Editorial Commentary: Button Fixation for Glenoid Bone Grafting Results in Less Graft Resorption Compared to Screws.

Iliac crest bone grafting is conducted in cases of anteroinferior shoulder instability with substantial bone loss of the glenoid rim to reconstruct the glenoid concavity and its stabilizing function. The technique is more than 100 years old, and it evolved to include graft fixation with metal screws. The disadvantages of metal screw fixation include risk of screw migration, loosening, and breakage, as well as irritation and injury to the surrounding osseous and soft tissue structures (e.g., humeral cartilage and subscapularis muscle). With the implementation of arthroscopic techniques, new graft fixation techniques were introduced, including absorbable or biologic screws, buttons, interconnected suture anchors, and bone cerclage techniques. Recent research shows button fixation is a successful alternative to screw fixation. In addition, buttons show less graft resorption and related pain.

[Treatment strategies for traumatic anterior shoulder dislocation]. / Therapiestrategien bei traumatischer ventraler Schultererstluxation.

Anterior glenohumeral instability is the most frequent type of shoulder instability. This is often associated with labral and osseous lesions leading to recurrent instability. A detailed medical history, a physical examination and targeted diagnostic imaging are necessary to assess possible pathological soft tissue alterations as well as bony lesions of the humeral head and the glenoid bone. Early surgical treatment has been shown to reduce the risk of recurrence, especially in young active athletes, and can avoid secondary damage. Shoulder dislocations in older patients also require a detailed assessment and selection of treatment as persisting pain and limitation of movement can occur due to rotator cuff lesions and nerve injuries. The purpose of this article is to provide an overview of the currently available evidence and results regarding diagnostic considerations and conservative vs. surgical treatment and time to return to sport after treatment of a primary anterior shoulder dislocation.

Patient education on subacromial impingement syndrome : Reliability and educational quality of content available on Google and YouTube.

OBJECTIVE: The purpose of this study was to assess the reliability and educational quality of content available on Google and YouTube regarding subacromial impingement syndrome (SAIS). METHODS: Google and YouTube were queried for English and German results on SAIS using the search terms "shoulder impingement" and the German equivalent "Schulter Impingement". The analysis was restricted to the first 30 results of each query performed. Number of views and likes as well as upload source and length of content were recorded. Each result was evaluated by two independent reviewers using the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-5) to assess reliability and the DISCERN score (score range, 16-80) and a SAIS-specific score (SAISS, score range, 0-100) to evaluate educational content. RESULTS: The 58 websites found on Google and 48 videos found on YouTube were included in the analysis. The average number of views per video was 220,180 ± 415,966. The average text length was 1375 ± 997 words and the average video duration 456 ± 318 s. The upload sources were mostly non-physician based (74.1% of Google results and 79.2% of YouTube videos). Overall, there were poor results in reliability and educational quality, with sources from doctors having a significantly higher mean reliability measured in the JAMA score (p < 0.001) and educational quality in DISCERN (p < 0.001) and SAISS (p = 0.021). There was no significant difference between German and English results but texts performed significantly better than videos in terms of reliability (p = 0.002) and educational quality (p < 0.001). CONCLUSION: Information on SAIS found on Google and YouTube is of low reliability and quality. Therefore, orthopedic health practitioners and healthcare providers should inform patients that this source of information may be unreliable and make efforts to provide patients with higher quality alternatives. LEVEL OF EVIDENCE: IV, case series.

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up.

PURPOSE: To investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability. METHODS: Seventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed. RESULTS: Fourteen patients [mean age 31.1 (range 18-50) years] were available after a follow-up period of 78.7 (range 60-110) months. The SSV averaged 87 (range 65-100) %, CS 94 (range 83-100) points, RS 89 (range 30-100) points, WD 87 (range 25-100) points, and WOSI 70 (range 47-87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a significant increase of the glenoid index from preoperative 0.8 ± 0.04 (range 0.7-0.8) to 1.0 ± 0.11 (range 0.8-1.2) at the final follow-up (p < 0.01). CONCLUSION: Arthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting technique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid configuration was observed. LEVEL OF EVIDENCE: IV.

The Biomechanical Effect of Bone Grafting and Bone Graft Remodeling in Patients With Anterior Shoulder Instability.

