humeral head to glenoid fossa could not be clearly identified. An axillary view was unobtainable because of severe pain and the limited joint motion available. CT showed posterior dislocation of the humeral head. The bony defect of the humeral head was incarcerated by the posterior rim of the glenoid process. Open reduction via an anterior approach was performed on both patients, who recovered with good shoulder function after rehabilitation (the Constant score of Case 1 was 85 and that of Case 2 was 75). We concluded that “Mouzopoulos sign” obtained via an anteroposterior view is helpful for the diagnosis of posterior dislocation of the shoulder joint and that CT is required for a definitive diagnosis. If the dislocation is locked and closed reduction fails, then open reduction should be carried out.     

Innovative use of computer-assisted tomography in the management of an irreducible anterior shoulder dislocation

Anterior dislocation of the shoulder is a common injury which is often reduced in the emergency department, without specialist orthopedic input. We report a case of an irreducible locked anterior glenohumeral dislocation with impaction of the humeral head onto the antero-inferior glenoid rim and subsequent generation of a Hill-Sachs lesion. To our knowledge, we describe the first reported case of using computer-assisted tomography to generate a sequence of movements to safely disimpact the locked dislocation without causing further iatrogenic injury or a fracture through the humeral articular surface. This novel image-assisted closed reduction technique spared the patient from the morbidity associated with performing open reduction surgery. At 6-month follow-up, the patient reported no re-dislocations, returned to work and had excellent range of motion.     

Recurrent, locked posterior glenohumeral dislocation requiring hemiarthroplasty and posterior bone block with humeral head autograft

This article describes the case of a 77-year-old man with a recurrent posterior shoulder dislocation, treated with humeral hemiarthroplasty and reconstruction of a large posteroinferior glenoid defect with a bone block created from humeral head autograft. On examination, the patient's left arm was held in internal rotation against his stomach, with minimal swelling about the deltoid. His shoulder was nontender to palpation; however, he had substantial motion restrictions, and attempted motion was painful. He could forward elevate to 30°, extend to 0°, internally rotate to belly, and passive external rotation was limited to -30°. He maintained full elbow, wrist, and hand range of motion, and his neurovascular examination was intact. Radiographs revealed a recurrent posterior glenohumeral dislocation, with a large reverse Hill-Sachs defect involving the lesser turberosity and humeral head. Computed tomography with 3-D reconstruction revealed the humeral head defect involving the lesser tuberosity and approximately 40% of the humeral head and a large comminuted posteroinferior glenoid fracture measuring 2.7×0.8 cm, encompassing approximately 30% of the posteroinferior glenoid surface. Standard fixation was not possible; therefore, the resected humeral head was fashioned into an elliptical piece mirroring the size of the defect of the posteroinferior glenoid. Rough measurements of the defect were made and marked on the humeral head, which was then cut with an oscillating saw to approximate the size and shape of the defect. The glenoid graft provided an extension to the glenoid and prevented posterior subluxation with no block to motion. One year postoperatively, he had full strength (5/5) with external rotation, forward elevation, and internal rotation, 140° of active forward elevation, 30° of external rotation, internal rotation to T7, and no episodes of instability. To our knowledge. this is the first report of this technique in the literature. It is an alternative to total shoulder arthroplasty.     

Zementfreier Oberflächenersatz bei Dislokationsarthropathie des Schultergelenks

Background

Only a few reports in the literature describe that total shoulder replacement provides better functional results in dislocation arthropathy than hemiarthroplasty. Nevertheless, the risk of aseptic loosening in young and active patients is high after long-term follow-up. We evaluated the results of cementless humeral head resurfacing in this group.

Methods

We evaluated 29 patients with dislocation arthropathy who had been followed up for a mean of 39 months. The mean age at the time of operation was 43.7±14.7 years. Preoperatively, cuff deficiency was seen in 11 cases.

Results

The mean adjusted Constant score improved from 16.8±15.2% to 78.1±21.9%. Negative prognostic factors turned out to be female sex, age, cuff tears especially of the subscapularis tendon, and previous bone block procedures. Revision was performed in five patients, and two developed painful glenoid erosion which required conversion to total shoulder arthroplasty.

Conclusion

Cementless humeral head replacement is a viable option in the treatment of dislocation arthropathy. Revision can be performed easily since the bone stock has been preserved. On the basis of our data, humeral head replacement in patients <40 years with dislocation arthropathy offers promising short- to midterm results with an acceptable complication rate.     

