Combined shoulder techniques effective for glenoid bone loss, complex instability

The treatment of glenoid bone loss and also hypoplasia requires understanding the bony anatomy, using an array of surgical techniques.

Issue: Issue 4 2012

GENEVA — To treat complex shoulder bone loss and instability, surgeons should rely on their knowledge base for successful outcomes rather than on evidence-based medicine alone, according to a shoulder surgeon from Oslo.

Perspective from Radovan Mihelic, MD

“In really complex cases like this, you cannot rely on performed studies alone. You need to combine techniques and always try to find the best solution,” Tom Clement Ludvigsen, MD, said in a keynote lecture at the European Society of Sports Traumatology, Knee Surgery and Arthroscopy Congress 2012, here. “You need really a large toolbox to take care of these patients and must combine the tools that you have.”

“In this situation, extensive knowledge of anatomy and function is critical,” he said.

$An extensive Hill-Sachs fracture and anterior glenoid bone loss$

Shown is an extensive Hill-Sachs fracture and anterior glenoid bone loss in a patient with seizures.

Images: Ludvigsen TC

Differing amounts of bone loss in shoulder instability cases require variations in the procedures typically used, Ludvigsen said. He uses an open Latarjet procedure or arthroscopic Bankart repairs in the absence of bone loss.

“We have to calculate if there is bone loss or not. If there is no bone loss, we do a normal arthroscopic Bankart [procedure], or an open Latarjet if the soft tissue is not good. The decision is made at arthroscopy,” Ludvigsen said.

For moderate bone loss, he uses a Bankart or combined Bankart and Remplissage procedure with bone grafting. However, extensive bone loss in the presence of Bankart and/or Hill-Sachs lesions requires an open Latarjet technique and placing iliac crest bone graft to fill the defect.

“In cases like this, it is useful to do a combined procedure where we take bone graft from the iliac crest that we shape to fit … Usually we shave … well into the Hill-Sachs defect and [perform] a modified Latarjet procedure at the glenoid defect,” he said.

Latarjet surgery for the shoulder has a low 3% recurrence rate and is supported in the literature by studies with long-term results, according to Ludvigsen. However, despite his success with this surgery, he said Latarjet procedures have a slightly increased rate of osteoarthritis in long-term follow-up studies and some loss of external rotation postoperatively.

The patient was treated with a combined Latarjet procedure and transfer of iliac crest bone

The patient with seizures was treated with a combined Latarjet procedure and transfer of iliac crest bone to the Hill-Sachs defect.

An open Scott osteotomy of the neck of the scapula and a modified Eden-Hubinette was used to treat instability due to glenoid hypoplasia.

A combined arthroscopic procedure has been useful in Ludvigsen’s hands and has not led to osteoarthritis, he said. “It is tolerated well and has excellent stability.”

For rarer conditions and increased instability and pain, such as glenoid hypoplasia, Ludvigsen recommends a posterior Bankart procedure, using a subanterior arthroscopic approach in mild cases. More severe or recurrent instability combined with glenoid hypoplasia may be resolved with an open osteotomy of the neck of the scapula. Glenoid fracture and dislocation were reported with arthroscopic osteotomies for hypoplasia, he said.

Regardless of treatment preference, following evidence-based medicine only is not enough in these rare cases, Ludvigsen said. Furthermore, more level 4 studies and related expert opinions are needed in the absence of studies with large patient cohorts, he said.

“We talk about evidence-based medicine. That is very good, but it is not everything, especially not in rare cases like this,” Ludvigsen said.

He told Orthopaedics Today Europe, “When treating complex shoulder instability, it is essential to have the ability to combine open and arthroscopic techniques. We therefore have to educate our young fellows also in open shoulder surgery to become true experts in the field.” – by Jeff Craven

Reference:

Ludvigsen TC. Complex instability problems related to bony deformities. Paper #KN25-5055. Presented at the European Society of Sports Traumatology, Knee Surgery and Arthroscopy Congress 2012. May 2-5. Geneva.

