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Arthroscopic Autologous Scapular Spine Bone Graft Combined With Bankart Repair for Anterior Shoulder Instability With Subcritical (10%-15%) Glenoid Bone Loss
The purpose of our study is to prove that the autologous scapular spine bone graft is an alternative for the treatment of anterior shoulder instability and the clinical and radiological results are promising.
Method
From July 2016 to August 2018, patients who were diagnosed as having anterior shoulder instability with subcritical (10%-15%) glenoid bone loss were treated by arthroscopic repair with autologous scapular spine bone graft. The inclusion criteria were (1) anterior shoulder instability underwent arthroscopic autologous scapular spine bone graft; (2) glenoid bone loss was within 10% to 15% (measured by Sugaya's method); (3) three complete sets of computed tomography (CT) scans (preoperative, 1 week after surgery, and 1 year after surgery) available; and (4) clinical follow-up time was at least 2 years. The exclusion criteria were (1) concomitant rotator cuff tear; (2) concomitant remplissage or SLAP repair; (3) previous surgery of the affected shoulder; (4) open surgery; and (5) incomplete radiological or clinical follow-up. The preoperative and postoperative Constant-Murley score, dietary approaches to stop hypertension (DASH) score, visual analog scale (VAS) score, and range of motion (ROM) were recorded. CT scans with 3-dimensional reconstruction were obtained at the first week after operation and at 1 year after operation; the graft resorption rate was consequently calculated.
Results
Twenty-seven patients were qualified and enrolled in the study. No severe complication was recorded during follow-up. No redislocation or subluxation was found, and the apprehension tests were all negative. At the last follow-up, the mean Constant-Murley score was 89.74 ± 3.71, the mean DASH score was 9.77 ± 5.31, the mean VAS score was 0.74 ± 0.64, which are all improved significantly compared with preoperative scores (P = .00,.00,.00, respectively). At the last follow-up, the ROM including anterior flexion, external rotation by side, and the internal rotation were well restored without significant difference compared with the contralateral shoulder (P =.48, .08, .47, respectively). At 1 year after operation, the resorption rate of the bone graft was 19.4%.
Conclusion
This study found that anterior shoulder instability with subcritical (10%-15%) glenoid bone loss treated with arthroscopic autologous scapular spine bone graft with suture anchor fixation is safe and could achieve satisfactory result at short-term follow-up.
Level of Evidence
Therapeutic case series.
Glenoid bone loss is one of the most important risk factors for recurrent dislocation after anterior shoulder instability surgery. Authors had reported high postoperative recurrence rate in patients with large glenoid bone loss (>15%) who had been treated with soft tissue repair (Bankart).
Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.
Bony procedures like Latarjet-Bristow or autologous iliac crest bone graft (ICBG) are recommended for this patient group. However, there is no consensus for patients with sub-critical glenoid bone loss at 10% to 15%. Considerable failure rate of soft tissue reconstruction for this type of bone loss in patients with high sports level or joint laxity had been reported.
Arthroscopic Bankart repair with remplissage in comparison to bone block augmentation for anterior shoulder instability with bipolar bone loss: A systematic review.
Risk factors for recurrence after arthroscopic instability repair-the importance of glenoid bone loss >15%, patient age, and duration of symptoms: a matched cohort analysis.
set a 15% glenoid bone loss as a borderline for bony augmentation. However, 1 current system review has indicated the recurrence rate would significantly go up if the glenoid bone loss is more than 10%. In this study, they reported higher recurrence rate of arthroscopic soft tissue repair (6.1%-13.2%) than bony augmentation (0%-8.2%) for subcritical glenoid bone loss(10%-15%). Meanwhile the complication rate of bony block (0%-66.7%) is much higher than that in Bankart repair (0%-2.3%).
Arthroscopic Bankart repair with remplissage in comparison to bone block augmentation for anterior shoulder instability with bipolar bone loss: A systematic review.
Latarjet-Bristow procedures had been reported for this type of patients with low recurrence rate, but severe graft resorption had been reported for patients with minor glenoid bone loss.
Hendy BA, Padegimas EM, Kane L, et al. Early postoperative complications after Latarjet: A single institution experience over 10 years [published online September 30, 2020]. J Shoulder Elbow Surg. https://doi.org/10.1016/j.jse.2020.09.002.
