Glenoid Bone Loss Management: Alllograft€¦ · % Bone Loss = (Amount of bone loss in mm / 2 x distance from posterior glenoid rim to bare spot in mm) * 100) Bare spot as accurate

Glenoid Bone Loss Management CDR Provencher MT AOSSM Specialty Day 2013 Naval Med Center San Diego

Matthew T. Provencher, MD CDR MC USN Professor of Surgery & Orthopaedics, USUHS

Director Orthopaedic Shoulder, Knee and Sports Surgery Department of Orthopaedic Surgery, Naval Medical Center San Diego

34800 Bob Wilson Dr. Ste 112 San Diego, CA 92134 1. Potential Pitfalls in Any Shoulder Instability Repair

Glenoid bone loss – Lots of attention in recent literature

Significant Hill-Sachs lesion

Revision situation – post thermal cases

Revision situation with prior capsular insufficiency

Prior anchor placement

Error in diagnosis

Rehabilitation issues and compliance

Technical errors o Correct anchor placement o Proper capsular mobilization (HAGL) o RI Closure? o Prior thermal cases? o Adequate capsular tensioning – 1cm? o HAGL injuries

Associated injuries o SLAP, HAGL, bony deficiencies o Neurologic injury (winging!)

Boileau (JBJS 2006)4 – “Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair”

o 91 patients followed prospectively o 15.3% recurrence (36 months f/u), at 17 months post-surgery o Recurrence higher in hyperlaxity, bone loss, and number of anchors (4 or more

was good prognostic sign)

Tauber32 – “Reasons for failure after surgical repair of anterior shoulder instability” o 41 patients followed 49 months o At revision surgery – 56% with persistent bony defect, patulous capsule 22%,

laterally torn capsule 5%

Glenoid Bone Loss Management: Alllograft


2. Glenoid Bone Loss – Prevalence, Etiology, Classification, and History

Burkhart and DeBeer Arthroscopy 20005 o 21 of 194 patients with “significant” glenoid bone loss o Defined “Inverted Pear” glenoid o 61 % failure in patients with inverted pear glenoid treated arthroscopically

100 CT scans of shoulder instability patients (Sugaya JBJS 2003)28 o 50% osseous Bankart lesion (1 large -27%, 27 med– 11%, 22 small – 3%)

Location of glenoid defect – mean at 4:17 o’clock (antero-inferior). (Saito AJSM 2005)27 o Parallel to long axis of glenoid o At higher % defects, the line of bone loss changes somewhat to slightly more

oblique

Griffith – AJR 20089 o More bone loss in recurrent instability o 145 patients with CT scan –

0-10% bone loss – 51% 10-20% bone loss – 37% 20-25% bone loss – 6% >25% bone loss – 6%

Glenoid bone loss higher rate of failure after stabilization procedures (Bigliani AJSM 1998)2

o Amount and type of bone loss quantified and classified into 3 types o 25 patients with glenoid rim lesions were classified o 22 / 24 shoulder with good stability at 30 months (88%) o Type I (16 pts); Type II (5 pts); Type IIIA (3 pts); Type IIIB (1 pt)

Burkhart and DeBeer, Arthroscopy 20005 - 194 athletes (101 rugby players) with arthroscopic Bankart Repair - 3 metallic suture anchors on average - 10.8% recurrence rate (21 total; 14 redislocations, 7 subluxations) - 173 without bony defects 4% recurrence - 21 with bony defects 67% recurrence - Contact athletes with bone defect 89% recurrence

- Significant bone defect = “Inverted pear glenoid” (not precisely measured, but as viewed from the anterosuperior portal the inferior diameter of the glenoid was smaller than the superior diameter”)17

Conclusion: Patients with significant bone defects, especially contact athletes are not candidates for arthroscopic repair

- Approximately 11% had significant glenoid bone defects


Patient History – low threshold for glenoid bone loss suspicion especially if (Piasecki, Provencher, Romeo et al; JAAOS 2009, in print):

o Long-term instability o Multiple dislocations o Mechanical clunk o Multiple reductions/ER reductions. o Progressive ease of dislocation and also reduction o History of self reduction (Not MDI) o Instability symptoms in mid-ranges of motion

3. Glenoid Bone Loss - Biomechanics

- Biomechanics: Itoi (JBJS 2000)15 – glenoid defects anteroinferiorly of >21% (mean 6.8 mm) causes persistent instability and limit ER after Bankart repair.

