Joint Preserving Treatment of Chronic Locked Posterior Shoulder Dislocation by Means of Combined Humeral Allograft Reconstruction and Posterior Glenoid Autograft Augmentation.

Chronic locked posterior shoulder dislocations are challenging to treat and often warrant total shoulder arthroplasty. While joint preserving treatment is preferable in young patients, surgical techniques to treat this pathology have rarely been described in the literature. This technical note presents the treatment of a 30-year-old male patient with a chronic locked posterior shoulder dislocation by means of combined humeral allograft reconstruction and posterior glenoid autograft augmentation. Restoration of the spheric humeral head surface was obtained using a fresh-frozen femoral allograft fixed with two reabsorbable screws. Due to the intraoperatively persistent posterior instability after humeral reconstruction, the posterior glenoid was augmented with a tricortical iliac crest autograft, which was fixed with two metal screws. This treatment strategy resulted in a full range of motion and a centered stable shoulder joint at one-year follow-up. Therefore, the procedure of segmental reconstruction of the humeral head with a fresh-frozen allograft combined with a posterior glenoid augmentation with an iliac crest bone autograft is a joint-preserving treatment alternative to shoulder arthroplasty in young patients when humeral head reconstruction alone does not suffice.

Steroid-induced osteonecrosis of the humeral head in a 20-year-old man treated with an osteochondral autograft: A case report.

To our knowledge, only one previous report described the treatment of osteochondral autograft for steroid-induced osteonecrosis of the humeral head (ONHH) in a middle-aged patient. The present report describes a 20-year-old man who was found to have avascular osteonecrosis of the right humeral head after corticosteroid pulse treatment, followed by oral corticosteroid therapy. The patient complained of serious right shoulder pain and limited range of motion (ROM). Anteroposterior (AP) radiographs of the right shoulder revealed a crescent sign at the humeral head, indicating subchondral bone collapse with a linear sclerotic change and normal articular surface of the glenoid. The case was categorized as Stage 3 according to the Cruess classification. In general, Cruess classification Stage 3 is treated with humeral head replacement and shoulder arthroplasty. The patient underwent surgical treatment involving osteochondral autograft transplantation. Autografts were harvested from the right knee. At the 1.5-year follow-up, the patient was pain-free and showed an improved active ROM. Furthermore, AP radiographs demonstrated that the glenohumeral joint space was maintained, and no progression of humeral head collapse was observed. This case may be helpful in decision-making if young patients with ONHH require surgical treatment. Furthermore, osteochondral autograft transplantation may be an effective treatment for ONHH.

[Management of Glenoid Defect by a Bone Graft in Reverse Total Shoulder Arthroplasty - Surgical Technique and Two-Year Clinical Outcomes]. / Resení defektu glenoidu kostním stepem pri implantaci reverzní totální endoprotézy ramene ­ operacní technika a dvouleté klinické výsledky.

PURPOSE OF THE STUDY The purpose of the study is to share the first experience of authors with the management of glenoid defects by a bone graft in reverse total shoulder arthroplasty. MATERIAL AND METHODS Evaluation of 7 patients was conducted, who underwent reverse total shoulder arthroplasty at the authors' department. Due to the presence of glenoid bone defect, augmentation was performed by bone graft, obtained either as an autograft harvested from the humeral head of the patient intraoperatively or as an allograft from the femoral head from the bone tissue bank. In all the implantations, a glenoid component with an extra-long "revision" peg was used. Postoperative fixation was secured only by a shoulder brace. Limited rehabilitation was commenced on the first postoperative day, full rehabilitation 5 weeks after the surgery. RESULTS The total ASES Shoulder Score increased from the mean 39.8 preoperatively to 75.2 postoperatively. Also, the overall range of motion improved, with the preoperative ventral flexion increasing from the mean 65.5° to 135.2°, abduction increasing from 63.9° preoperatively to 127.7° postoperatively, and external rotation increasing from 27.4° preoperatively to 45.1° postoperatively. In the evaluated group, 2 complications were observed, namely 1 case of bone graft breakage intraoperatively, necessitating the harvesting of a new bone graft, and 1 case of postoperative paresthesia of the fourth and the fifth finger, which completely disappeared within 4 months after the surgery. In the group of followed-up patients, no loosening of endoprosthetic components has so far been reported. DISCUSSION Glenoid defect constitutes one of the problems that need to be dealt with by the surgeon during the reverse total shoulder arthroplasty, most often it is accompanied by glenoid retroversion. The basic approach to defect management is to use the eccentric reaming technique which is, however, limited by the size of glenoid retroversion and can also worsen the already present glenoid medialization, with all the resulting consequences. Another option is to use solid bone grafts to correct glenoid version and simultaneously to lateralize the glenoid component. Yet another option is to use the prefabricated glenoid augments that are, however, not commonly available in the Czech market. CONCLUSIONS The short-term clinical outcomes of patients, in whom glenoid defect was during the reverse total shoulder arthroplasty managed by bone grafts, are very good. Radiological signs of bone-to-graph incorporation were present in all the patients of the followed-up group. Nonetheless, for the sake of evaluation of this method, more patients shall be included in the group and a longer follow-up is needed for their evaluation. Key words: reverse total shoulder arthroplasty, glenoid bone loss, glenoid retroversion, augmented implant.

