Joint-preserving treatment options for irreparable rotator cuff tears

An irreparable cuff tear is defined as the inability to achieve direct repair of native tendon to the great tuberosity despite intra- and extra-articular release of the remaining tissue. Three distinct anatomic patterns are identified: posterosuperior cuff tears which involve the supraspinatus, infraspinatus and teres minor; anterosuperior tears which involve the supraspinatus and subscapularis; and global tears which comprise both. Subacromial debridement and tenotomy or tenodesis of the long head of the biceps are proposed for older patients with a functional but very painful shoulder. Partial repair—particularly the infraspinatus and the subscapularis—is indicated for young patients if the muscle is still trophic with a fatty infiltration less than 3. It can be combined with a tendon transfer. In irreparable posterosuperior tears, latissimus dorsi or lower trapezius transfer has been reported to improve active elevation and external rotation. In anterosuperior cuff tears, pectoralis major or latissimus transfer has been used. If the lack of external rotation is isolated with good active forward elevation, the L’Episcopo procedure is the procedure of choice. New techniques with a short follow-up have been proposed recently: implantation of a balloon-shaped, biodegradable spacer in the subacromial space to maintain the position of the humeral head and to facilitate deltoid action; capsular superior reconstruction with a fascia lata or an artificial graft implanted between the superior glenoid rim and the great tuberosity to reproduce the natural capsule of the supra- and infraspinatus and to stabilize the humeral head.     

Mechanical properties of the long‐head of the biceps tendon are altered in the presence of rotator cuff tears in a rat model

Rotator cuff tears are disabling conditions that result in changes in joint loading and functional deficiencies. Clinically, damage to the long‐head of the biceps tendon has been found in conjunction with rotator cuff tears, and this damage is thought to increase with increasing tear size. Despite its importance, controversy exists regarding the optimal treatment for the biceps. An animal model of this condition would allow for controlled studies to investigate the etiology of this problem and potential treatment strategies. We created rotator cuff tears in the rat model by detaching single (supraspinatus) and multiple (supraspinatus + infraspinatus or supraspinatus + subscapularis) rotator cuff tendons and measured the mechanical properties along the length of the long‐head of the biceps tendon 4 and 8 weeks following injury. Cross‐sectional area of the biceps was increased in the presence of a single rotator cuff tendon tear (by ～150%), with a greater increase in the presence of a multiple rotator cuff tendon tear (by up to 220%). Modulus values decreased as much as 43 and 56% with one and two tendon tears, respectively. Also, multiple tendon tear conditions involving the infraspinatus in addition to the supraspinatus affected the biceps tendon more than those involving the subscapularis and supraspinatus. Finally, biceps tendon mechanical properties worsened over time in multiple rotator cuff tendon tears. Therefore, the rat model correlates well with clinical findings of biceps tendon pathology in the presence of rotator cuff tears, and can be used to evaluate etiology and treatment modalities. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:416–420, 2009     

Superior excursion of the humeral head: a diagnostic tool in rotator cuff tear surgery

Superior excursion of the humeral head on the face of the glenoid was investigated to determine whether a relationship exists between the degree of humeral head excursion and the identity of the injured tendon in a shoulder with a torn rotator cuff. Twenty-seven patients with unilateral full-thickness rotator cuff tears diagnosed by either positive arthrogram or magnetic resonance imaging were included in this study. Three groups were formed based on intraoperative findings: 10 patients had isolated supraspinatus tendon tears (group 1), 11 patients had supraspinatus and infraspinatus tears (group 2), and 6 patients had supraspinatus, infraspinatus, and subscapularis tendon tears (group 3). There was no statistically significant difference between the degree of humeral head excursion in groups 1 and 2. However, patients in group 3 had a statistically significantly higher degree of excursion of the humeral head (P < .05) when compared with groups 1 and 2. In addition, an inverse relationship between the degree of humeral head excursion and preoperative Constant scores was found. Superior excursion of the humeral head on the glenoid had a significantly higher incidence in patients with subscapularis tears, and a larger amount of excursion was present in patients who had lower preoperative Constant scores.     