Sequential osteotomies ABER: Capsular structures held ABIR: Shoulder Up to 21% bone loss subluxated easily

- However, he demonstrated stability in ABER position due to competent capsular constraints. ABD&IR allowed to subluxate. CONCLUSION: Glenoid Defects >21% (approx 6.8 mm) may cause continued instability and limit ER after Bankart Repair (especially with capsular repair) Clinical Applicability: What is also inferred from Itoi’s work is that in up to a 21% bone defect, the capsular restraints will potentially be enough for stability when adequately repaired


Biomechanical Implications of Glenoid Bone Loss

↓ glenohumeral stability

↓ articular arc length = ↓ balance stability angle

↓ articular arc depth = ↓ concavity-compression stability

↑ glenohumeral contact pressures

↑ surgical failure rates (if not addressed appropriately)

↑ shear forces seen by isolated soft-tissue repairs = ↑ failure rates

4. Quantifying Glenoid Bone Loss Radiographic:

- Axillary view and also true AP of the glenohumeral joint may offer “hint” of subtle bone loss - Easier to see large losses. Body habitus, radiographic quality (axillary esp.), and other factors may inhibit determination of amount of glenoid bone loss by plain radiography

- Special axillary views that are helpful:

Apical oblique – Garth JBJS 19848 West Point View – Roukis and Feagin CORR 197226

-Itoi AJSM 200314: cadaveric glenoids utilized to create glenoid bone defects, and West Point and CT scan compared.

- 21% defect was 18.6% on the West Point - 21% defect was 50% of width on single slice (axial)

Sugaya et al. JBJS 200328 - 100 instability shoulder with CT scan studied

- Defect measured based on CT scan and digitized the inferior 2/3rds of the glenoid - The inferior 2/3rds of glenoid is consistently a “circle”11, 13


- Gold Standard to assess bone loss is by 3D CT scan, with humeral head digitally subtracted - Loss of circle bone comprises amount (percent) of bone loss



- Conclusions – Radiographic Measurements:

1. CT scan remains the gold standard for determination of bone loss 2. Large Majority of instability patients have some form of bone loss (erosion or “attritional” versus bony fragment)

Arthroscopic Measurements

Lo, Parten & Burkhart, “The inverted pear glenoid: An indicator of significant glenoid bone loss” Arthroscopy 200417

Cadaveric study and clinical study (53 patients) to evaluate amount of glenoid bone loss arthroscopically

termed “inverted pear glenoid” when viewed from anterosuperior portal. Correlated with cadaveric measurements Based upon measurements from the glenoid bare spot7

Distance from bare spot

In Vivo (mm) “X”

Cadavers (mm) “X”

Posterior glenoid rim

11.4

12.3

Anterior glenoid rim (normal) Inverted pear

10.3 vs. 3.3 mm (inverted pear) = 35%

12.1

Easy formula to calculate – with scope from anterosuperior portal:


% Bone Loss = (Amount of bone loss in mm / 2 x distance from posterior glenoid rim to bare spot in mm) * 100)

Bare spot as accurate reference is disputed: - Kralinger Arthroscopy 200616 - 20 embalmed cadavers – - Bare spot to anterior rim: 10.9 mm - Bare spot to posterior rim: 13.7 mm - May not be accurate determination of bone loss - Criticism - embalmed specimens may not accurately represent the bare spot

Griffith – AJR 20089

Bone loss between CT scan and arthroscopy show high correlation

Provencher – AJSM 200823 – Arthroscopic measurement errors - No difference in a clinical bone loss model (bone loss parallel to the long axis of

the glenoid) in measurement with: 2 different posterior portals Different trajectories

5. Glenoid Bone Loss – Treatment Algorithm *** Clinical suspicion remains paramount! ****

- Low threshold to obtain advanced imaging to assess for glenoid bone loss with the following (not all inclusive):

- Prior failed instability procedure - Multiple prior instability events, multiple subluxations or dislocations - Long history, chronic instability (> 6 months?) - Trivial trauma for first instability event (glenoid hypoplasia) - Bilateral history of shoulder instability - Plain film suggestion of bony glenoid deficiency

