Management of Glenoid Bone Loss in Shoulder Instability: Where We Are in 2023.

The management of glenoid bone loss in shoulder instability can be challenging. Although shoulder instability can often be managed with arthroscopic soft-tissue procedures alone, the extent of glenoid bone loss and bipolar bone defects may require bone augmentation procedures for restoration of stability. In this setting, patient evaluation, examination, treatment options, and surgical pearls are vital. Furthermore, a treatment algorithm is established to guide both indications and the technical application of procedures including Bankart repair with remplissage, Latarjet procedure, and glenoid bone graft options. The limitations, complications, and current research pertinent to each treatment assist in guiding treatment.

The forgotten joint: quantifying the anatomy of the proximal tibiofibular joint.

PURPOSE: Limited objective data exist detailing the quantitative anatomy of the individual bundles of the proximal tibiofibular joint and their relation to surgically pertinent osseous landmarks. The purpose of this study was to qualitatively and quantitatively describe the ligamentous anatomy of the proximal tibiofibular joint and its relation to relevant bony landmarks. METHODS: Ten non-paired, fresh-frozen cadaveric knee specimens were dissected to identify the proximal tibiofibular joint ligament bundles. Pertinent bony landmarks were identified and served as reference points for the tibial and fibular attachments for each bundle. Ligament bundle footprints, lengths and orientations were measured using a 3D coordinate measuring device. RESULTS: Up to four bundles were identified anteriorly and up to three bundles posteriorly. The inferior bundle was identified anteriorly and posteriorly in 60% and 20% of the cases, respectively. For the anterior complex, the centres of the tibial attachments were a mean distance of 12.5 mm (95% CI [10.7, 14.3]) and 25.3 mm (95% CI [21.6, 29.0]) from the tibial plateau for the superior and inferior bundles, respectively. The centres of the fibular attachments were 11.3 mm (95% CI [7.4, 15.1]) and 27.0 mm (95% CI [24.0, 30.0]) from the apex of the fibular styloid for the superior and inferior bundles, respectively. For the bundles of the posterior complex, the centres of the tibial attachments were 13.4 mm (95% CI [11.6, 15.2]) and 38.8 mm (95% CI [31.0, 46.6]) distal to the tibial plateau for the superior and inferior bundles, respectively, and the centres of the fibular attachments were 8.0 mm (95% CI [5.8, 10.1]) and 29.3 mm (95% CI [25.5, 33.1]) from the apex of the fibular styloid for the superior and inferior bundles, respectively. In the coronal plane, the mean 2D angle between the medial to lateral knee joint axis and the axis passing through the centre of the proximal tibiofibular joint and the centre of the tibial plateau was 16.9° (95% CI [12.8, 21.0]). CONCLUSION: The ligament bundles of the proximal tibiofibular joint were reproducibly identified between specimens in relation to surrounding bony landmarks. Up to four bundles were identified in the anterior ligament complex and up to three in the posterior complex. Variation in bundle orientation and footprint size was observed. Based on these findings, an anatomic reconstruction can be performed using surrounding reliable landmarks.

Progressive displacement of clavicular fractures in the early postinjury period.

BACKGROUND: Historically, minimally to moderately displaced clavicular fractures have been managed nonoperatively. However, there is no clear evidence on whether clavicular fractures can progressively displace following injury and whether such displacement might influence decisions for surgery. METHODS: We retrospectively reviewed data on 56 patients who received operative treatment for clavicular fractures at our institution from February 2002 to February 2007 and identified those patients who were initially managed nonoperatively based on radiographic evaluation (<2 cm displacement) and then subsequently went on to meet operative indications (≥2 cm displacement) as a result of progressive displacement. Standardized radiographic measurements for horizontal shortening (medial-lateral displacement) and vertical translation (cephalad-caudad displacement) were developed and used. RESULTS: Fifteen patients with clavicle fractures initially displaced less than 2 cm and treated nonoperatively underwent later surgery because of progressive displacement (14 diaphyseal and 1 lateral). Radiographs performed during the injury workup and at a mean of 14.8 days postinjury demonstrated that progressive deformity had taken place. Ten of 15 patients (67%) displayed progressive horizontal shortening. Average change in horizontal shortening between that of the injury radiographs and the repeat radiographs in this group was 14.3 mm (5.9-29 mm). Thirteen of 15 patients (87%) displayed progressive vertical translation. Eight of 15 patients (53%) displayed both progressive horizontal shortening and vertical translation. CONCLUSION: We have demonstrated that a significant proportion of clavicle fractures (27% of our operative cases over a 5-year period) are minimally displaced at presentation, but are unstable and demonstrate progressive deformity during the first few weeks after injury. Because of this experience, we recommend close monitoring of nonoperatively managed clavicular fractures in the early postinjury period. A prudent policy is to obtain serial radiographic evaluation for 3 weeks, even for initially, minimally displaced clavicle fractures.