Glenoid cartilage mechanical properties decrease after rotator cuff tears in a rat model

Rotator cuff repairs are commonly performed to reduce pain and restore function. Tears are also treated successfully without surgical intervention; however, the effect that a torn tendon has on the glenohumeral cartilage remains unknown. Clinically, a correlation between massive rotator cuff tears and glenohumeral arthritis has often been observed. This may be due to a disruption in the balance of forces at the shoulder, resulting in migration of the humeral head and subsequently, abnormal loading of the glenoid. Our lab previously demonstrated changes in ambulation and intact tendon mechanical properties following supraspinatus and infraspinatus rotator cuff tendon tears in a rat model. Therefore, the purpose of this study was to investigate the effects of supraspinatus and infraspinatus rotator cuff tears on the glenoid cartilage. Nine rats underwent unilateral detachment of the supraspinatus and infraspinatus tendons and were sacrificed after 4 weeks. Cartilage thickness significantly decreased in the antero‐inferior region of injured shoulders. In addition, equilibrium elastic modulus significantly decreased in the center, antero‐superior, antero‐inferior, and superior regions. These results suggest that altered loading after rotator cuff injury may lead to damage to the joint with significant pain and dysfunction. Clinically, understanding the mechanical processes involved with joint damage will allow physicians to better advise patients. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1435–1439, 2012     

Disruption of the anterior–posterior rotator cuff force balance alters joint function and leads to joint damage in a rat model

The rotator cuff assists in shoulder movement and provides dynamic stability to the glenohumeral joint. Specifically, the anterior–posterior (AP) force balance, provided by the subscapularis anteriorly and the infraspinatus and teres minor posteriorly, is critical for joint stability and concentric rotation of the humeral head on the glenoid. However, limited understanding exists of the consequences associated with disruption of the AP force balance (due to tears of both the supraspinatus and infraspinatus tendons) on joint function and joint damage. We investigated the effect of disrupting the APforce balance on joint function and joint damage in an overuse rat model. Twenty‐eight rats underwent 4 weeks of overuse to produce a tendinopathic condition and were then randomized into two surgical groups: Detachment of the supraspinatus only or detachment of the supraspinatus and infraspinatus tendons. Rats were then gradually returned to their overuse protocol. Quantitative ambulatory measures including medial/lateral, propulsion, braking, and vertical forces were significantly different between groups. Additionally, cartilage and adjacent tendon properties were significantly altered. These results identify joint imbalance as a mechanical mechanism for joint damage and demonstrate the importance of preserving rotator cuff balance when treating active cuff tear patients. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:638–644, 2014.     

Shoulder magnetic resonance imaging findings in manual wheelchair users with spinal cord injury

Objective: To investigate the prevalence of rotator cuff and long head of the biceps pathologies in manual wheelchair (MWC) users with spinal cord injury (SCI).Design: Cross-sectional study.Setting: Outpatient clinic at a tertiary medical center.Participants: Forty-four adult MWC users with SCI (36 men and 8 women) with an average age (SD) of 42 (13) years. SCI levels ranged from C6 to L1; complete and incomplete SCI.Outcome Measures: Participants’ demographic and anthropometric information, presence of shoulder pain, Wheelchair User’s Pain Index (WUSPI) scores, and magnetic resonance imaging findings of shoulder pathologies including tendinopathy, tendon tears, and muscle atrophy.Results: Fifty-nine percent of the participants reported some shoulder pain. The prevalence of any tendinopathy across the rotator cuff and the long head of biceps tendon was 98%. The prevalence of tendinopathy in the supraspinatus was 86%, infraspinatus was 91%, subscapularis was 75%, and biceps was 57%. The majority of tendinopathies had mild or moderate severity. The prevalence of any tears was 68%. The prevalence of tendon tears in the supraspinatus was 48%, infraspinatus was 36%, subscapularis was 43%, and biceps was 12%. The majority of the tears were partial-thickness tears. Participants without tendon tears were significantly younger (P < 0.001) and had been wheelchair user for a significantly shorter time (P = 0.005) than those with tendon tears.Conclusion: Mild and moderate shoulder tendinopathy and partial-thickness tendon tears were highly prevalent in MWC users with SCI. Additionally, the findings of this study suggest that strategies for monitoring shoulder pathologies in this population should not be overly reliant on patient-reported pain, but perhaps more concerned with years of wheelchair use and age.     

Thirty-six consecutive reverse shoulder arthroplasties in cuff arthropathy: our experience with the anterosuperior approach

Background

The purpose of this study was to analyze the results obtained with the anterosuperior approach with reverse shoulder arthroplasty in terms of functional recovery, pain, and stability of the implant.

Methods

In a cohort of 33 patients with cuff arthropathy, 36 consecutive reverse shoulder arthroplasties were implanted by the same surgeon, using the anterosuperior approach, saving the subscapularis tendon. Those cases were evaluated preoperatively and postoperatively after an average of 37 months on the basis of constant score, X-ray evaluation, and incidence of dislocation.