- Best to know ahead of time your operative plan, as surgical technique is based upon the amount of glenoid bone loss

6. Glenoid Bone Loss – Treatment Options

Based upon preoperative or intraoperative determination of bone loss

Key: How to obtain a successful stabilization procedure with minimal losses of motion

Nonoperative

Smaller fragments

Lower demand individuals


Maquieira (JBJS-Br 2007) found no redislocations in 14 patients with >5 mm bone fracture treated nonoperatively

Arthroscopic Repair

Glenoid bone loss less than 20 to 25%

Can be successful

Provencher et al (2007)19– results better with incorporation of bony fragment

Sugaya et al (2006)29, 30 – bony lesion, if repaired with arthroscopic techniques can heal to more normal/near anatomic position

Reconstitutes the bone loss of glenoid

Better if more acute injury

Less predictable if attritional/erosion loss

Open Repair without Bony Augmentation

Described for open capsulolabral repair to address bone loss Probably similar to arthroscopic repairs, potentially higher success? 0/14 recurrences in open repair procedure20

Open repairs – screw fixation of acute fractures31

Bone Augmentation Procedures

Glenoid bone loss of potentially any amount

Especially in loss >20-25%

Variety of options and techniques

Arthroscopic bone grafts

Arthroscopic coracoid transfer o Open bone grafts

Coracoid transfer o Bristow – “tip” of coracoid o Latarjet – larger piece of coracoid o Management of the “Latarjet” – can be confusing o Many “ways” to do a Latarjet

o Subscapularis tendon management Split longitudinal Complete take-down

o Conjoint tendon management Leave on as a “sling” Reattach to remnant coracoid

o Orientation of the coracoid Lateral edge (traditional) or inferior edge

(Burkhart) as the glenoid face With INFerior edge as glenoid face:

More bone to work with – up to 14mm


Better congruity of the glenoid and humerus (REF)

“Fits better” – Figure:

Iliac crest bone graft o Large inner table shelf o Haaker10 (Mil Medicine); Warner33 o Can be utilized for very large defects

Allograft o Concerns of noncontained graft incorporation in the past o Femoral head allografts have been shown to heal (1996 data)12 o May be option in future? Have to demonstrate efficacy, healing,

and capsular management

New advancement - Allograft Option Recently Described:

- Fresh osteochondral distal tibia allograft as an alternative to fresh glenoid - Prior difficulty obtaining fresh glenoid allograft (contamination and harvest issues) - Investigated novel application of distal tibia to the glenoid (REF)

Exceptional fit and near perfect radius of curvature to the humeral head and glenoid (REF)

Figure: Fresh – weight bearing bone; excellent corticocancellous fixation As of Sept 2009, have performed 7 cases, most over 10 months out, all with

documented healing on CT scan (axial images) and full return to military duties Still “investigational” as prior allograft concerns are evident, however, this

represents new fresh allograft technique to the glenoid.

No prior graft processing (radiation, sterilization)

Excellent weight-bearing bone

Basic science and clinical evidence that the bone “fits” well


Glenoid Mapping: Distal Tibia Mapping Ghodadra, Provencher et al. 2009

Distal Tibia Glenoid From: Ghodadra, Provencher, Romeo et al. 2009

Near identical radius of curvature, cartilage thickness, and surface area replaced From: Ghodadra, Provencher et al. 2009

Other bone grafts

J-bone graft from Iliac Crest to glenoid1

Femoral head allograft (AJSM 2009)


References:

1. Auffarth A, Schauer J, Matis N, Kofler B, Hitzl W, Resch H. The J-bone graft for anatomical glenoid

reconstruction in recurrent posttraumatic anterior shoulder dislocation. The American journal of sports medicine. Apr 1 2008;36(4):638-647.

2. Bigliani LU, Newton PM, Steinmann SP, Connor PM, McLlveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. Jan-Feb 1998;26(1):41-45.

3. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: the "belt-and-suspenders" operative technique and preliminary results. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. Jun 1 2007;23(6):593-601.

4. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. The Journal of bone and joint surgery American volume. Aug 1 2006;88(8):1755-1763.

5. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. Oct 2000;16(7):677-694.

6. Burkhart SS, De Beer JF, Barth JR, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. Oct 1 2007;23(10):1033-1041.

7. Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy. May-Jun 2002;18(5):488-491.