Hemiarthroplasty for proximal humerus fractures with conservation of the whole humeral head as autograft: does it improve greater tuberosity healing?

PURPOSE: Hemiarthroplasty (HA) for proximal humerus fracture (PHF) is associated with tuberosity complications like migration, non-union, and resorption. In order to improve the rate of consolidation of the greater tuberosity (GT), we have developed a hollow humeral head prosthesis in which the whole humeral head is inserted and used as autograft. This study is designed to evaluate the consolidation rate of the GT with this device. METHOD: Twenty-two patients at mean age of 68 were treated between 2015 and 2017 for four-part fractures, fracture-dislocations, and head-split fractures with HA including the bony humeral head. The humeral prosthesis device comprises a prosthetic cephalic cup in which the detached humeral head is inserted and a cementless adjustable humeral stem which works like a jack. Mean follow-up was 14 months. The consolidation of GT was followed on X-rays. As comparison, 15 published series were selected and analyzed. RESULTS: There were two mechanical complications related to GT consolidation (9.1%). In the 20 other cases, the GT was radiologically consolidated without displacement. While the raw proportion of complications observed in the present series was lower than that reported in each of the 15 comparative series, the proportion of complications observed in the present series was significantly different from that observed only in seven out of the 15 previous series. CONCLUSION: Whole conservation of the humeral head as an autograft along with proper surgical technique yielded in 20 consolidations of GT without displacement in 22 cases of PHF treated with hemiarthroplasty.

Structural glenoid grafting during primary reverse total shoulder arthroplasty using humeral head autograft.

BACKGROUND: Large glenoid bone defects in the setting of glenohumeral arthritis can present a challenge to the shoulder arthroplasty surgeon. The results of large structural autografting at the time of reverse total shoulder arthroplasty (RTSA) are relatively unknown. METHODS: This retrospective case series describes the clinical and radiographic results of large structural autografting from the humeral head to the glenoid during primary RTSA. RESULTS: Of 17 patients who met inclusion criteria, 14 (82% follow-up) were evaluated postoperatively at a mean of 2.6 years (range, 2.0-5.4 years). Mean inclination correction was 19° ± 12° (range, 3°-35°). Complications occurred in 3 patients, including 1 transient brachial plexus palsy, 1 loose baseplate, and 1 dislocation treated with closed reduction. Radiographic images showed 100% of grafts incorporated. Active forward elevation improved from 80° ± 40° to 130° ± 49° (P = .028). The visual analog scale score for pain improved from 8.1 ± 1.3 to 2.5 ± 3.1 (P = .005). The Simple Shoulder Test improved from 1.8 ± 1.1 to 6.5 ± 4 (P = .012). The American Shoulder and Elbow Surgeons score improved from 22 ± 10 to 66 ± 25 (P = .012). All patients (100%) were satisfied, and all patients (93%) but 1 stated that they would undergo the procedure again if given the chance. CONCLUSIONS: RTSA incorporating structural grafting of the glenoid with humeral head autograft results in significant improvements in active forward elevation, pain, and function, with a low complication rate. This technique can reliably be used to achieve correction of large (up to 35°) glenoid defects with a 93% chance of baseplate survival and a 100% chance of graft incorporation in the short-term.

Arthroscopic Osteochondral Autograft Transfer for Juvenile Osteochondritis Dissecans of the Humeral Head: A Case Report.

CASE: Osteochondritis dissecans (OCD) rarely affects the humeral head. We describe a 14-year-old adolescent who, despite conservative treatment, had persistent pain in the left shoulder as well as limited function. Radiographs and a computed tomography (CT) arthrogram revealed an osteochondral defect of the humeral head. He was managed with an arthroscopic osteochondral autograft transfer from the knee, which provided a satisfactory outcome. CONCLUSION: Arthroscopic osteochondral autograft transfer is an effective option for the treatment of OCD of the humeral head.

Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management of glenoid bone loss and erosion.