A reliable radiographic measurement technique for extra-articular scapular fractures.

BACKGROUND: Currently, neither well-defined nor standardized measurement techniques exist for assessing deformity of extra-articular scapular fractures. To properly evaluate these injuries, compare observations across studies, and make clinical decisions, a validated measurement protocol for evaluating scapular fractures is needed. QUESTIONS/PURPOSES: We describe techniques to quantitatively characterize extra-articular scapular fracture deformity; evaluate the reliability of these characterizations in plain film radiographs and CT scans; and determine potential differences in the characterization of the deformity between the two imaging modalities. PATIENTS AND METHODS: We evaluated injury radiographs and three-dimensional CT images of 45 patients with extra-articular scapular fracture. Techniques for measuring medial/lateral displacement, angulation, translation, glenopolar angle, and glenoid version were established and utilized in two trials, performed 6 weeks apart, by three observers. We determined descriptive statistics for each measurement parameter. RESULTS: Interobserver reliability based upon interclass correlation coefficients ranged from 0.36 to 0.76 for radiographs and from 0.48 to 0.87 for three-dimensional CT. Intraobserver reliability using Pearson r coefficient ranged from 0.60 to 0.75 for radiographs and 0.64 to 0.89 for three-dimensional CT. Both individual and pooled measurements for angulation and glenopolar angle were higher on three-dimensional CT versus radiographs. CONCLUSIONS: Our data suggest three-dimensional CT is more reliable than plain radiography in the assessment of scapula fracture displacement. Therefore, we believe this modality should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies. LEVEL OF EVIDENCE: Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Comparison of Postoperative Anatomy Using Anatomic Total Shoulder Arthroplasty Versus Soft-Tissue Balancing Total Shoulder Arthroplasty.

BACKGROUND: The importance of anatomic reconstruction of the proximal humerus on shoulder biomechanics and kinematics after anatomic total shoulder replacement (aTSR) has been highlighted by a number of investigations. The humeral head designs of current-generation shoulder arthroplasty emphasize either anatomic or soft-tissue balancing total shoulder arthroplasty (sbTSR) philosophies. The purpose of this study was to compare the postoperative anatomy of TSR systems used to treat primary glenohumeral osteoarthritis. METHODS: This was a matched cohort study of 60 patients treated with either press-fit aTSR or sbTSR by two shoulder surgeons. The analysis of postoperative true AP radiographs was performed to calculate multiple representative anatomic parameters of the TSR. RESULTS: A significant difference was observed in the average measurements between the sbTSR and aTSR designs about the humeral head center offset (5.2 ± 0.4 mm versus 3.9 ± 0.3 mm; P = 0.02), implant-humeral shaft angle (0.3 ± 0.3 varus versus 1.7 ± 0.3 valgus, P < 0.001), and humeral head to tuberosity height (8.8 ± 0.4 mm versus 6.2 ± 0.4, P < 0.001), respectively. No significant difference was observed in the average measurements between the two systems' designs regarding the head-shaft angle (133.4° ± 0.8° versus 135.0° ± 1.0°, P = 0.16) and the relation of humeral head to lateral humeral cortex (0.15 ± 0.6 mm inside the lateral cortex versus 0.19 ± 0.6 outside the lateral cortex; P = 0.69), respectively. CONCLUSIONS: Despite differing design philosophies of these systems, and some notable differences, the absolute differences between the measured anatomic parameters were small and not likely clinically relevant. Anatomic and soft-tissue balancing humeral arthroplasty implants can both reliably reconstruct proximal humeral anatomy.

Progressive displacement of scapula fractures.

