An anatomic, computed tomographic assessment of the coracoid process with special reference to the congruent-arc latarjet procedure.

PURPOSE: The purpose of this study was to determine the dimensions of the coracoid and to compare the radius of curvature (ROC) of the intact glenoid to the ROC of the coracoid undersurface, as oriented in the congruent-arc Latarjet procedure. The ROC of the coracoid undersurface was also compared with various glenoid bone loss scenarios. METHODS: Thirty-four computed tomography-based 3-dimensional models of the shoulder were examined by use of commercially available software. The mean dimensions of the coracoid were determined, and the ROC was calculated for the coracoid undersurface, the intact glenoid, and 20%, 35%, and 50% anterior glenoid bone loss scenarios. Intra-rater and inter-rater statistics were calculated. RESULTS: The mean length, width, and thickness of the coracoid were 16.8 mm (SD, 2.5 mm), 15.0 mm (SD, 2.2 mm), and 10.5 mm (SD, 1.7 mm), respectively. The mean ROC values were 13.6 mm (SD, 3.4 mm) for the coracoid, 13.8 mm (SD, 2.1 mm) for the intact glenoid, 27.6 mm (SD, 5.3 mm) for 20% anterior glenoid bone loss, 30.5 mm (SD, 5.2 mm) for 35% bone loss, and 33.3 mm (SD, 5.2 mm) for 50% bone loss. The coracoid ROC was not significantly different from the intact glenoid (P = .75); however, it was significantly less (P < .01) when compared with all glenoid bone loss scenarios. Intra-rater reliability and inter-rater reliability were good or excellent. A coracoid oriented in the congruent-arc manner can reconstitute a significantly greater glenoid bone defect than a coracoid oriented in the classic manner (P < .001). CONCLUSIONS: This image-based anatomic study found that the ROC of the coracoid undersurface matches the ROC of the intact anterior glenoid articular margin. In conditions with anterior glenoid bony deficiency, the radii of curvature differ significantly at the graft-native glenoid interface; however, the coracoid graft placed in the congruent-arc manner reconstitutes the ROC of the missing anterior glenoid rim. In addition, orienting the coracoid in the congruent-arc manner can reconstitute a greater glenoid bone defect than a coracoid placed in the original manner as described by Latarjet. CLINICAL RELEVANCE: The congruent-arc Latarjet procedure, a modification of the original procedure, is truly congruent in relation to the intact anterior glenoid rim. In addition, the congruent-arc modification can reconstitute a greater glenoid bone defect when compared with the original Latarjet procedure.

Humeral head bone defects: remplissage, allograft, and arthroplasty.

The Hill-Sachs lesion is a well-known entity that threatens recurrent instability, but the treatment options are multiple and the surgical indications remain undefined. The evidence for each operative technique is limited to retrospective reviews and small case series without controls. The decision of which technique to use resides with the surgeon. Older, osteopenic patients, especially those with underlying arthritis and large defects, should be managed with complete humeral resurfacing. Humeralplasty is best used in younger patients with good quality bone in an acute setting with small- to moderate-sized bone defects. Partial resurfacing and remplissage are best used with small to moderate lesions, and both require further study. Allograft humeral reconstruction is an established technique for patients with moderate to large defects, and is best applied to nonosteopenic bone. Surgeons must be able to recognize the presence of humeral bone loss via specialized radiographs or cross-sectional imaging and understand its implications. The techniques to manage humeral bone loss are evolving and further biomechanical and clinical studies are required to define the indications and treatment algorithms.

Fatal knee dislocation in a morbidly obese Jehovah's Witness. A case report.

We describe a case of a morbidly obese Jehovah's Witness who sustained a popliteal artery and vein transection after a spontaneous knee dislocation. Following surgical repair, the patient fatally deteriorated, while blood products had to be withheld according to the patient's preoperative request.