8. Garth WP, Slappey CE, Ochs CW. Roentgenographic demonstration of instability of the shoulder: the apical oblique projection. A technical note. The Journal of bone and joint surgery American volume. Dec 1 1984;66(9):1450-1453.

9. Griffith JF, Antonio GE, Yung PS, et al. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR American journal of roentgenology. May 1 2008;190(5):1247-1254.

10. Haaker RG, Eickhoff U, Klammer HL. Intraarticular autogenous bone grafting in recurrent shoulder dislocations. Military medicine. Mar 1 1993;158(3):164-169.

11. Huijsmans PE, Haen PS, Kidd M, Dhert WJ, van der Hulst VP, Willems WJ. Quantification of a glenoid defect with three-dimensional computed tomography and magnetic resonance imaging: a cadaveric study. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. Jan 1 2007;16(6):803-809.

12. Hutchinson JW, Neumann L, Wallace WA. Bone buttress operation for recurrent anterior shoulder dislocation in epilepsy. The Journal of bone and joint surgery British volume. Nov 1 1995;77(6):928-932.

13. Huysmans PE, Haen PS, Kidd M, Dhert WJ, Willems JW. The shape of the inferior part of the glenoid: a cadaveric study. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. Jan 1 2006;15(6):759-763.

14. Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med. Jan-Feb 2003;31(1):112-118.

15. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. Jan 2000;82(1):35-46.


16. Kralinger F, Aigner F, Longato S, Rieger M, Wambacher M. Is the bare spot a consistent landmark for shoulder arthroscopy? A study of 20 embalmed glenoids with 3-dimensional computed tomographic reconstruction. Arthroscopy. Apr 2006;22(4):428-432.

17. Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. Feb 2004;20(2):169-174.

18. Mologne TS, Michio H, Zhao K, An KN, Provencher MT. The Addition of Rotator Interval Closure after Arthroscopic Repair of either Anterior or Posterior Shoulder Instability: Impact of Glenohumeral Translation and Range of Motion. American Journal of Sports Medicine. 2008;TBD(In Print).

19. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic Stabilization in Patients With an Inverted Pear Glenoid: Results in Patients With Bone Loss of the Anterior Glenoid. Am J Sports Med. Mar 26 2007.

20. Pagnani MJ. Open Capsular Repair Without Bone Block for Recurrent Anterior Shoulder Instability in Patients With and Without Bony Defects of the Glenoid and/or Humeral Head. The American journal of sports medicine. Apr 30 2008.

21. Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and anterior-posterior translation. Am J Sports Med. Oct 2006;34(10):1656-1661.

22. Porcellini G, Paladini P, Campi F, Paganelli M. Long-term outcome of acute versus chronic bony Bankart lesions managed arthroscopically. The American journal of sports medicine. Dec 1 2007;35(12):2067-2072.

23. Provencher MT, Detterline AJ, Ghodadra N, et al. Measurement of glenoid bone loss: a comparison of measurement error between 45 degrees and 0 degrees bone loss models and with different posterior arthroscopy portal locations. The American journal of sports medicine. Jun 1 2008;36(6):1132-1138.

24. Provencher MT, Mologne TS, Hongo M, Zhao K, Tasto JP, An KN. Arthroscopic versus open rotator interval closure: biomechanical evaluation of stability and motion. Arthroscopy. Jun 2007;23(6):583-592.

25. Rhee YG, Lim CT. Glenoid defect associated with anterior shoulder instability: results of open Bankart repair. International orthopaedics. Oct 1 2007;31(5):629-634.

26. Roukos J, Feagin J. Modified axillary roentgenogram: A useful adjunct in the diagnosis of recurrent instability of the shoulder. Clin Orthop Relat Res. 1972;82:84-86.

27. Saito H, Itoi E, Sugaya H, Minagawa H, Yamamoto N, Tuoheti Y. Location of the glenoid defect in shoulders with recurrent anterior dislocation. Am J Sports Med. Jun 2005;33(6):889-893.

28. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. May 2003;85-A(5):878-884.

29. Sugaya H, Moriishi J, Kanisawa I, Tsuchiya A. Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability. J Bone Joint Surg Am. Aug 2005;87(8):1752-1760.