Hendy BA, Padegimas EM, Kane L, et al. Early postoperative complications after Latarjet: A single institution experience over 10 years [published online September 30, 2020]. J Shoulder Elbow Surg. https://doi.org/10.1016/j.jse.2020.09.002.
the early graft failure rate is 4.7% and nerve injury rate is 3.2%. Two-thirds of the graft failures required reoperation and half of the nerve injuries led to residual symptoms. Another study from Castricini et al.
has shown a complication rate as high as 16%, even the operation is given from an experienced hand. Similar complications and complication rate had been reported by Updegrove et al.,
Latarjet procedure for anterior glenohumeral instability: early postsurgical complications for primary coracoid transfer versus revision coracoid transfer after failed prior stabilization.
including superficial infections, superficial vein thrombosis, musculocutaneous neurapraxia, and hardware complications. Some studies have shown much higher complication rate as 25% to 30%, which may attribute to unskilled hands.
Multiple complications of iliac crest bone graft harvest have been reported, including infection, hematoma, meralgia paresthetica, and iliac wing fracture. The overall reported complication rate for iliac crest bone graft harvest is about 25% to 30%.
As with scapular spine bone grafting, there are several theoretical advantages. First, the donor site is located in the same area of arthroscopic portals, which makes the preparation and draping more convenient. Second, multisite morbidity can be avoided. Third, with preoperative measurement of shoulder computed tomography (CT) scans, the size of the scapular spine can simultaneously be evaluated. Hence, we describe a new technique of arthroscopic autologous scapular spine bone graft to treat anterior shoulder instability with subcritical (10%-15%) glenoid bone loss.
The purpose of our study is to prove that the autologous scapular spine bone graft is an alternative for the treatment of anterior shoulder instability and the clinical and radiological results are promising. We hypothesize that this technique is safe and durable at short-term follow-up.
Methods
This study was approved by Institutional Review Board. From July 2016 to August 2018, patients who were diagnosed as anterior shoulder instability with sub-critical bone loss (10%-15%) and underwent arthroscopic autologous scapular spine bone graft transplant were enrolled in this study. The glenoid bone loss was evaluated by the method described by Sugaya.
The inclusion criteria were (1) anterior shoulder instability underwent arthroscopic autologous scapular spine bone graft; (2) glenoid bone loss was within 10% to 15%; (3) three complete sets of CT scans (preoperative, 1 week after surgery and 1 year after surgery) available; and (4) clinical follow-up time was at least 2 years. The exclusion criteria were (1) concomitant rotator cuff tear; (2) concomitant remplissage or SLAP repair; (3) previous surgery of the affected shoulder; (4) open surgery; and (5) incomplete radiological or clinical follow-up.
Surgical Technique
All surgeries were done by 1 senior surgeon (M.X.). After general anesthesia and interscalene block, the patient was put in lateral decubitus position. The routine posterior portal was established to introduce the scope. A thorough check of the lesion of biceps tendon, cuff, and capsular integrity both on the glenoid and the humeral side was carried out. Anterosuperior and anteroinferior portal were routinely established with cannulas.
We then switched the arthroscope to the anterosuperior portal and the retracted anteroinferior capsule-ligamentous complex was released from the glenoid neck by the liberator knife. The anterior glenoid rim was appropriately decorticated either by a shaver or a burr. Two suture anchors were inserted at the 4- and 5-o’clock (right shoulder) at the anterior glenoid rim as the "graft-anchors" (Fig 1). Additional 1 or 2 anchors might be needed for further labral repair (the “labral anchors”).
Fig 1Preparation of the bone graft surface and anchor implantation (right shoulder view from the anterosuperior portal). (A) Release the anteroinferior capsule-ligamentous complex from the glenoid neck by the liberator knife. (B) The anterior glenoid rim was decorticated either by a shaver or a burr. (C) Graft-anchor inserted at the 5-o'clock position. (D) Graft-anchor inserted at the 4-o'clock position.