BACKGROUND: Historically, minimally to moderately displaced extra-articular scapula fractures have been managed conservatively. It is possible that operative criteria could be met for a given patient if progressive displacement were to occur. We hypothesize that certain displaced scapula fractures progressively displace in early postinjury period. METHODS: A consecutive series of 49 patients with operatively managed extra-articular scapula fractures was evaluated to identify patients initially managed nonoperatively and later operatively because of progressive displacement. Three examiners then independently analyzed radiographs to measure the displacement between injury films and the films used to determine operative indications. A standard method for radiographic measurement of deformity was developed and was used to determine the degree of deformity at injury and at follow-up time when operative care was decided. RESULTS: Eight patients met inclusion criteria. All sustained a specific extra-articular transverse fracture pattern Arbeitsgemeinschaft für Osteosynthefragen/Orthopaedic Trauma Association (AO/OTA) Type A3, Ada-Miller Type IIC). Mean time interval between injury and repeat radiographs was 11.3 (range, 9-15) days. All patients displayed progressive displacement in at least one of the four measured parameters (medial/lateral displacement, angulation, translation, and glenopolar angle), according to the three independent examiners. Predominantly "good" inter- and intraobserver scores were achieved. CONCLUSIONS: Certain extra-articular scapula fractures may displace in postinjury period. We recommend close monitoring of conservatively treated fractures to screen for progressive displacement.

Vulnerable neurovasculature with a posterior approach to the scapula.

Anatomic studies have described areas where there is no direct threat of inadvertent suprascapular nerve injury; however, these studies did not describe danger zones during open reduction and internal fixation of the fractured scapula. We therefore sought to define the topographic distribution in which these vulnerable structures most commonly are found, thus establishing danger zones. Twenty-four nonpaired cadaveric specimens were dissected. The infraspinatus and teres minor musculature were elevated off the posterior scapula body to reveal critical areas where the suprascapular neurovasculature and circumflex scapular artery were vulnerable to injury. We established radial coordinates to determine this relation to osseous landmarks. The mean distance from the spinoglenoid notch to the inferior border of the danger zone was 2.4 cm (range, 1.2-3.8 cm). The mean distance from the medial extent of the scapular spine to the medial border of the danger zone was 4.3 cm (range, 3.0-6.7 cm). The entry of the ascending branch of the circumflex scapular artery was located at the lateral border 5.6 cm (range, 4.5-7.0 cm) inferior to the spinoglenoid notch. These danger zones can aid the surgeon in determining the risk for suprascapular nerve injury, specifically with scapula fractures involving the spinoglenoid notch and/or lateral border.

A Transosseous Bone Bridge Repair for Posterior Horn Meniscal Root Tears During Anterior Cruciate Ligament Reconstruction.

Meniscal root tears occur in isolation or concurrently with ligamentous knee injury and cause significantly altered knee mechanics with the loss of normal meniscus hoop stress. This loss of normal meniscus function can result in abnormal knee kinematics and, subsequently, more rapid degenerative changes of the knee articular surface. In the setting of anterior cruciate ligament tear, the posterolateral meniscus root is most commonly damaged. Several techniques exist for meniscus root repair; however, none have been shown to be clearly superior. We present a safe, effective, and reproducible arthroscopic transtibial technique for posterior horn lateral meniscal root tears.

Arthroscopic Pancapsular Shift With Labral Repair for Multidirectional Instability of the Shoulder.

Initial treatment of shoulder multidirectional instability (MDI) consists of nonoperative modalities of physical therapy and rehabilitation; if this fails, surgical treatment can become necessary. MDI of the shoulder can be challenging to manage in individuals who fail conservative management. Historically, surgical treatment for MDI has been open capsular plication; however, arthroscopic capsular plication has now become the standard of care, with outcomes similar to the open procedure. The purpose of this article and Video 1 is to describe our arthroscopic technique for pancapsular shift with labral repair.

Arthroscopic Hip Labral Augmentation Technique With Iliotibial Band Graft.

The importance of the acetabular labrum has been well documented for the function and overall health of the hip joint. Several biomechanical studies have shown the sealing effect of the acetabular labrum. In the past decade, labral repair procedures have gained increased attention, with the literature suggesting that the outcomes after hip arthroscopy are directly related to labral preservation. However, a primary labral repair can be challenging in cases of hypoplastic, ossified, or complex and irreparable labral tears in which there is insufficient tissue to perform a primary repair. For these cases, labral reconstruction becomes a viable option with good outcomes at short-term and midterm follow-up. A subset of these patients may show viable remnants of the labral circumferential fibers but, because of the low tissue volume, these remnant fibers are unable to maintain the suction seal. In this situation, a labral augmentation may be a viable alternative to labral reconstruction while preserving as much native labral tissue as possible. The purpose of this Technical Note is to describe an arthroscopic hip labral augmentation technique using iliotibial band autograft or allograft.

Arthroscopic Remplissage and Open Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability With Severe Bipolar Bone Loss.