Results

The constant score increased from 30.4 points preoperatively to 68.3 points. No case of instability was observed.

Conclusions

The good functional results observed with a mean follow-up of approximately 3 years doubtlessly resulted from the correct surgical technique on the glenoid component and the preservation of the anterior wall composed of the subscapularis tendon. Analyzing literature and taking into account our experience, we can say that the anterosuperior approach has certain advantages; this approach takes advantage of the absence of the upper part of the rotator cuff to facilitate exposure of the joint that makes it particularly indicated in cuff arthropathy.     

Die subpektorale Tenodese der langen Bizepssehne bei Pathologien der langen Bizepssehne und des Pulley-Systems

Objective

The presented surgical technique aims at fixation of the long head of the biceps tendon at the proximal humerus, distal to the bicipital groove, after arthroscopic tenotomy. This preserves the length and shape of the biceps muscle belly and avoids groove tenderness.

Indications

All forms of degenerative changes of the long head of the biceps tendon, biceps instability due to pulley lesions, irreparable SLAP tears. The technique offers a cosmetically favorable outcome compared to a tenotomy.

Contraindications

Old complete tears of the long head of the biceps, significant loss of bone density due to osteoporosis, tumor or bone cysts, implants in the proximal humerus, such as intramedullary nails, stem of total shoulder replacement. The presented technique is not indicated for patients with unspecific chronic shoulder pain or if asymmetric shape of the upper arm due to distal migration of the biceps is not relevant.

Surgical technique

After arthroscopic tenotomy of the long head of the biceps tendon, a small incision at the level of the pectoralis major tendon is made to the axillary fold. The stump of the long head of the biceps tendon is tenodesed to a predrilled hole with a bioabsorbable screw.

Postoperative management

No active training of the biceps for 6?weeks, a sling for comfort is optional until healing of the wound is completed.

Results

Clinical studies of several authors have shown significant postoperative increase in all scores evaluated. Safety of the screw fixation and a low complication rate have been proven.     

Evidence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon

Background

The primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology.

Methods

We investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells.

Results

A strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions.

Conclusion

Our results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.     

Relative Fixation Strength of Rabbit Subscapularis Repair Is Comparable to Human Supraspinatus Repair at Time 0

Background

Recent evidence suggests that the rabbit subscapularis tendon may be anatomically, biomechanically, and histologically suitable to study rotator cuff pathology and repair. However, biomechanical comparisons of rotator cuff repairs in this model have not been evaluated and compared to those in human cadaveric specimens.

Questions/purposes

We quantified the biomechanical properties of the repaired rabbit subscapularis tendon after (1) single-row, (2) double-row, and (3) transosseous-equivalent rotator cuff repair techniques and compared the ratios of repairs to previously published data for human repairs.

Methods

Tensile testing was performed on 21 New Zealand White rabbit subscapularis tendon-humerus complexes for single-row repair, double-row repair, and transosseous-equivalent repair (n = 7 for each group). Video digitizing software was used to quantify deformation. Load elongation data were then used to quantify structural properties. We compared the ratios of rotator cuff repairs for the rabbit data to data from human supraspinatus repair studies previously performed in our laboratory. For our primary end points (linear stiffness, yield load, ultimate load, and energy absorbed to failure), with the numbers available, our statistical power to detect a clinically important difference (defined as 15%) was 85%.

Results

The ratios of single-row/double-row repair were 0.72, 0.73, 0.71, and 0.66 for human supraspinatus and 0.77, 0.74, 0.79, and 0.89 for rabbit subscapularis repair for linear stiffness, yield load, ultimate load, and energy absorbed to failure, respectively. The ratios of double-row/transosseous-equivalent repair were 1.0, 0.86, 0.70, and 0.41 for human supraspinatus and 1.22, 0.85, 0.76, and 0.60 for rabbit subscapularis for linear stiffness, yield load, ultimate load, and energy absorbed to failure, respectively. There were no differences comparing rabbit to human repair ratios for any parameter (p > 0.09 for all comparisons).

Conclusions

Subscapularis repairs in the rabbit at Time 0 result in comparable ratios to human supraspinatus repairs.

Clinical Relevance

The biomechanical similarities between the different types of rotator cuff repair in the rabbit subscapularis and human supraspinatus at Time 0 provide more evidence that the rabbit subscapularis may be an appropriate model to study rotator cuff repairs.     