Balloon treatment of posterior shoulder dislocation with reverse Hill–Sachs injury: description of a new technique

Purpose

Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as “reverse Hill-Sachs lesions” may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation.

Methods

From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior “reverse Hill-Sachs” impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up.

Results

At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation.

Conclusion

Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.     

复发性肩关节前脱位肩盂骨缺损的影像学研究

目的 正确评估复发性肩关节前脱位患者肩盂骨缺损的影像学研究,应用64层螺旋CT扫描三维重建规范化肩盂标准正面观影像.方法 对35例(70侧)成人志愿者的肩盂进行64层螺旋CT扫描,之后在三维工作站上通过重建肩盂的三维图像(去除肱骨头影像),在三个多平面重建和一个三维容积再现重建图像上,通过调整不同平面上的彩色参考线,按标准化确定肩盂标准正面观.为验证该方法的可重复性,三位放射科医师根据上述方法在三维工作站上分别取得肩盂的标准三维正面观影像及标尺,并以二维图像的格式导出,利用AutoCAD软件进行分析.结果 通过测量三位医师在三维工作站上所制作的肩盂正面观的图像,肩盂下部前缘最突点、后缘最突点之间的距离为[(28.1±3.3)mm,下同],肩盂上缘最突点、下缘最突点之间的距离为(38.7±3.7)mm.三位医师所取得正面观影像的测量值之间的差异无统计学意义(P>0.05).结论 根据我们提出的方法,在三维工作站上取得肩盂标准正面观影像是简便、可行的,其可重复性较高,对临床工作中规范化肩盂标准正面观以精确评估肩盂骨缺损具有重要意义.     

手术复位治疗产瘫肩关节内旋挛缩伴盂肱关节后脱位存在的问题及改进

目的观察肩关节前路松解复位、后路关节囊紧缩及关节孟后路截骨治疗产瘫肩关节内旋挛缩畸形伴肩关节后脱位的临床效果。方法经CT或MRI检查确诊为孟肱关节脱位的7例产瘫并发肩关节内旋挛缩畸形患者，男2例，女5例，年龄1．4～4岁，平均2岁2个月。孟肱关节畸形按照Water的标准进行分型，Ⅳ型5例，Ⅴ型2例。2例行肩关节前路松解复位，肩关节最大外旋位固定6周；5例同时行后路关节囊松解、紧缩及关节孟截骨，将后倾的关节孟向前掀起，取三角形髂骨块植骨，术后行石膏固定4周。结果2例单纯行前路松解复位者术后分别随访48，60个月，Mallent评分分别由术前6分至术后10分；CT及X线平片复查示，肱骨头前脱位，关节孟后侧部分仍后倾。5例同时后路行关节孟截骨，术后随访36～49个月，平均3年4个月，Mallant评分由术前平均5。4分至术后8．6分；经CT及X线平片复查，孟肱关节复位良好，关节孟包容良好，关节孟后倾纠正。结论对于产瘫肩关节内旋挛缩导致的肩关节脱位，前路松解复位、后路关节囊松解、紧缩及关节孟后路截骨，可使脱位的孟肱关节复位并恢复关节孟的包容同时改善其肩关节功能。     

A Shearing Osteochondral Fracture of the Humeral Head Following an Anterior Shoulder Dislocation in a Child

A dislocation of the shoulder joint is rare in children with an open physis. The fractures associated with an anterior dislocation generally reported in the literature have been Hill-Sachs lesions, avulsions of the greater tuberosity and glenoid fractures. We present a case of a previously unreported shearing osteochondral fracture, which is distinct from a classic Hill-Sachs lesion of the humeral head, in 12-year-old boy. The patient suffered a traumatic anterior shoulder dislocation with a spontaneous reduction along with this associated fracture. The fracture subsequently healed with no further evidence of persistent instability.     

Retroverted glenoid reconstruction using glenoid plate in reverse shoulder arthroplasty

Purpose

The objective of this study is to evaluate the clinical and radiological results of reverse shoulder arthroplasty (RSA) with glenoid plating in a consecutive series of patients affected by cuff tear glenohumeral arthropathy with glenoid retroversion >15°. We hypothesized that autologous humeral head graft may be better stabilized between the baseplate and the native glenoid surface with the use of a glenoid plate.

