Aleksandra Sibilska1*, Adam Kosim2, Marcin Krzyżanowski2, Gabriela Motyl1, Adam Kwapisz3, Łęgosz Paweł1, Sławomir Struzik1
1Department of Orthopedics and Traumatology, Medical University of Warsaw, Poland
2Department of Orthopedics Street Anne’s Regional Hospital for Trauma Surgery in Warsaw, Poland
3Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Poland
*Correspondence author: Aleksandra Sibilska, Department of Orthopedics and Traumatology, Medical University of Warsaw, Poland; Email: [email protected]
Published Date: 13-05-2024
Copyright© 2024 by Sibilska A, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Recurrent shoulder instability is known to be a challenge in terms of the success rate of surgical stabilization of the shoulder joint. According to the latest literature the choice of the glenohumeral stabilization surgical treatment is guided by the degree of bone loss. Among the techniques dedicated to significant glenoid bone loss, one will find many already reported, but each has its drawbacks. As we observe currently popular techniques, we conclude that we should continue to look for techniques or some modifications to those already available that are laden with as few complications as possible. In 2019, a new technique called bone block cerclage has been described. It is a new approach, using when metal implants are not used while providing benefits such as maintenance and integrity and function of structures like coracobrachialis, short head of biceps, pectoralis minor and preservation of subscapularis tendon. Currently, there are not many reported cases in the literature after BBC with a longer follow-up time. In this paper, we present the case of our patient operated on 24 months ago with this technique with good results. The patient is still under our observation. Due to the relatively new technique and the small number of described follow- ups, we feel it is relevant to describe our case.
Keywords: Glenoid Bone Augmentation; Bone Loss; Metal Implants
Introduction
Recurrent glenohumeral instability has been known to present a challenge when it comes to the success rate of glenohumeral surgical stabilization. However, management of glenohumeral instability in association with glenoid bone loss presents an even greater challenge, especially due to the fact that it mainly occurs in young active individuals and can permanently affect their quality of life. According to the latest literature the choice of the glenohumeral stabilization surgical treatment is guided by the degree of bone loss. Historically “critical” bone loss has been estimated to be 20-25%, while newer studies carried out by Tokish, et al., show that 13.5% should be considered as the critical amount of bone loss that leads to unacceptable outcomes of arthroscopic soft tissue stabilization [1]. Patients with lesser degrees of bone loss (below 13.5 %) may benefit from soft tissue procedures, including arthroscopic or open Bankart repair and remplissage. While patients with significant bone loss should be opted for bony augmentation including coracoid transfer (Latarjet, Bristow) and autograft (iliac crest or distal clavicular) or allograft (distal tibia) reconstruction. Nonetheless, coracoid transfer, specifically the Latarjet procedure, still remains the golden standard to this day. However, Latarjet is not without its faults, as it has a substantial complication and reoperation rate (30% and 7%, respectively) [2]. Additionally, it is a risk factor for development or progression of low-grade shoulder Osteoarthritis (OA) [3]. That is why it is crucial to develop a more effective and less invasive surgical method. A promising method seems to be Arthroscopic Bone Block Cerclage (BBC). In this paper we would like to summarize current literature on glenohumeral surgical stabilization in association with bone loss. Additionally, due to the fact that there are few studies on arthroscopic bone block cerclage with long follow ups, we are going to present the results of our treatment with a description of BBC technique performed by our surgical team.
Background
Latest literature reports that in patients with glenoid bone loss Bankart repair or remplissage procedure has a fairly high recurrence rate, particularly in patients with critical glenoid bone loss [2]. For a long period of time, the Latarjet procedure was regarded as the procedure of choice, but nowadays more and more attention is being paid to new techniques. Recently, alternative proposals for glenoid bone augmentation have appeared in the literature. Although in the literature we can find quite a lot of descriptions of techniques (however those arthroscopic ones are less common), a significant part of them includes the use of metal implants to attach the graft to the anterior glenoid, which can affect the long-term results, as we already know from the literature.
