Iliac bone grafting of the intact glenoid improves shoulder stability with optimal graft positioning

doi:10.1016/j.jse.2014.09.018

Journal of Shoulder and Elbow Surgery

Volume 24, Issue 4, April 2015, Pages 533-540

https://doi.org/10.1016/j.jse.2014.09.018 Get rights and content

Background

Bone grafting procedures are increasingly popular for the treatment of anterior shoulder instability. In patients with a high risk of recurrence, open coracoid transplantation is preferred but can be technically demanding. Free bone graft glenoid augmentation may be an alternative strategy for high-risk patients without significant glenoid bone loss. This biomechanical cadaveric study assessed the stabilizing effect of free iliac crest bone grafting of the intact glenoid and the importance of sagittal graft position.

Methods

Eight fresh frozen cadaveric shoulders were tested. The bone graft was fixed on the glenoid neck at 3 sagittal positions (50%, 75%, and 100% below the glenoid equator). Displacement and reaction force were monitored with a custom device while translating the humeral head over the glenoid surface in both anterior and anteroinferior direction.

Results

Peak force (PF) increased significantly from the standard labral repair to the grafted conditions in both anterior (14.7 ± 5.5 N vs 27.3 ± 6.9 N) and anteroinferior translation (22.0 ± 5.3 N vs 29.3 ± 6.9 N). PF was significantly higher for the grafts at the 50% and 75% positions compared with the grafts 100% below the equator with anterior translation. Anteroinferior translation resulted in significantly higher values for the 100% and 75% positions compared with the 50% position.

Conclusions

This biomechanical study confirms improved anterior glenohumeral stability after iliac crest bone graft augmentation of the anterior glenoid. The results also demonstrate the importance of bone graft position in the sagittal plane, with the ideal position determined by the direction of dislocation.

Section snippets

Materials and methods

Eight fresh frozen cadaveric shoulders (4 right and 4 left shoulders) from 4 male and 4 female donors, and 3 pairs of fresh frozen iliac crests from 3 male donors were obtained from our institutional anatomic bequest program. The mean age at the time of death was 66.5 years (range, 54-87 years) for the shoulder donors and 55.4 years (range, 51-61 years) for the iliac crest donors. We excluded specimens from donors with a history of shoulder instability and specimens with radiologic or clinical

Results

Anterior translation of the humeral head resulted in a mean ± standard deviation PF of 14.9 ± 3.9 N for the intact condition, 12.0 ± 5.0 N for the Bankart lesion condition, 14.7 ± 5.5 N for the labral repair condition, and 27.3 ± 6.9 N for the bone graft-augmented condition. PF significantly decreased after the creation of the Bankart lesion (P = .048) and significantly increased between the repaired and the grafted condition (P = .028). The mean ETD was 118.4 ± 35.8 mJ in the intact condition,

Discussion

This biomechanical study confirms the positive stabilizing effect of free iliac crest graft augmentation of the intact glenoid, with a significantly higher PF and ETD in the bone-grafted conditions compared with standard labral repair. In addition, the vertical position of the graft had an important effect on stability. Bone grafts centered on the equator and 75% below the equator displayed a significantly greater PF and ETD than grafts positioned 100% below the equator when translating in the

Conclusions

This biomechanical study confirms improved anterior and anteroinferior glenohumeral stability after free iliac crest bone graft augmentation of the anterior glenoid. The results also demonstrate the importance of bone graft position in the sagittal plane, with significant differences in glenohumeral stability, depending on the direction of dislocation. Further research is needed to explore the intra-articular kinematics of the unstable shoulder and to determine specific clinical scenarios where

Acknowledgment

We thank Shaun G. Heath, from Mayo Clinic Department of Anatomy, for his support and assistance.

Disclaimer

This research was partly funded by the Belgian Society for Orthopeadics and Traumatology (Belgische Vereniging voor Orthopedie en Traumatologie), and partly by the More Foundation of AZ Monica, Deurne, Belgium. Sarah F. Eby was supported by a National Institutes of Health grant from the National Institute of General Medical Sciences (T32-GM-65841).