BACKGROUND: Individual constitutional differences in glenoid shape and bone remodeling require a patient-specific and longitudinal approach to evaluate the biomechanical effects of glenoid bone grafting in patients with anterior shoulder instability. PURPOSE: To quantify the longitudinal, in vivo, biomechanical effects of bone grafting, bone graft remodeling, and glenoid shape in patients with anterior shoulder instability by means of patient-specific finite element models. STUDY DESIGN: Descriptive laboratory study. METHODS: In total, 25 shoulders of 24 patients with anterior shoulder instability and anterior glenoid bone loss underwent an arthroscopic iliac crest bone graft transfer (ICBGT) procedure with either autologous or allogenic bone. Patient-specific finite element simulations based on preoperative, postoperative, and follow-up computed tomography scans were used to quantify the bone-mediated stability ratio (SR) and the distance to dislocation. Additionally, the relationship between glenoid morphological parameters and the SR was assessed. RESULTS: The ICBGT procedure significantly increased the SR and distance to dislocation in the 2-, 3-, and 4-o'clock directions immediately after the surgical intervention (P < .01) in both the autograft and the allograft groups. Although the SR and distance to dislocation decreased subsequently, autografts showed long-term effects on SR and dislocation distance in the 3-o'clock direction (P < .01) and on SR in the 4-o'clock direction (P < .01). Allografts showed no significant effect on SR and dislocation distance in long-term follow-up (P > .05). Overall, glenoid retroversion as well as cavity depth predicted stability in all 4 dislocation directions, with glenoid cavity depth showing the highest correlation coefficients (R = 0.71, 0.8, 0.73, and 0.7 for 2-, 3-, 4-, and 5-o'clock, respectively). CONCLUSION: The autologous ICBGT procedure biomechanically improved anterior shoulder stability in long-term follow-up, whereas the use of allografts did not show any bone-mediated biomechanical effect at follow-up due to resorption. Furthermore, in addition to measurements of defect extent, the glenoid depth and version seem to be useful parameters to determine the biomechanical effect and need for glenoid bone grafting in patients with shoulder instability. CLINICAL RELEVANCE: This study proposes the use of autologous bone grafts for a successful long-term stabilization effect. Additionally, this study proposes additional glenoid morphological measures to predict shoulder stability.

Massive graft resorption after iliac crest allograft reconstruction for glenoid bone loss in recurrent anterior shoulder instability.

INTRODUCTION: Donor site morbidity constitutes the most prevalent source of complications during anatomic glenoid reconstruction. Therefore, the aim of this study was to evaluate the clinical and radiologic results of arthroscopic anatomic glenoid reconstruction using an allogenic, tricortical iliac crest bone graft for glenoid bone loss in recurrent anterior shoulder instability. MATERIALS AND METHODS: Ten patients [one female/nine male, mean age 31.9 years (range, 26-40)] underwent allogenic iliac crest bone grafting and were evaluated clinically [range of motion, subscapularis tests, apprehension sign, Constant score (CS), Rowe score (RS), Walch-Duplay score (WD), Western Ontario Shoulder Instability Index (WOSI), Subjective Shoulder Value (SSV)] and radiographically [3-dimensional computed tomography (CT) scans]. RESULTS: After 23.2 months, the CS averaged 90 points (range, 84-98), RS 83 points (range, 50-100), WD 81 points (range, 50-100), WOSI 72% (range, 41-86) and the SSV 83% (range, 70-95). All patients showed a free range of motion and intact subscapularis muscle function. The apprehension sign was positive in three patients (30%) with a recurrent subluxation in one patient (10%). The glenoid surface area increased significantly from 84.4% (range, 73.5-92.1) preoperatively to 118.4% (range, 105.6-131.2) after surgery, while the glenoid defect was significantly reduced from 16.2% (range, 9.2-26.5) to 0.6% (range, 0-1.6). One year postoperative, total resorption of the allografts was observed with a glenoid surface area of 86.6% (range, 76.4-98.0) and corresponding increase of the glenoid defect to 14.0% (range, 2.9-23.6). CONCLUSION: Arthroscopic glenoid reconstruction using an iliac crest bone allograft achieves satisfactory clinical results and glenohumeral stability during a short-term follow-up. However, this procedure was not observed to accomplish an anatomic reconstruction of the glenoid concavity due to excessive graft resorption. LEVEL OF EVIDENCE: Level IV, case series, therapeutic study.

Autologous chondrocyte implantation for treatment of focal articular cartilage defects of the humeral head.

BACKGROUND: Autologous chondrocyte implantation (ACI) constitutes an established treatment option for cartilage defects of the knee joint. Experience in the shoulder, however, is limited, and the management of cartilage defects remains a challenge. The purpose of this study was to evaluate the results after ACI with 3-dimensional spheroids of human autologous matrix-associated chondrocytes in the shoulder. METHODS: Seven male patients (median age, 42.8 years [range, 18-55 years]) underwent ACI for symptomatic focal grade IV cartilage lesions of the humeral head by an open or arthroscopic approach. Clinical parameters (range of motion, visual analog scale score, Subjective Shoulder Value, Constant score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score) and osteoarthritis grades were assessed. Arthroscopic re-evaluation was additionally performed in 5 patients. RESULTS: After a median follow-up period of 32 months (range, 22-58 months), the median Subjective Shoulder Value was 95% (range, 70%-100%) compared with 60% (range, 30%-60%) preoperatively, the visual analog scale score was 0 at rest and was a median of 0 (range, 0-2) during exercise, the median Constant score was 95 points (range, 80-100 points), and the median American Shoulder and Elbow Surgeons score was 97 points (range, 90-100 points). The median preoperative size of the cartilage lesion was 3 cm2 (range, 2.3-4.5 cm2). Arthroscopically, complete coverage of the cartilage defect was observed in 4 cases whereas a circumferential residual defect of 0.25 cm2 was found in 1 patient. Grade I osteoarthritis (Samilson and Prieto classification) was observed in 2 cases. One patient had postoperative adhesive capsulitis and required revision surgery. CONCLUSION: ACI using 3-dimensional spheroids of human autologous matrix-associated chondrocytes for treatment of grade IV articular cartilage lesions of the humeral head achieves satisfactory clinical results during a short- to mid-term follow-up period and leads to successful defect coverage with only minor radiologic degenerative changes. In this case series, ACI proved to constitute a viable treatment in the shoulder joint. However, in consideration of the 2-stage surgical design and the cost intensiveness of this procedure, the indication is restricted to young and active symptomatic patients in our practice.