Bipolar bone loss in patients with anterior glenohumeral instability is challenging to treat. The goal of the treatment is to restore stability by ensuring that the humeral head remains within the glenoid vault. This can be achieved either with the combination of an arthroscopic Bankart procedure and remplissage (glenoid bone loss <25%), or with a Latarjet procedure (glenoid bone loss >25%). In cases with more severe bipolar bone loss of both the glenoid and the humeral head, the conventional approach has been to lengthen the articular arc of the glenoid and to ignore the Hill-Sachs lesion. However, it has recently been shown that this can still lead to an "off-track" situation with persistent shoulder instability from engagement of the Hill-Sachs on the anterior glenoid. In these cases, the combination of a Hill-Sachs remplissage and the Latarjet procedure can be effective in preventing persistent instability. In this technical note, the surgical technique of an arthroscopic Hill-Sachs remplissage in combination with an open Latarjet procedure is presented.

Surgical management of isolated greater tuberosity fractures of the proximal humerus.

Because the greater tuberosity is the insertion site of the posterior superior rotator cuff, fractures can have a substantial impact on functional outcome. Isolated fractures should not inadvertently be trivialized. Thorough patient evaluation is required to make an appropriate treatment decision. In most cases surgical management is considered when there is displacement of 5 mm or greater. Although reduction of displaced greater tuberosity fractures has traditionally been performed with open techniques, arthroscopic techniques are now available. The most reliable techniques of fixation of the greater tuberosity incorporate the rotator cuff tendon bone junction rather than direct bone-to-bone fixation.

Surgical management of isolated acromion fractures: technical tricks and clinical experience.

SUMMARY: Acromion fractures of the scapula are rare and most often occur with concomitant fractures of the ipsilateral glenoid, neck and body of the scapula as sequelae of high-energy injuries. Indications for operative management include symptomatic nonunion, displaced fractures, or acromion fractures associated with other lesions of the superior shoulder suspensory complex. Less displaced acromion fractures resulting in decreased subacromial space may also warrant surgery. Although surgical indications have been reported, the literature regarding surgical approaches and fixation techniques for management of these factures is limited. Acromion fractures can generally be addressed with a direct posterior approach using either tension band or low-profile plating in combination with cortical lag screws to obtain a stable construct. This technique is both effective in achieving fracture union and safe to the patient. When associated with a more complex fracture of the glenoid and/or scapula body, the surgical approach and fixation strategy should be dictated by the optimal approach to other displaced elements of a scapula fracture. The purpose of this study was to describe a step-wise approach to the surgical management of isolated acromion fractures, describe surgical tips and techniques, and to present the early clinical outcomes in 13 patients after surgical treatment with this approach.

Surgical management of coracoid fractures: technical tricks and clinical experience.

The coracoid process plays a pivotal role in the foundation of the coracoacromial arch and in cases of displaced fractures; surgical management may be warranted to avoid functional compromise or impingement. A direct approach through Langer's lines allows for easy exposure and direct visualization for an anatomic reduction of simple fractures through the shaft or base of the coracoid. An anterior approach for fractures that extend into the superior glenoid fossa allows for direct exposure to obtain an anatomic articular reduction and indirect reduction of the coracoid fracture. In cases where a complex glenoid or scapula neck/body fracture is being addressed simultaneously either a posterior Judet approach can be used with an indirect reduction method or a separate anterior approach must be combined to address it if not in continuity with the superior scapular segment. Implant selection, primarily interfragmentary screws or a buttress plate, should be based on the size of the fragment, the degree of comminution, and the degree of articular involvement to ensure adequate stabilization. The purpose of this manuscript was to describe a stepwise approach to the surgical management of displaced coracoid fractures, describe surgical tips and techniques, and to present the clinical outcomes in 22 patients after surgical treatment with this approach.

Radiographic follow-up of 84 operatively treated scapula neck and body fractures.