Zhu, et al., reported 90,5% graft resorption at 1 year after the Latarjet procedure using imaging studies. In their paper, four surgeons used the classification system their proposed to evaluate the severity of the graft resorption on the computed tomography scan performed 1 year postoperatively and the coracoid graft resorption was classified as grade 0 in 6 patients, grade I in 26, grade II in 25 and grade III in 6 [3]. Similar results were also reported by other authors. Poliart, et al., investigated whether coracoid bone graft osteolysis is more pronounced in cases without glenoid bone loss, which may be due to a diminished mechanotransduction effect at the bone healing site. They indeed found that the coracoid bone graft underwent much less osteolysis in patients with significant glenoid bone loss (>15%) than in those without it [4].
Over the last few years, new proposals have emerged for techniques that enable the above-mentioned complications to be avoided. One of the new techniques was published in 2019 by Hachem, et al. They proposed Arthroscopic Bone Block Cerclage (BBC), when they do not use metal implants while providing benefits such as maintenance and integrity and function of structures like coracobrachialis, short head of biceps, pectoralis minor and preservation of subscapularis tendon [5,6]. More promisingly in 2021 the short-term results of such metal-free fixation for chronic anteroinferior shoulder instability by Hachem, et al., were published. Functional scores showed good outcomes and no serious complications were reported. Radiological consolidation was also demonstrated 3 months after surgery. The most recent paper by Sheibel, et al., in which he describes this technique, also suggests a rehabilitation protocol consistent with our case that is described below [7,9,11].
Case Description
Initial Interview
The patient (male, age 24) visited the inpatient orthopedics department due to recurrent dislocations and pain of his shoulder. He stated a history of more than 200 dislocations, including dislocations that occurred during sleep. He presented in our clinic in 2019, one year after the injury that initiated the dislocation (severe shoulder sweep). During this time, he was in rehabilitation with no improvement.
History of Treatment
The patient was qualified by our senior surgeon for arthroscopic stabilization of the right shoulder joint. The qualification was done after a physical examination and consideration of the MRI results. Bone loss was then estimated at about 12%. In February 2019, we performed arthroscopy of the right shoulder joint and right subacromial space. We performed a remplissage using a 4.5 mm CorkScrew Titan 4.5 mm. We also reconstructed the anteroinferior labrum using 3 Titan Fastak 2.8 mm. A few months after the arthroscopy the patient went back to playing soccer, which he played recreationally three times a week. He suffered an injury during a soccer game: another player caught him with his upper limb in external rotation and abduction and then the shoulder joint dislocated. He reported another several dislocations after that episode. The patient was qualified for another surgery based on MRI, CT (where glenoid bone loss was estimated to be 24% using the “Sugaya method”- Fig. 1) and after clinical examination. Based on that, he was qualified for reoperation. We performed the BBC procedure in 2022 and we have summarized it below (Fig. 2-5).
Technique
Step 1 – Setup and Graft Harvesting
We did the washing and draping of the surgical field as typical. Firstly, access was performed in the area of the right iliac crest. The iliac crest was accessed in layers and the tricortical bone graft of approx. 25x15x10 mm was taken (Fig. 6,7). We planned the graft harvesting in advance based on a CT scan (Fig. 1).
Step 2 – Patient Positioning and Portal Placement
The patient was then placed in a beach chair position. We did the portals: posterior – widened in the second part of the procedure, anterosuperior, anteromedial in anterior interval – widened in the second part of the procedure for the autograft.
Step 3 – Autograft Fixation with Tapes
Then we inserted Guidewires (Arthrex) from the posterior portal perpendicular to the glenoid and made two oblong holes in the glenoid, according to the surgical technique. Fibertape and TigerTape which were passed through the developed autograft were guided through these holes (Fig. 5-7). Eventually, we performed a reverse fixation of the autograft with the above-mentioned tapes. The intraoperative and postoperative course was uneventful, with no complications.