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.     

Restoration of anterior–posterior rotator cuff force balance improves shoulder function in a rat model of chronic massive tears

The rotator cuff musculature imparts dynamic stability to the glenohumeral joint. In particular, the balance between the subscapularis anteriorly and the infraspinatus posteriorly, often referred to as the rotator cuff “force couple,” is critical for concavity compression and concentric rotation of the humeral head. Restoration of this anterior–posterior force balance after chronic, massive rotator cuff tears may allow for deltoid compensation, but no in vivo studies have quantitatively demonstrated an improvement in shoulder function. Our goal was to determine if restoring this balance of forces improves shoulder function after two‐tendon rotator cuff tears in a rat model. Forty‐eight rats underwent detachment of the supraspinatus and infraspinatus. After four weeks, rats were randomly assigned to three groups: no repair, infraspinatus repair, and two‐tendon repair. Quantitative ambulatory measures including medial/lateral forces, braking, propulsion, and step width were significantly different between the infraspinatus and no repair group and similar between the infraspinatus and two‐tendon repair groups at almost all time points. These results suggest that repairing the infraspinatus back to its insertion site without repair of the supraspinatus can improve shoulder function to a level similar to repairing both the infraspinatus and supraspinatus tendons. Clinically, a partial repair of the posterior cuff after a two‐tendon tear may be sufficient to restore adequate function. An in vivo model system for two‐tendon repair of massive rotator cuff tears is presented. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1028–1033, 2011     

Die Glenoid-Rekonstruktionsschale bei Defektarthropathie

Aim

The aim off this study was to evaluate the function of the shoulder after implantation of a glenoid reconstruction socket (EPOCA RECO^®) for cuff tear arthropathy or for instable prosthesis in combination with a rotator cuff defect.

Patients and method

From 2002–2007, a total of 35 reconstruction sockets (EPOCA RECO^®) were implanted for cuff tear arthopathy or for instable shoulder prosthesis in combination with a rotator cuff defect in 34 patients (6 men, 28 women – in a female patient implantation was performed on both sides within an interval of 8 months). A total of 23 patients (24 glenoid reconstruction sockets) were examined 2 years (range 4–60 months) postoperatively. The symptom-based classification of Loews was used to classify the cuff tear arthropathy. To evaluate the function of the shoulder, the Constant-Murley score (CM) was used. The influence of the subscapularis muscle on postoperative shoulder function was also evaluated.

Results

Implantation of the glenoid reconstruction sockets led to a highly significant increase in the CM scores. Pain was also significantly reduced. In addition, the range of motion for active abduction, internal and external rotation was improved. All patients reported they would undergo this operation again. Overall there were 5 major and 2 minor complications (complication rate 20%). All postoperative luxations of the prosthesis showed a subscapularis muscle defect. The increase of function for primary operations was higher compared to revision operations. However, no significant influence of indication on the postoperative shoulder function could be demonstrated.

Conclusion

The implantation of glenoid reconstruction sockets for cuff tear arthropathy or for instable prosthesis in combination with damage to the cuff tear leads to significant improvement of shoulder function. There is a high risk of luxation in case of a subscapularis muscle defect. Young patients should forego this kind of reconstruction.     

Lesions of the rotator cuff footprint: diagnostic performance of MR arthrography compared with arthroscopy

Background

To evaluate the diagnostic performance of magnetic resonance arthrography (MR-A) of the shoulder in the diagnosis of rotator cuff tears involving the humeral insertion of the supraspinatus and infraspinatus tendon (footprint), using arthroscopy as the reference standard.

Materials and methods

The study population included 90 consecutive patients with history and clinical diagnosis of instability of the shoulder, rotator cuff tear or posterosuperior glenoid impingement. A total of 108 MR arthrograms were performed, since 18 patients had undergone a bilateral procedure. Arthroscopy, which was performed within 45 days after MR-A, was used as the reference standard. Sensitivity, specificity, accuracy, positive and negative predictive values were then calculated.

Results

Magnetic resonance arthrography showed a sensitivity of 92 % and a specificity of 78 % for the overall detection of tears involving the rotator cuff footprint. The diagnostic accuracy was 90 %, and the positive and negative predictive values were 95 and 64 %, respectively. Ten lesions were non-classifiable on surgery, of which eight were non-classifiable on MR-A also.