The Effect of Scapula Tilt and Best-Fit Circle Placement When Measuring Glenoid Bone Loss in Shoulder Instability Patients.

PURPOSE: To analyze the effect of lack of standardization on the reliability of current measurement techniques for glenoid bone loss in clinical practice. METHODS: Ten consecutive patients with anterior glenoid bone loss due to recurrent anterior shoulder instability and available computed tomographic (CT) scans of the affected shoulder were included in this study. One hundred seventy 3-dimensional en-face view images of the 10 glenoids with up to 20° degrees of tilt in the anterior, posterior, superior, and inferior direction were rendered. Three independent observers first identified the en-face view images and subsequently performed measurements of the defect surface and diameter as well as the glenoid surface and diameter on all 170 images. Measurements were completed based on the conventional best-fit circle technique using the edge of the visible glenoid bone as reference and additionally based on the so-called spoon technique, which places the best-fit circle on the edge of the visible glenoid concavity. RESULTS: The overall agreement regarding en-face view image selection between the observers was 30% (K-alpha = 0.10, 95% confidence interval 0.02-0.22). Tilt of the en-face view in any direction resulted in significant alterations of all 4 measurement parameters as well as the relative defect area and diameter (P < .05). The conventional and the spoon techniques rendered significantly different results regarding all 4 measurement parameters as well as the relative defect area (P < .05). CONCLUSION: Impreciseness of scapula positioning for creation of an en-face view of the glenoid as well as varying best-fit circle placement significantly alter glenoid defect size measurement results. CLINICAL RELEVANCE: Because the glenoid defect size plays an important role in the choice of treatment for anterior shoulder instability, measurement techniques need to be as precise as possible.

Arthroscopic Glenoid Reconstruction for Chronic Anteroinferior Shoulder Instability Using a Tricortical Iliac Crest Bone Graft.

INTRODUCTION: Arthroscopic glenoid reconstruction using a tricortical iliac crest bone graft is performed to anatomically reconstruct the glenoid and reestablish glenohumeral stability in patients with chronic anteroinferior shoulder instability and substantial osseous defects1-3. STEP 1 PATIENT POSITIONING: Place the patient in the lateral decubitus position and prepare the arm and ipsilateral iliac crest. STEP 2 DIAGNOSTIC ARTHROSCOPY AND PORTAL PLACEMENT: Perform a diagnostic arthroscopy via the posterior portal and establish an anteroinferior, an anterosuperior, and a deep anteroinferior portal. STEP 3 CAPSULOLABRAL COMPLEX RELEASE AND SCAPULAR NECK PREPARATION: Depending on the pathology and morphology of the defect, release the capsulolabral complex from the scapular neck and prepare the glenoid rim and scapular neck with a motorized burr to ensure adequate osseous healing. STEP 4 HARVESTING AND PREPARATION OF THE ILIAC CREST BONE BLOCK: Harvest an autologous tricortical iliac crest bone block from the ipsilateral side and contour it appropriately for an anatomic reconstruction of the glenoid. STEP 5 GRAFT INSERTION AND POSITIONING: Enlarge the passage for the graft through the rotator interval, insert the bone block, and position it anatomically at the scapular neck. STEP 6 GRAFT FIXATION: With the aid of a drill sleeve, temporarily stabilize the graft using Kirschner wires and then definitively attach it to the scapular neck using 2 Bio-Compression screws. STEP 7 CAPSULOLABRAL REPAIR: Reattach the capsulolabral complex to the original glenoid, inferior and superior to the bone block, using 2 knotless suture anchors to complete the anatomic reconstruction of the glenoid. STEP 8 REHABILITATION AND POSTOPERATIVE TREATMENT: Immobilize the arm for 6 weeks postoperatively and limit flexion and external rotation during this time period. RESULTS: Fifteen patients with a mean age of 31.4 years (range, 17 to 49 years) with anteroinferior glenohumeral instability and substantial glenoid defects underwent arthroscopic iliac crest bone-grafting and were prospectively evaluated for an average period of 20.6 months (range, 12 to 65 months)12.