The middle-point of the scapular spine was then located and a 4cm straight incision was then made along the scapular spine. After careful dissection between the fascia and aponeurosis of the trapezius and posterior deltoid insertion, the scapular spine is nicely exposed and a 20 mm × 10 mm × 8 mm tricortical bone graft was harvested by osteotome (Figs 2 and 3). The deltoid fascia was repaired by suturing after the harvest. Slightly decortication was performed on one of the graft’s cortical faces that we tended to integrate with anterior glenoid. Two parallel bone tunnels were drilled by 1.5 mm Kirschner wire through the 2 parallel cortices facing each other. The two tunnels were separated approximately 10 mm apart, and each tunnel was 5 mm away from the graft edge. One limb of each of the 2 graft-anchors was then shuttled through the bone tunnels separately, and the bone graft was then carefully slid into the joint through the anteroinferior cannula (size 10 mm × 15 mm × 130 mm; Hangzhou Rejoin Mastin Medical Device Co., Ltd, Hangzhou, Zhejiang, China). All sutures that passed through the bone tunnel of the graft and from additional labral anchors were shuttled by suture hooks into the corresponding labral tissue. The bone graft was meticulously adjusted by a probe or a retriever to be flush with the glenoid surface. While adjusting the orientation of the bone graft, caution should be made to orientate the cancellous face of the bone graft medially and the bigger end of the bone graft is located inferiorly. With the pre-tensioning of the suture limbs, the bone graft was secured at suitable position superiorly-inferiorly and then fixed by tying the sutures of the 2 graft-anchors. Then the other sutures were also tied to accomplish labral repair (Fig 4, Fig 5).
Fig 2Scapular spine bone graft harvest (right shoulder).
Fig 4Implantation of the autologous scapular spine bone graft (right shoulder viewing from the anterosuperior portal). (A) The switch pod or the probe was used to adjust the rotation of the bone graft until the long axis of the bone graft parallel to the anterior glenoid edge. The same tool was used to push the bone down to be flush with the anterior glenoid edge in medial-lateral direction. (B) After confirmation of the congruence of the bone graft with the glenoid edge from the anterosuperior portal. Fixation of the bone graft was done by tying the suture wire.
The shoulder was strictly immobilized in a sling for 6 weeks after surgery. Passive ROM exercises were begun after 4 weeks and daily activity was after 6 weeks. Strengthening exercise began at 10 to 12 weeks. All sports activity would be allowed after 6 months after surgery.
Clinical Evaluation
All clinical evaluations were carried out by an independent observer (X.C.H., fellowship-trained shoulder surgeon who didn’t get involved in the surgery). Active range of motion (ROM) of preoperative and at the last follow-up were recorded with manual goniometer including anterior flexion, external rotation by the side and internal rotation. The Constant-Murley score, dietary approaches to stop hypertension (DASH) score, and visual analog scale (VAS) score (these 3 patient-reported outcome measures [PROMs] used have been validated with studies) were recorded at pre-operative and at the last follow-up. The subject satisfactory degrees of patients were evaluated at the last follow-up. Patients were asked to rate their result as very good, good, fair or bad due to the subject feeling of the shoulder function and pain. Patients would rate the result as very good, good, fair, or bad because of the subjective feeling of shoulder function and pain at the last follow-up, and the subjective satisfactory degree of each patient was consequently recorded.
Radiological Evaluation
A complete set of CT scans with 3-dimensional reconstruction of the glenoid was obtained before and at 1 week and 1 year after surgery. All radiological evaluations were carried out by the same independent observer that did the clinical evaluation. The radiological evaluation included graft union, resorption rate of the bone graft, and the graft-articular congruence.
Graft resorption was evaluated on the en face view of the 3-dimensional CT reconstruction. The preoperative glenoid bone loss was measured on the en face view with the method reported by Sugaya and calculated by software (Infinitt, Phillipsburg, NJ) and recorded as L. Then glenoid bone loss at 1 week and 1 year after surgery were both measured in the same way and recorded as L1w and L1y, respectively. The bone graft resorption rate was calculated as (L1y – L1w)/(L − L1w) × 100%. The measurement was performed twice by the observer with an interval of 3 months. The value of each time point was recorded, and the average value of the 2 was taken as the final evaluation (Fig 6).
Fig 6Measurement of the bone graft resorption (showing preoperative, postoperative 1 week and postoperative 1 year, respectively) (Right shoulder view on 3-dimensional computed tomography scan). (A) Preoperative. (B) One week after surgery. (C) One year after surgery. Black arrow shows the glenoid bone loss.
Graft union and graft-articular congruence were evaluated on the axillary cut of the CT scan. If the scapular spine graft was more than 3 mm medial or 1 mm lateral to the articular surface of the glenoid, then the position of the graft was defined as a medial position or lateral overhanging position. Otherwise, if the scapular spine graft was within 3 mm medial or 1 mm lateral to the glenoid, the position of the graft would be defined as a flush position.