30. Sugaya H, Moriishi J, Kanisawa I, Tsuchiya A. Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability. Surgical technique. The Journal of bone and joint surgery American volume. Sep 1 2006;88 Suppl 1 Pt 2:159-169.

31. Tauber M, Moursy M, Eppel M, Koller H, Resch H. Arthroscopic screw fixation of large anterior glenoid fractures. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. Mar 1 2008;16(3):326-332.

32. Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. May-Jun 2004;13(3):279-285.

33. Warner JJ, Gill TJ, O'hollerhan JD, Pathare N, Millett PJ. Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. The American journal of sports medicine. Feb 1 2006;34(2):205-212.

34. Yamamoto N, Itoi E, Tuoheti Y, et al. Effect of rotator interval closure on glenohumeral stability and motion: a cadaveric study. J Shoulder Elbow Surg. Nov-Dec 2006;15(6):750-758.


- Additional Reading and Resources

1. Piasecki D, Ghodadra N, Bach BR, Romeo AA, Provencher MT. The diagnosis and management of glenoid bone loss in recurrent anterior shoulder instability. Journal of the American Academy of Orthopaedic Surgeons 2009; 17(8):482-493.

2. Seroyer S, Nho S, Provencher MT, Romeo AA. Four-Quadrant Approach to Capsulolabral Repair: An Arthroscopic Roadmap to The Glenoid. Arthroscopy (In Press).

3. Detterline AJ, Provencher MT, Ghodadra N, Bach BR, Verma N, Romeo AA. A novel measurement of anterior glenoid bone loss; correlation measurements of the inverted pear glenoid. Arthroscopy 2009. In print.

4. Grumet R, Ghodadra N, Romeo AA, Bach BR Jr., Provencher MT. Recurrent shoulder instability with

glenoid bone loss. Orthopaedic Knowledge Update, Online 7(9); http://www5.aaos.org/oko/description.cfm?topic=SHO032. Accessed September 2, 2009.

5. Provencher MT, Ghodadra N, LeClere L, Bach BR, Solomon DJ, Romeo AA. Anatomical osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy 2009;25(4)446-452

6. Kang RW, Frank R, Nho S, Ghodadra N, Verma NN, Romeo AA, Provencher MT. Complications Associated with Anterior Shoulder Instability Repair. Arthroscopy 2009; 25(8):909-920.

7. Provencher MT, Detterline AJ, Ghodadra N, Romeo AA, Bach BR, Cole BJ, Verma N. Measurement of

glenoid bone loss: A comparison of measurement error between 45 and 0 bone loss models and with different posterior arthroscopy portal locations. American Journal of Sports Medicine 2008; 36(6):1132-1138.

8. Schroder DT, Provencher MT, Mologne TS, Cox JS. The modified Bristow Procedure for anterior

shoulder instability: 26-year outcomes in Naval Academy Midshipmen. American Journal of Sports Medicine 2006;34(5):778-786.

9. Mologne TS, Provencher MT, Menzel KA, Bell SJ. Arthroscopic stabilization of patients with glenoid bone deficiency. American Journal of Sports Medicine 2007;35(8)1276-1283.

10. Provencher MT, Ghodadra N, Romeo AA, Solomon DJ. Characterization of anterior shoulder instability. AAOS Annual Meeting Multimedia Presentation, New Orleans, LA, 2010.

11. Ghodadra N, Grumet R, Mologne TS, Bach BR, Romeo AA, Provencher MT. The diagnosis and management of glenoid bone loss. AAOS Annual Meeting Scientific Exhibit, New Orleans, LA, 2010.

12. Provencher MT. Pearls and pitfall in the surgical treatment of recurrent instability of the shoulder – techniques and bailouts. AAOS Annual Meeting Multimedia Presentation, Las Vegas, NV 2009.

13. Provencher MT, Solomon DJ. The diagnosis, measurement, and treatment of shoulder instability in

patients with glenoid bone loss. AAOS Annual Meeting Multimedia Presentation, Las Vegas, NV 2009.

http://www5.aaos.org/oko/description.cfm?topic=SHO032


Documents

Glenoid Bone Loss Management: Alllograft€¦ · % Bone Loss = (Amount of bone loss in mm / 2 x distance from posterior glenoid rim to bare spot in mm) * 100) Bare spot as accurate