Methods

Twenty consecutive patients affected by cuff tear arthropathy with glenoid retroversion >15° (B2 or C according to Walch classification) were enrolled in this study. To reconstruct the glenoid, a dedicated plate was used in addition to the standard reverse shoulder baseplate and the glenosphere. Clinical and radiological assessment was performed using constant score (CS), subjective shoulder value (SSV), X-rays and CT scan at 6, 12 and 24 months of follow-up. Healing and resorption of the graft and detection of the glenoid version were assessed.

Results

Sixteen patients were available for final follow-up. The mean preoperative retroversion of the glenoid was 24°, while the post-op was 2° (p = 0.002). At 24 months of follow-up, mean CS and SSV were 61 and 70. Respect to preoperative scores, the results were statistically significant (p < 0.001). The last CT scan revealed: a complete healing of the graft in 100% of cases; graft resorption less than 25% in two patients (12.5%); glenoid retroversion of 4°. A negative statistically significant correlation was found between final CS and preoperative glenoid retroversion (0.039).

Conclusions

The present study reports the favorable outcomes of retroverted glenoid reconstruction with glenoid plates in RSA, an alternative method to address severe glenoid deficiency.

Level of evidence

Level IV, case series with no comparison group.

     

Anterior shoulder dislocation with posterior displacement of the long head of the biceps tendon. Arthrographic findings. A case report

An acute anterior dislocation of the shoulder was accompanied by disruption and posterior displacement of the long head of the biceps tendon. This prevented concentric reduction of the humeral head into the glenoid and restricted shoulder motion. The diagnosis was confirmed by arthrogram.     

Pathomorphologie der Schulterinstabilität

In cases of a traumatic anterior first-time dislocation of the shoulder, pathomorphological changes may initially occur at three different sites: at the capsule itself, at its origin or at its insertion. The typical injury is an avulsion of the labrum and the capsule from the glenoid and is called a Bankart lesion. There is a tendency to underestimate the amount of plastic deformation of the capsule and alternative injuries, such as avulsion of the capsule from the humeral head (HAGL lesion). Bony deformities at the humeral head or at the glenoid are of utmost importance for the prognosis of shoulder instability. In the dislocated position the anterior glenoid rim may notch the posterior surface of the humeral head (Hill-Sachs lesion). Bony defects of the glenoid may be caused by a fracture or due to chronic wear (fracture or erosion type). If bony defects exceed a certain size, isolated reconstruction of soft tissues does not guarantee stability of the shoulder.     

Sekundäre posttraumatische Schulterendoprothetik

Indications

Displaced proximal humerus fractures after osteosynthesis are frequently associated with complications, such as loss of reduction, displaced fragments, non-union or avascular necrosis of the humeral head. In addition, after non-operative treatment with malunion of fractures of the humeral head or in chronic shoulder dislocations, a prosthetic replacement can be necessary in order to achieve a painless shoulder function.

Choice of therapy

In these cases the choice of implant depends on the posttraumatic glenohumeral bone situation on the one hand and on the quality of the rotator cuff on the other. Especially in cases of glenoid bone loss an implanted prosthesis can be difficult to anchor, which can involve augmentation of the glenoid defect using a bone graft.

Outcome

In particular, secondary or revision arthroplasty was found in the literature to be sometimes associated with high rates of complications.

     

Osteoarticular allograft reconstruction for hill-sachs lesion in an adolescent

Glenoid and humeral head bone loss is the most common cause of failure after surgical shoulder instability stabilization. Large Hill-Sachs lesions involving >30% of the articular surface of the humeral head typically occur after neglected or locked shoulder dislocations. Such large lesions may require osteochondral allograft reconstruction or prosthetic replacement to regain shoulder stability and function.Previous reports of osteochondral allograft reconstruction have focused on adults. This article describes a case of a 16-year-old autistic boy who sustained an anterior dislocation of the right shoulder following a seizure episode. The dislocation was diagnosed 12 days later as a progressive deformity, and his parents noticed his inability to use his upper extremity. The patient had a large (30%) humeral head Hill-Sachs lesion and persistent anterior shoulder instability after initial closed reduction. He underwent an open osteochondral allograft reconstruction for the restoration of the humeral head articular surface. The sizing of the defect, matching harvest of the allograft, and perfect fit of the allograft to the defect are critical steps to ensure congruent restoration of the humeral head. The allograft was stabilized in the defect of the humeral head using cancellous screws placed from below the articular surface. Radiographs 20 months postoperatively showed complete incorporation of the osteochondral allograft. At 30 months postoperatively, his shoulder was stable and functional.