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Baker, Uribe, Whitman 1990 45 patients 6 capsular tear 11 partial Bankart 28 complete Bankart

Ribbans et al, JBJS(B) 1990: All patients < 50 yo had Bankart 75% > 50 yo had Bankart Capsular tears, cuff tears fractures more common in older patients

Arciero: West Point Study, 1992-1998 54 pts with acute dislocation (55 shoulders)

52 treated arthroscopically 3 treated primary open

Findings 55 Hill-Sachs 52 Bankart

1 combined with HAGL (B-HAGL) 3 combined with capsular tear

1 HAGL 1 capsular tear 13 SLAP

9 Type II

•  Cadaveric Study •  Tested Progressive Glenoid

Loss •  >21% loss of glenoid width

compared to length may cause instability and limit range of motion after Bankart repair.

J Bone Joint Surg Am. 2000;82:35-46.

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VIDEO

THE GOOD… Ø  Hovelius L: JSES 2004 - 118 Patient followed 15 years - 1/118 recurrence after 2 years - 3/118 recurrence after 15 years - 98% patient satisfaction at 15 years Ø  Hovelius L: JSES 2001 - Compared Bankart vs Latarjet Bankart Latarjet 26 shldrs (24yrs) 30 shldrs (15yrs) 1 redislocation 1 redislocation OA in 16/26 OA in 9/30

Ø  Burkhart SJ et al: Arthroscopy, 2007 - 102 patients with “inverted pear glenoid” - 32-108 months F/U - Constant score 94% - 4 recurrent disl+1 recurrent sublux/102= 5% Ø  Allain J et al: JBJS, 1998

- 58 Shoulders F/U 14yrs (range 10-23yrs) - No recurrences (6 with apprehension) - Rowe score: 88% good/ex - OA Grades: I(25); II(4); III(3); IV(2); IV-post (2)

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70% LESS FORCE FOR DISLOCATION

Gerber & Nyffler, 2002

Ø  Suspicion of Glenoid bone loss:

ü  Failed prior surgery ü  Large Number of recurrences ü  Reducing force necessary for dislocation

ü  Marked Apprhension/Relocation on PEx

ü  Plain Radiographs: Trauma series ü  MRI: Many came with this… ü  CT-Arthrogram ü  3-Dimensional CT Reconstruction

Latarjet Versus ICBG

Am J Sports Med 2009 37: 87

•  Laterjet reduces anterior translation 354% compared to defect alone

•  ICBG decreases translation 179% •  Biomechanically, Favors Latarjet over ICBG

Latarjet Versus ICBG

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ORIGINAL ARTICLE

Bone Grafting Severe Glenoid Defects in Revision ShoulderArthroplasty

Jason J. Scalise MD, Joseph P. Iannotti MD, PhD

Received: 21 August 2007 / Accepted: 1 November 2007! The Association of Bone and Joint Surgeons 2008

Abstract During revision total shoulder arthroplasty,bone grafting severe glenoid defects without concomitant

reinsertion of a glenoid prosthesis may be the only viable

reconstructive option. However, the fate of these grafts isunknown. We questioned the durability and subsidence of

the graft and the associated clinical outcomes in patients

who have this procedure. We retrospectively reviewed 11patients with severe glenoid deficiencies from aseptic

loosening of a glenoid component who underwent con-

version of a total shoulder arthroplasty to a humeral headreplacement and glenoid bone grafting. Large cavitary

defects were grafted with either allograft cancellous chips

or bulk structural allograft, depending on the presence orabsence of glenoid vault wall defects, without prosthetic

glenoid resurfacing. Clinical outcomes (Penn Shoulder

Score, maximum 100 points) improved from 23 to 57 at aminimum 2-year followup (mean, 38 months; range, 24–

73 months). However, we observed substantial graft

subsidence in all patients, with eight of 11 patients havingsubsidence greater than 5 mm; the magnitude of graft

resorption did not correlate with clinical outcome scores.

Greater subsidence was seen with structural than cancel-lous chip allografts. Bone grafting large glenoid defects

during revision shoulder arthroplasty can improve clinical

outcome scores, but the substantial resorption of the graftmaterial remains a concern.Level of Evidence: Level III Prognostic study. See the

Guidelines for Authors for a complete description of levels

of evidence.