BACKGROUND: Certain scapula fractures may warrant surgical management to restore shoulder anatomy and promote optimal function. The purpose of this study is to determine the early radiographic follow-up of open reduction internal fixation (ORIF) for displaced, scapular fractures involving the glenoid neck and body. METHODS: Eighty-four patients with a scapula body or neck fracture (with or without articular involvement) underwent ORIF between 2002 and 2010 at a single level I trauma centre. This study represents a retrospective review of data prospectively collected into a dedicated scapula fracture database. All patients met at least one of the following operative criteria: ≥20 mm medial/lateral (M/L) displacement (lateral border offset), ≥45° of angular deformity on a scapular-Y X-ray, the combination of angulation ≥30° plus M/L displacement ≥15 mm, double disruptions of the superior shoulder suspensory complex both displaced ≥10 mm, glenopolar angle (GPA) ≤22° and open fractures. Eighty-eight percent (74/84) had sufficient follow-up defined as at least 6 months. Measured outcomes included rates of scapula union and malunion, as well as surgical complications and re-operations. RESULTS: All fractures were caused by high-energy trauma with 24 (29%) resulting from motor-vehicle collisions. Associated injuries occurred in 94% of patients, most commonly involving the chest (70%) and ipsilateral shoulder girdle (43%). Forty-eight patients had M/L displacement as an operative indication with a mean displacement of 25.7 mm (range=20-40). Thirty-eight (45%) had ≥2 operative indications. A single surgeon performed ORIF in all patients using a posterior approach. Five patients also required an anterior (deltopectoral) approach. The fixation strategy included lateral and vertebral border stabilisation with dynamic compression and reconstruction plates, respectively. Union was achieved in all cases. There were three cases of malunion based on a GPA difference >10° from the uninjured shoulder. Re-operations included removal of hardware (seven patients) and manipulation under anaesthesia (three patients). There were no infections or wound dehiscence. CONCLUSIONS: ORIF for displaced scapula fractures is a relatively safe and effective procedure for restoration of anatomy and promotion of union. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Surgical and functional outcomes after operative management of complex and displaced intra-articular glenoid fractures.

BACKGROUND: Operative treatment is indicated for displaced fractures of the glenoid fossa. However, little is known regarding functional outcomes in these patients. This study assesses surgical and functional results after treatment of displaced, high-energy, complex, intra-articular glenoid fractures. METHODS: Thirty-three patients with displaced intra-articular fractures of the glenoid were treated surgically between 2002 and 2009. The indications for operative treatment included articular fracture gap or step-off of ≥ 4 mm. Twenty-five patients also had extra-articular scapular involvement. A posterior approach was utilized in twenty-one patients, an anterior approach in seven, and a combined approach in five. Functional outcomes, including Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores, shoulder motion and strength, and return to work and/or activities, were obtained for thirty patients (91%). RESULTS: At a mean follow-up of twenty-seven months (range, twelve to seventy-three months), all patients had radiographic union of the fracture. The mean DASH score was 10.8 (range, 0 to 42). All mean SF-36 subscores were comparable with those of the normal population. Twenty-six patients (87%) were pain-free at the time of follow-up, and four had mild pain with prolonged activity. Twenty-seven (90%) of thirty patients returned to their preinjury level of work and/or activities. CONCLUSIONS: Our data suggest that surgical treatment for complex, displaced intra-articular glenoid fractures with or without involvement of the scapular neck and body can be associated with good functional outcomes and a low complication rate.

Anterior pelvic external fixator versus subcutaneous internal fixator in the treatment of anterior ring pelvic fractures.

OBJECTIVES: To compare the short-term results of anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) applied subcutaneously in the context of surgical treatment of pelvic ring injuries. DESIGN: A single center retrospective chart review. SETTING: A level 1 trauma center. METHODS: A consecutive series of 48 patients who underwent surgical stabilization of their anterior pelvic ring (24 utilizing APIF and 24 utilizing APEF) by 2 surgeons at a single hospital were studied. The choice to use either APEF or APIF was left up to each surgeon, the indications for use are the same. Data collected included surgical or postoperative complications including infection, implant failure, reoperation, documented surgical site pain persisting to clinical follow-up visits, and radiographic union. Measurements on inlet and outlet pelvic radiographs were made immediately postoperation and at all follow-up clinic visits to determine whether there were differences in maintaining pelvic fracture reduction. Statistical analysis was performed to evaluate significant differences between the 2 groups with regard to each of these variables. RESULTS: The APIF group was found to have a significantly lower incidence of wound complication (P < 0.05) and a lower occurrence of associated morbidity events as compared with the APEF group. In addition, the APIF group was found to have a significantly lower rate of surgical site pain persisting through all clinical follow-up intervals (P = 0.05). There was no difference between the 2 groups in terms of maintenance of pelvic reduction in the early postoperative phase or at final follow-up. No other significant differences were observed between the 2 groups. CONCLUSIONS: The present study, which was based on our initial experience with the subcutaneous anterior pelvic fixator, demonstrated encouraging clinical outcomes in terms of a lower wound complication rate and associated morbidity, and surgical site symptoms, although maintaining equivalent reduction. These findings suggest that further analysis of this technique is warranted to determine if it can be definitively recommended for general use. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.