Conclusions

Magnetic resonance arthrography is extremely accurate for the detection and classification of rotator cuff footprint tears. Most of these lesions are articular-sided (partial articular-sided supraspinatus tendon avulsion lesions) with predominance in younger patients and concealed type of tear (concealed interstitial delamination lesions).

     

The high frequency of superior labrum,biceps tendon,and superior rotator cuff pathologies in patients with subscapularis tears: A cohort study

Background

The purpose of this study was to assess the frequency of superior labrum anterior posterior (SLAP) lesions, long head of biceps tendon (LHBT) pathologies, and superior rotator cuff tears accompanying subscapularis tears. We hypothesised that LHBT lesions, superior rotator cuff tears, and especially SLAP lesions were very frequent with subscapularis tears.

Rotator cuff rupture

The rotator cuff is the complex of four muscles that arise from the scapula; supscapularis, supraspinatus, infraspinatus and teres minor. The long head of the biceps tendon may be considered a functional part of the rotator cuff. The rotator cuff is key structure of the shoulder which gives dynamic stability and movements. Rotator cuff tears my occur as consequence of impingement syndrome or degenerative changes. Most tears occur in the supraspinatus tendon. The patients are usually older than 40 years. On clinical examination there is weakness of abducation and external rotation of the arm. Open or arthroscopic repair should be performed in active individuals.     

Evaluation of the Effusion within Biceps Long Head Tendon Sheath Using Ultrasonography

Background

Many shoulder diseases are related to glenohumeral joint synovitis and effusion. The purpose of the present study is to detect effusion within the biceps long head tendon sheath as the sign of glenohumeral joint synovitis using ultrasonography, and to evaluate the clinical meaning of effusion within the biceps long head tendon sheath.

Methods

A consecutive series of 569 patients who underwent ultrasonography for shoulder pain were reviewed retrospectively and ultimately, 303 patients were included. The authors evaluated the incidence and amount of the effusion within the biceps long head tendon sheath on the ultrasonographic short axis view. Furthermore, the authors evaluated the correlation between the amount of effusion within the biceps long head tendon sheath and the range of motion and the functional score.

Results

The effusion within the biceps long head tendon sheath was detected in 58.42% of the patients studied: 69.23% in adhesive capsulitis, 56.69% in rotator cuff tear, 41.03% in calcific tendinitis, and 33.33% in biceps tendinitis. The average amount of the effusion within the biceps long head tendon sheath was 1.7 ± 1.6 mm, and it was measured to be the largest in adhesive capsulitis. The amount of effusion within biceps long head tendon sheath showed a moderate to high degree of correlation with the range of motion, and a low degree of correlation with the functional score and visual analogue scale for pain in each type of shoulder disease.

Conclusions

The effusion within the biceps long head tendon sheath is closely related to the range of motion and clinical scores in patients with painful shoulders. Ultrasonographic detection of the effusion within the biceps long head tendon sheath might be a simple and easy method to evaluate shoulder function.     

Arthroscopic Percutaneous Repair of Anterosuperior Rotator Cuff Tear Including Biceps Long Head: A 2-Year Follow-up

Background

To report the results of an arthroscopic percutaneous repair technique for partial-thickness tears of the anterosuperior cuff combined with a biceps lesion.

Methods

The inclusion criteria were evidence of the upper subscapularis tendon tear and an articular side partial-thickness tear of the supraspinatus tendon, degeneration of the biceps long head or degenerative superior labrum anterior-posterior, above lesions treated by arthroscopic percutaneous repair, and follow-up duration > 24 months after the operation. American Shoulder and Elbow Surgeons (ASES) score, constant score, the pain level on a visual analogue scale, ranges of motion and strength were assessed.

Results

The mean (± standard deviation) age of the 20 enrolled patients was 56.0 ± 7.7 years. The forward flexion strength increased from 26.3 ± 6.7 Nm preoperatively to 38.9 ± 5.1 Nm at final follow-up. External and internal rotation strength was also significantly increased (14.2 ± 1.7 to 19.1 ± 3.03 Nm, 12.3 ± 3.2 to 18.1 ± 2.8 Nm, respectively). Significant improvement was observed in ASES and constant scores at 3 months, 1 year and the time of final follow-up when compared with preoperative scores (p < 0.001). The mean subjective shoulder value was 86% (range, 78% to 97%).

Conclusions

The implementation of complete rotator cuff repair with concomitant tenodesis of the biceps long head using arthroscopic percutaneous repair achieved full recovery of normal rotator cuff function, maximum therapeutic efficacy, and patient satisfaction.     

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.