BACKGROUND: Glenoid deficiency and erosion (excessive retroversion/inclination) must be corrected in reverse shoulder arthroplasty (RSA) to avoid prosthetic notching or instability and to maximize function, range of motion, and prosthesis longevity. This study reports the results of RSA with an angled, autologous glenoid graft harvested from the humerus (angled BIO-RSA). METHODS: A trapezoidal bone graft, harvested from the humeral head and fixed with a long-post baseplate and screws, was used to compensate for residual glenoid bone loss/erosion. For simple to moderate (<25°) glenoid defects, standardized instrumentation combined with some eccentric reaming (<15°) was used to reconstruct the glenoid and obtain neutral implant alignment. For severe (>25°) and complex (multiplanar) glenoid bone defects, patient-specific grafts and guides were used after 3-dimensional planning. Patients were reviewed with minimum 2 years of follow-up. Mean follow-up was 36 months (range, 24-81 months). Preoperative and postoperative measurements of inclination and version were performed in the plane of the scapula on computed tomography images. RESULTS: The study included 54 patients (41 women, 13 men; mean 73 years old). Fifteen patients had combined vertical and horizontal glenoid bone deficiency. Among E2/E3 glenoids, inclination improved from 37° (range, 14° to 84°) to 10.2° (range -28° to 36°, P < .001). Among B2/C glenoids, retroversion improved from -21° (range, -49° to 0°) to -10.6° (-32° to 4°, P = .06). Complete radiographic incorporation of the graft occurred in 94% (51 of 54). Complications included infection in 1 and clinical aseptic baseplate loosening in 2. Mild notching occurred in 25% (13 of 51) of patients. Constant-Murley and Subjective Shoulder Value assessments increased from 31 to 68 and from 30% to 83%, respectively (P < .001). CONCLUSION: Angled BIO-RSA predictably corrects glenoid deficiency, including severe (>25°) multiplanar deformity. Graft incorporation is predictable. Advantages of using an autograftharvested in situ include bone stock augmentation, lateralization, low donor-site morbidity, low relative cost, and flexibility needed to simultaneously correct posterior and superior glenoid defects.

Posterior shoulder dislocation with a reverse Hill-Sachs lesion treated with frozen femoral head bone allograft combined with osteochondral autograft transfer.

Management of a posterior shoulder dislocation with an associated reverse Hill-Sachs lesion is challenging, both diagnostically and therapeutically. Diagnosis is frequently delayed or missed, whereas the resulting humeral head defect is often larger and more difficult to salvage than in anterior shoulder dislocations. This report presents the case of a 29-year-old male with a recurrent posterior shoulder dislocation associated with a large reverse Hill-Sachs defect, treated with bone augmentation of the lesion with a combination of fresh femoral head allograft and a locally harvested humeral head autograft transfer, with a successful outcome. Level of evidence V.

Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture.

BACKGROUND: Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture. HYPOTHESIS: RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury. DESIGN: Retrospective case series. MATERIAL AND METHODS: Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse. RESULTS: At final follow-up, average active elevation was 135° (range 110°-145°), abduction 122° (range 60°-160°), and external rotation 30° (range 0 to 45°). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series. DISCUSSION/CONCLUSION: RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure. LEVEL OF EVIDENCE: III.

Reverse total shoulder arthroplasty with structural bone grafting of large glenoid defects.

BACKGROUND: Large glenoid defects pose difficulties in shoulder arthroplasty. Structural grafts consisting of a humeral head autograft, iliac crest, and allograft have been described. Few series describe grafts used with reverse total shoulder arthroplasty (RTSA). METHODS: We retrospectively reviewed patients who had undergone primary or revision RTSA. We identified 44 patients (20 men and 24 women; mean age, 69 years) as having a bulk structural graft to the glenoid behind the baseplate. The grafts consisted of a humeral head autograft in 29, iliac crest autograft in 1, or femoral head allograft in 14. Range of motion data, American Shoulder and Elbow Surgeons score, simple shoulder test, shoulder pain and disability index, and Constant scores were obtained from preoperative and the latest follow-up visits. Radiographs were reviewed from the initial postoperative visit and the latest follow-up. The grafting cohort was compared with an age- and sex-matched cohort of RTSA patients without glenoid grafting. RESULTS: Improvements were seen in the functional outcome scores at the latest follow-up. No significant differences were found in the preoperative or postoperative data between allografts and autografts. Postoperative scores for the bone graft cohort were significantly lower than those in the cohort without grafting. Complete or partial incorporation was shown radiographically in 81% of grafts. Six baseplates were considered loose. Complications included 2 infections, 1 dislocation, 1 humeral loosening, and 2 instances of clinical aseptic baseplate loosening. Six patients showed mild scapular notching. CONCLUSIONS: The use of bulk structural grafts is a promising treatment option. Allografts may yield equally acceptable results compared with autografts.