Statistics
SPSS 21.0 (SPSS, Inc., Chicago, IL) was used to perform the statistical analysis, the comparison of ROM and clinical outcomes of before surgery and at the last follow-up was performed by paired t-testing. The glenoid bone loss at preoperative and 1 week and 1 year after surgery were compared by repeated-measures analysis of variance. P < .05 was considered the significant statistical difference. The power analyses were performed and the analysis power of each test was more than 0.9 (1-β > 0.9).
Results
All surgeries were performed by 1 senior doctor. From July 2016 to August 2018, 64 patients diagnosed as having anterior shoulder instability were surgically treated in our department, of whom 27 with subcritical glenoid bone loss (the other 37 patients were excluded because the glenoid bone loss was not between 10%-15%, and alternative surgeries were performed accordingly). Twenty-seven shoulders of 27 consecutive patients were enrolled, the mean follow-up time was 29.3 months (25-39 months), the mean age at the follow-up was 31.6 years (20-50 years). There were 20 males and 7 females. The mean episodes of dislocation were 8.6 ± 2.9. And 2 patients were diagnosed as having general laxity (Beighton score 6 for both patients). The demographic characteristics are described in Table 1.
No severe complications such as infection, neurovascular injuries, or donor site morbidity were identified. During this period of follow-up, no redislocations had occurred, and the apprehension test results were negative on all patients. No complications were found regarding donor site morbidity.
At the last follow-up, the mean Constant-Murley score was 89.74 ± 3.71, the mean DASH score was 9.77 ± 5.31, the mean VAS score was 0.74 ± 0.64, which are all improved significantly compared to those from before surgery (Table 2). At the last follow-up, the mean anterior flexion was 160° ± 12°, the mean external rotation by side was 41° ± 12°, the mean internal rotation was 69° ± 14°, which all decreased but without significant difference (Table 3). For subjective satisfactory degrees at the last follow-up, 19 patients rated the outcomes as very good, 6 patients rated as good, 2 patients rated as fair, and no patient rated the outcome as poor. According to previous studies
Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair.
for the minimal clinical important difference (MCID) of Constant-Murley, DASH and VAS, 24 patients met the MCID of Constant-Murley, 25 patients met the MCID of DASH, and 15 patients met the MCID of VAS.
Table 2Comparison of Constant, DASH, and VAS Before Surgery and at the Last Follow-Up
The intraobserver reliability coefficient between 2 measurements was 0.983 (P < .05); thus the consistency of the measurements was confirmed. All bone graft were healed at the 1-year postoperative CT scan. And the mean resorption rate of the bone graft at 1 year after surgery was 19.4% ± 7.5% (20.2% ± 8.0% and 18.5% ± 7.4%, respectively, in each time point of measurement) (Table 4). At 1 week after surgery, bone grafts were flush with the articular surface of the glenoid in 22 patients, 5 were in a lateral overhanging position, and 0 were in a medial position. At 1 year after surgery, bone grafts of all 27 cases were flush with the articular surface of the glenoid (Fig 7). Arthritic changes had not been found in any patient at final follow-up.
Fig 7The remodeling of the bone graft. (Right shoulder viewing on horizontal plane of computed tomography scan). (A) One week after surgery. (B) One year after surgery.
The most important finding of this study is that arthroscopic autologous scapular spine bone graft is a safe and effective treatment for anterior shoulder instability with subcritical (10%-15%) glenoid bone loss. For anterior shoulder instability patients with glenoid bone loss less than 10%, Bankart repair (with or without remplissage) can achieve a low recurrence rate and promising clinical function.
The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (Study III): Long-term follow-up in 319 shoulders.
One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study I–clinical results.
But patients with subcritical glenoid bone loss between 10% and 15% are common. A recent systematic review showed that bony surgery should be recommended in this patients’ group to minimized the risk of postoperative recurrence, especially for those high-activity level patients or patients with joint laxity.
An arthroscopic bone block procedure is effective in restoring stability, allowing return to sports in cases of glenohumeral instability with glenoid bone deficiency.
If Latarjet-Bristow procedures are adopted for this type of patient, more severe graft resorption had been reported for patients with minor glenoid bone loss compared with those with marked glenoid bone loss.
Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss.
So, an alternative bone graft source might be needed for this group of patients.