Introduction

Aseptic loosening of the glenoid component continues tobe a frequent indication for revision of a total shoulder

arthroplasty (TSA) [1, 7–10, 13, 15, 17–19, 22, 25]. In

some instances, the unstable glenoid implant causes largecavitary defects of the cancellous glenoid vault. When

combined with defects of the thin cortical vault walls,

implantation of a new glenoid component may not bepossible. Bone grafting the glenoid defect without new

glenoid component implantation combined with hemiar-

throplasty is a reconstructive option in these circumstances[1, 17, 18]. However, previous reports have not described

the extent of graft subsidence [1], the use of structural

allograft for reconstruction of cavitary defects combinedwith glenoid vault wall defects [17], or the clinical out-

comes after glenoid bone grafting [18].

We questioned the extent of resorption of the differentallografts used (morsellized chips or bulk structural graft)

and whether that resorption related to the functional out-

comes for patients in whom large glenoid insufficiencies

Each author certifies that he or she has no commercial associations(eg, consultancies, stock ownership, equity interest, patent/licensingarrangements, etc) that might pose a conflict of interest in connectionwith the submitted article.Each author certifies that his or her institution has approved thehuman protocol for this investigation, that all investigations wereconducted in conformity with ethical principles of research, and thatinformed consent for participation in the study was not required byour Institutional Review Board after review and approval of theprotocol.

J. J. Scalise (&)The CORE Institute, 14420 W Meeker Blvd, Suite 300, Sun CityWest, AZ 85375, USAe-mail: jason.scalise@thecoreinstitute.com

J. P. IannottiDepartment of Orthopaedic Surgery, Cleveland Clinic,Cleveland, OH, USA

123

Clin Orthop Relat Res (2008) 466:139–145

DOI 10.1007/s11999-007-0065-7

Fate of large structural allograft for treatment of severeuncontained glenoid bone deficiency

Joseph P. Iannotti, MD, PhDa,*, Salvatore J. Frangiamore, MDb

aOrthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USAbDepartment of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA

Background: Structural allografts have been used for management of large defects of the glenoid. Wedescribe a surgical technique for graft preparation and the radiographic and clinical results of a seriesof patients using this technique.Materials and methods: In 19 consecutive patients, a polymethyl methacrylate mold was used to shapea single graft from a fresh-frozen femoral head to press fit within the glenoid defect. We evaluated the clin-ical and radiographic results with a minimum 2-year follow-up or until revision to another total shoulderreplacement.Results: Six patients showed more than 50% resorption of the graft. Four of these six patients also had lessthan 50% graft incorporation, and these findings were associated with a less favorable clinical outcome. In3 of 6 cases in which poly-L-lactic acid bioresorbable screws were used, a significant giant cell reactionwas noted at the time of revision surgery. Seven of nine patients with metal screw fixation had bent, broken,or worn screws because of graft collapse and contact with the prosthetic humeral head. Four of the fiverevision cases that were converted to a reverse total shoulder replacement had sufficient bone incorporationand volume of bone to allow for secure glenoid and screw fixation.Conclusion: The surgical technique described is useful in creation of a well-fitting graft. The amount ofbone resorption and bone incorporation and clinical outcome have wide variability. In those cases whererevision was performed with another total shoulder replacement, there was sufficient bone incorporationand sufficient bone mass to allow component fixation.Level of evidence: Level IV, Case Series, Treatment Study.! 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Glenoid bone deficiency; structural allograft; clinical and radiographic outcome; surgical tech-nique for grafting

Structural allografts are used to treat severe global orcavitary glenoid bone loss. Severe glenoid bone loss mayoccur as a result of glenoid component loosening or failed

humeral hemiarthroplasty.1-3,8-11,13 Graft resorption andgraft incorporation may influence clinical outcome or theability to place another glenoid component during a laterrevision surgery. Large structural grafts are often fixed withmetal or bioabsorbable screws. Metal screws can result inmetal-on-metal wear debris and mechanical failure of thescrew requiring removal.12 Poly-L-lactic acid (PLLA) screwscan also undergo mechanical failure and have wear anddegradation debris or products that cause bone resorption.4,5

Approval received from Cleveland Clinic institutional review board (CC10-1033).

*Reprint requests: Joseph P. Iannotti, MD, PhD, Orthopaedic andRheumatologic Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland,OH 44195, USA.

E-mail address: iannotj@ccf.org (J.P. Iannotti).

J Shoulder Elbow Surg (2012) 21, 765-771

www.elsevier.com/locate/ymse

1058-2746/$ - see front matter ! 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.doi:10.1016/j.jse.2011.08.069

0%

20%

40%

60%

80%

100%

PERCENTAGE STABLE

1

PROCEDURE

SHOULDER STABILITY WITH INSTABILITY REPAIR

Series1Series2Series3Series4Series5

Thermal capsulorrhaphy

ALPSA Repair

Scope Bankart Latarjet

Glenoid reconstruction