For more information:

Tom Clement Ludvigsen, MD, can be reached at the Department of Orthopaedic Surgery, Ulleval Hospital and Oslo University, Kirkeveien 166, 0407, Oslo, Norway; email: t.c.ludvigsen@ioks.uio.no.
Disclosure: Ludvigsen has no relevant financial disclosures.

Perspective

Radovan Mihelic, MD

The result of multiple shoulder dislocations is a bony defect on the humerus or anterior glenoid rim. In decision-making for the treatment strategy, it is important to know the size and location of the defect. The Hill-Sachs lesion is present in 80% to 90% of all recurrent dislocations, according to studies by Itoi and colleagues and by Kaar and colleagues. A lesion involving 16% to 25% of humeral head size requires a bone block procedure.

Yamamto and colleagues reconstructed the “glenoid track” on the humeral head, showing the contact area between humerus and glenoid. If the position and size of a Hill-Sachs lesion is medial to the glenoid track, there is a danger of engagement. Different methods have been used to determine the size of bony defect on the anterior glenoid rim, but multiplanar 3D CT reconstructions have proved to be the most accurate, according to studies by d’Elia, Magarelli and Provencher.

The glenoid is pear-shaped, but Huysmans and colleagues showed the inferior part can be imaged as a circle. In a damaged shoulder, the defect can present as a missing area to the ideal circle compared to the opposite healthy shoulder. There is still no clear consensus, however, of the critical glenoid defect size which requires a bone block procedure, which is 15% to 25% of the glenoid, according to Provencher, Sugaya, Taverna and colleagues.

Itoi and colleagues stated in their recent study that using the “missing area” is not accurate and we should consider the defect length or width. They noted critical sizes are 20% of glenoid length and 25% of glenoid width. But if we have a defect on both the humerus and glenoid, which occurs often, then 10% to 20% of the glenoid defect requires a bone block technique. Knowing the precise bone defect size and position can lead to correct surgical planning, but an arthroscopic Bankart procedure in the case of a glenoid bone defect can lead to failure.

References:

d'Elia G, Di Giacomo A, D'Alessandro P, Cirillo LC. Traumatic anterior glenohumeral instability: quantification of glenoid bone loss by spiral CT. Radiol Med. 2008;113(4):496-503.
Huysmans PE, Haen PS, Kidd M, et al. The shape of the inferior part of the glenoid: a cadaveric study. J Shoulder Elbow Surg. 2006;15:759-763.
Itoi H, Takayama A, Shirai Y. Radiographic evaluation of the Hill-Sachs lesion in patients with recurrent anterior shoulder instability. J Shoulder Elbow Surg. 2000;9:495-497.
Itoi E, Lee SB, Amrami KK, et al. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med. 2003;31:112-118.
Kaar SG, Fening SD, Jones MH, et al. Effect of humeral head defect size on glenohumeral stability: a cadaveric study of simulated Hill-Sachs defects. Am J Sports Med. 2010;38(3):594-599.
Magarelli N, Milano G, Sergio P, et al. Intra-observer and interobserver reliability of the Pico computed tomography method for quantification of glenoid bone defect in anterior shoulder instability. Skeletal Radiology. 2009;38:1071-1075.
Provencher MT, Bhatia S, Ghodadra NS, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92(2):133-151.
Sugaya H, Moriishi J, Dohi M, et al. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. 2003;85:878-884.
Taverna E., Golano P, Pascale V, Battistella F. An arthroscopic bone graft procedure for treating anterior-inferior glenohumeral instability. Knee Surg Sports Arthrosc. 2008;16:872-875.
Yamamoto N, Itoi E, Abe H, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of “glenoid track.” J Shoulder Elbow Surg. 2007;16:649-656.

Radovan Mihelic, MD

University Orthopaedic Clinic Lovran

Lovran, Croatia

Disclosures: Mihelic has no relevant financial disclosures.