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other

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The management of recurrent anterior shoulder dislocations with massive glenoid bone defects typically involves arthroscopic intervention. Autologous iliac bone grafting with double-row elastic fixation reportedly yields excellent outcomes. In this article, we introduce a specialized technique for iliac bone grafting that uses double-row elastic fixation and double antirotating anchors. Implementation of this technique prevents the occurrence of iliac graft rotation.
Open Versus Arthroscopic Latarjet Procedure for the Treatment of Chronic Anterior Glenohumeral Instability With Glenoid Bone Loss
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For all patients after both arthroscopic and open Latarjet surgery, there was no statistically significant difference between the mediolateral position of the graft and the functional results. Biomechanical studies have shown that the best graft position to prevent anterior dislocation of the humeral head is at 4 o’clock5,23,38 with more superior placement leading to recurrence.39,40 and more inferior positioning with a higher risk of non-union.41
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Between December 2009 to January 2015, all patients older than 18 years of age who were treated with a Latarjet procedure for chronic osseous anterior instability by a single surgeon were included in this retrospective cohort study. Range of motion, strength, Rowe, Western Ontario Shoulder Instability Index (WOSI) scores, and pain level according to the Visual Analog Scale (VAS) were evaluated. In addition, postoperative computed tomography scans were used to evaluate the position of the transferred coracoid, screw orientation, and degree of graft resorption.
Forty-eight patients with a mean age of 29.5 years (range 19-59 years) who underwent open (n = 15; group OL) and arthroscopic (n = 33; group AL) Latarjet procedures were included in the study. The mean follow-up was 30.5 months (range 24-50 months). At final follow-up there were significant differences in the mean internal rotation loss (mean of 9° vs 14°, P = .044) favoring open surgery and WOSI (P = .017) scores favoring arthroscopic. No significant differences were detected in mean forward flexion loss (P = .918), external rotation loss (P = .883), Rowe (P = .429), and Visual Analog Scale (P = .208) scores. Mean superoinferior position of the coracoid bone graft was found between the 1:55 and 4:49 o’clock positions (2:05-4:55 for group OL; 1:51-4:47 for group AL) in en-face views. The grafts were placed laterally in 13% (group OL) and 9% (group AL) of patients. The mean α angles of the screws were 11° and 19.2°, respectively (P = .004). The mean graft resorption rates were 21% and 34% (P = .087), respectively.
Good functional results were obtained after both open and arthroscopic Latarjet procedures for the treatment of chronic osseous anterior shoulder instability. Comparative analysis showed small but statistically significant differences in internal rotation loss favoring open and in WOSI favoring arthroscopic techniques. All measured radiographic parameters were similar with the exception of a significant difference in alpha angle with improved screw position in open surgery. OL and AL techniques provide similar clinical and radiographic outcomes.
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The cortical inner table of the ilium effectively extends the articular glenoid arc and restores static stability.72 Willemot et al73 demonstrated that a graft positioned 50%-75% below the glenoid equator is ideal in a biomechanical model. Recently, arthroscopic-assisted techniques have also been described.74-76
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Failed arthroscopic soft-tissue stabilization and anterior glenoid bone loss have been shown to have high failure rates after standard arthroscopic stabilization techniques. For patients with recurrent glenohumeral instability, the Bristow-Latarjet procedure is currently the standard of care. It is predominantly performed through an open deltopectoral approach but has recently been described arthroscopically. Although providing excellent clinical outcomes, the Bristow-Latarjet procedure violates the subscapularis muscle, has a steep learning curve with a high complication rate, and permanently changes the anterior shoulder anatomy, making any future revision surgery more challenging. We describe a technique for arthroscopic anterior glenoid augmentation using iliac crest bone graft that does not violate the subscapularis, by creating a far anterior-medial portal that traverses superior to the subscapularis and lateral to the conjoint tendon. The graft is passed through this portal and secured with rigid fixation. An arthroscopic Bankart capsulolabral repair is then performed, making the graft extra-articular. A remplissage can easily be added as indicated, allowing this procedure to arthroscopically address all 3 major components of structural instability: glenoid bone loss, capsulolabral tearing, and humeral bone loss.
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: This study was approved by the Mayo Clinic Biospecimen Subcommittee (Investigational Review Board 12-009195).

: This research was partly funded by the Belgian Society for Orthopeadics and Traumatology (BVOT, Belgische Vereniging voor Orthopedie en Traumatologie), and partly by the More Foundation of AZ Monica, Deurne, Belgium. SFE was supported by a NIH grant from the National Institute of General Medical Sciences (T32 GM 65841).

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Basic ScienceIliac bone grafting of the intact glenoid improves shoulder stability with optimal graft positioning

Background

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgment

Disclaimer

J Shoulder Elbow Surg

Orthop Traumatol Surg Res

Arthroscopy

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthrosc Tech

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Biomech

J Shoulder Elbow Surg

J Biomech

Arthroscopy

Rev Chir Orthop Reparatrice Appar Mot

Arthroscopy

Arthrosc Tech

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder

J Bone Joint Am

The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation

J Bone Joint Surg Br

Recurrent or habitual dislocation of the shoulder-joint

Br Med J

Basic Science
Iliac bone grafting of the intact glenoid improves shoulder stability with optimal graft positioning