Intra-operative Findings
Subsequently, during the arthroscopic procedure the anterior capsulolabral complex attachment was found to be damaged secondary to articular surface loss and chondromalacia of the II/III degree of the glenoid and the humeral head was also diagnosed. We also identified synovial hypertrophy with hemosiderin deposits, overgrown previous implant spots, protruding stumps of torn threads. We found two Fasttak implants, first in the lower and second in the middbone fragment and we removed them from the scapular neck. All was within extensive soft tissue scarring.
Post-Operation Rehabilitation and Follow Up
After surgery, the patient was in a brace with about 15 degrees of external rotation. After 4 weeks postoperatively, we started including an active assisted range of motion exercises. After 6 weeks, the patient was incorporating strengthening exercises. According to the patient’s report, he was able to return to work around week 7 after surgery. He returned to activity around the 4th month postoperatively. The patient is still under our supervision. Currently, almost 14 months after surgery, he does not require any of our interventions. Fig. 3 shows the patient’s range of movement at the 14 month post-surgery follow-up. In addition, we performed radiological checks, including X-rays, during the controls as shown in Fig. 2.
Figure 1: CT scan before BBC procedure. The glenoid bone loss was estimated at 24% using the “best fit circle” technique.
Figure 2: X-ray post op.
Figure 3: ROM 1 yr post BBC procedure.
Figure 4: Insertion of autograft.
Figure 5: Iliac bone crest before autograft harvesting.
Figure 6: Prepared autograft.
Figure 7: Insertion of autograft.
Conclusion
BBC is a relatively new technique, for which we find a limited number of clinical results with follow up in the literature. We decided to use this technique in 2022 and we are currently following the patient almost 14 months after the procedure, with very good results. We suggest that the presented technique is one that is worth considering, when it comes to surgical management of anterior instability with glenoid bone loss. It is a minimally invasive, arthroscopic technique in which metal devices are not used and the anterior wall of the shoulder can be protected. For glenoid augmentation autograft, allograft or xenograft may be used. What’s more, potential revisions after this technique will, more likely, be less concerning than after other, more frequently used techniques today. BBC is a relatively new technique, therefore up to now few articles that describe the use of the BBC technique exist and even fewer articles that describe long term follow-ups have been published. Nonetheless, complications of BBC technique were observed. Boehm E, et al., reported development of grade-I or grade-II osteoarthritis in three patients, temporary hypoesthesia at the harvesting site of the iliac crest and persistent feeling of a loose shoulder in one patient [8]. While Hachem A, et al., described one superficial infection and one stiffness on external rotation [7,9]. Bockmann B, et al., had one case of empyema of the shoulder and one infected superficial haematoma at the pelvis [9]. Only one article, by Bockmann B, et al., has reported recurrent dislocations of three patients (9%), which happened after severe trauma e.g. motorbike accident. To conclude, early results are very promising, however further studies involving larger groups of patients and longer follow up are needed.
Conflict of Interests
The author declares that there is no conflict of interest for this paper.
References
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- Bockmann B, Venjakob AJ, Gebing R, Nebelung W. All-arthroscopic glenoid reconstruction by iliac crest bone graft transfer does not affect structural integrity and 3-dimensional volume of the subscapularis muscle. Arch Orthop Trauma Surg. 2019
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Article Type
Case Report
Publication History
Accepted Date: 13-04-2024
Accepted Date: 05-05-2024
Published Date: 13-05-2024
Copyright© 2024 by Sibilska A, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Sibilska A, et al. Case Report of Arthroscopic Anatomical Bone Glenoid Augmentation with Subscapularis Tendon Protection with A 24 Months Follow-Up and Literature Review of The Current Concepts of Glenoid Bone Augmentation. J Ortho Sci Res. 2024;5(2):1-7.
Figure 1: CT scan before BBC procedure. The glenoid bone loss was estimated at 24% using the “best fit circle” technique.
Figure 2: X-ray post op.
Figure 3: ROM 1 yr post BBC procedure.
Figure 4: Insertion of autograft.
Figure 5: Iliac bone crest before autograft harvesting.
Figure 6: Prepared autograft.
Figure 7: Insertion of autograft.