Our results showed that satisfactory outcome could be expected in patients with sub-critical glenoid bone loss that were treated by scapular spine bone graft. During this period of follow-up, no redislocations had occurred and the apprehension tests were negative on all patients. Shoulder ROM recovery is satisfactory and 92.6% of the patients considered their surgeries as very good or good. Currently there are few studies specifically reporting the outcomes of subcritical glenoid bone loss. However, the newest study from Maman et al.
has reported multicentric outcomes of Bankart or Latarjet at minimum 5 years' follow-up. In their study, the mean DASH score in Bankart group and Latarjet group are 6.2 versus 4.5, respectively. The mean DASH score (9.77) in our study is slightly higher than that. The DASH score in our study may get further improved as the extension of follow-up to 5 years. The redislocation rate in their study is 3.7% versus 18.5% (Latarjet versus Bankart), which was similar in the study by Zimmermann et al.
they reported outcomes of Latarjet at 2 years after surgery. The Constant-Murley score (92.9) is comparative to our study (89.74).
The scapular spine is a good alternative for bone graft of the anterior glenoid defect. It is not as bulky as the coracoid graft and is basically located at the same area where the arthroscopic portals are made, thus avoiding additional donor site morbidity like ICBG. It also saves more preparation time by avoiding independent draping of the iliac crest area. The harvesting of the scapular spine graft is safe. The incision is located in the middle of the scapular spine, with an average distance of 47.7 mm to the area of the suprascapular nerve.
Also, the distance from the posterolateral corner of the acromion to the point at which the spinal accessory nerve passed under the trapezius is 5 to 7 cm, and the nerve enters the trapezius from its ventral surface between the muscle and its covering fascia. It runs parallel and about 2 cm from the anterior border of the muscle, and then it turns medially to run parallel to and about 4 cm from the insertion of the muscle into the spine of the scapula. At the medial end of the spine, the nerve turns caudally and runs with the transverse cervical vessels midway between the vertebral column and the medial border of the scapula, parallel to the latter.
So the whole procedure is safe if we keep the Bovie blade and the liberator only on the bone of scapular spine throughout the release and osteotomy.
Although nonrigid fixation of the bone graft was adopted, the graft healing rate is very promising because all grafts healed at 1 year after surgery. Anterior glenoid bone graft by suture anchor fixation had been well reported with high satisfaction rate.
With the twin-tunnel fixation fashion by the suture anchors, the graft can be stabilized securely and kept flush with the glenoid articular surface without rotation. The resorption rate (19.4%) remained relatively low in our series compared with relatively large bone graft like Latarjet (23.2%-63.9%).
Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss.
Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: A computed tomography scan study of twenty-six patients.
At 1 year after surgery, most of the bone graft had self-remodeled to best fit the circle of glenoid, and the resorption, as well as bone remodeling, will usually be stable at this time point.
One interesting finding of our result is that the graft-articular congruence was more significantly improved at 1 year after surgery than that at 1 week, which implies the possibility of later graft repositioning and remodeling potential by this nonrigid fixation fashion, while repositioning of the bone graft is impossible for screw fixation. And this later graft repositioning potential did not affect graft healing. Xu et al.
also reported a similar phenomenon in their Latarjet series with nonrigid endo-button fixation.
Limitation
There are several limitations of this study. First, this study is a retrospective study with a relatively small sample size; thus the statistical bias may affect the final results, and the potential complications may be overlooked. Second, no control group was set up; thus direct comparison of this technique between Latarjet-Bristow and ICBG technique cannot be obtained. Third, the follow-up time was relatively short, and we need long-term result to further elaborate the remodeling pattern of the graft.
Conclusion
This study found that anterior shoulder instability with subcritical (10%-15%) glenoid bone loss treated with arthroscopic autologous scapular spine bone grafting with suture anchor fixation is safe and could achieve satisfactory result at short-term follow-up.
Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.
Arthroscopic Bankart repair with remplissage in comparison to bone block augmentation for anterior shoulder instability with bipolar bone loss: A systematic review.
Risk factors for recurrence after arthroscopic instability repair-the importance of glenoid bone loss >15%, patient age, and duration of symptoms: a matched cohort analysis.
Hendy BA, Padegimas EM, Kane L, et al. Early postoperative complications after Latarjet: A single institution experience over 10 years [published online September 30, 2020]. J Shoulder Elbow Surg. https://doi.org/10.1016/j.jse.2020.09.002.
Latarjet procedure for anterior glenohumeral instability: early postsurgical complications for primary coracoid transfer versus revision coracoid transfer after failed prior stabilization.
Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair.
The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (Study III): Long-term follow-up in 319 shoulders.
One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study I–clinical results.
An arthroscopic bone block procedure is effective in restoring stability, allowing return to sports in cases of glenohumeral instability with glenoid bone deficiency.
Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss.
Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: A computed tomography scan study of twenty-six patients.
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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