Bone Grafting the Glenoid Versus Use of Augmented Glenoid Baseplates with Reverse Shoulder Arthroplasty.

BACKGROUND: Large glenoid defects are a difficult reconstructive problem for surgeons performing reverse shoulder arthroplasty (rTSA). Options to address glenoid defects include eccentric reaming, bone grafting, and augmented glenoid baseplates. Augmented glenoid baseplates may provide a simpler, cost-effective, bone-preserving option compared to other techniques. No studies report the use of augmented baseplates to correct glenoid deformity in rTSA relative to the use of glenoid bone graft. MATERIALS AND METHODS: We retrospectively reviewed 80 patients that received a primary rTSA and received either a structural bone graft or an augmented glenoid baseplate to address a significant glenoid defect. There were 39 patients in the augmented baseplate cohort and 41 patients in the bone graft cohort. The augmented baseplate cohort contained 24 8° posterior augment implants and 15 10° superior augment baseplates. The bone graft cohort consisted of 36 autograft humeral heads and 5 allograft femoral heads. The average follow-up for rTSA patients with an augmented baseplate was 28.3 ± 5.7 months, and the average follow-up for rTSA patients with glenoid bone graft was 34.1 ± 15.0 months. Each patient was scored preoperatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics. Range of motion data was obtained as well. RESULTS: All patients demonstrated significant improvements in pain, ROM, and functional scores following treatment with rTSA using either augmented baseplates or glenoid bone graft to correct glenoid defects. The database contained no complications for the augmented glenoid baseplate cohort, and six complications (14.6%) for the glenoid bone graft cohort (including two glenoid loosenings and graft failures). Additionally, the augmented baseplate cohort showed a lower scapular notching rate of 10% as compared to the bone graft cohort which had a notching rate of 18.5%. DISCUSSION: The results of this study suggest that either augmented glenoid baseplates or glenoid bone graft can be used to address large glenoid defects during rTSA with significant improvement in outcomes. Augmented glenoid baseplates may achieve a lower complication and scapular notching rate, but additional and longer-term clinical follow-up is required to confirm these results.

Effectiveness of CT for the detection of glenoid bone graft resorption following reverse shoulder arthroplasty.

INTRODUCTION: Glenoid bone grafting is often used in cases of reverse shoulder arthroplasty (RSA) with glenoid deficiency. Additionally, bony increased-offset RSA (BIO-RSA) uses a cylindrical bonegraft harvested from the humeral head and is positioned beneath the glenoid baseplate to increase lateralization. Postoperative computed tomography (CT) has been used to detect glenoid bonegraft resorption, which is typically identified by a gap between the bonegraft and baseplate; however, CT images are often degraded by implant metal artifact. The purpose of this CT imaging study was to determine if a simulated bonegraft resorption gap is detectable following RSA with glenoid bone grafting. HYPOTHESIS: CT is unable to detect bone graft resorption following reverse shoulder arthroplasty conducted with bone grafting beneath the glenoid baseplate. MATERIALS AND METHODS: RSA with glenoid bone grafting was performed on four cadaver shoulders. Glenoid bonegraft resorption gaps were simulated by fixing the implant at six different gap widths (0, 1, 2, 4, 6 and 8mm). Clinical CT scans were acquired for each gap resulting in 6 scans per specimen. Two experienced observers (blinded) analyzed DICOM images in the axial and coronal directions, and measured gap widths using Mimics(®) software. Each observer had access to approximately 200 images per condition per specimen. RESULTS: The sensitivity of CT imaging to positively identify bonegraft resorption was 38%, with an accuracy of 46%. Inter-observer agreement was 92%. Observers tended to visualize no-gap for most conditions. Resorption gap width measurements were consistently underestimated. DISCUSSION: Metal artifact prevented identification of simulated bonegraft resorption gaps and observers most often determined that there was bonegraft-to-implant "healing" on CT, when in fact a gap was clinically present. This study illustrates the need for more effective imaging techniques to determine if bonegraft resorption has occurred following RSA.

Avoiding superior tilt in reverse shoulder arthroplasty: a review of the literature and technical recommendations.

Superior tilt of the baseplate component in reverse total shoulder arthroplasty leads to tensile baseplate forces and may be a contributor to early loosening. The risk factors for this implant malposition include inadequate exposure through a superior approach and superior glenoid bone deficiency that obscures the native glenoid tilt. Here we review our preoperative evaluation and surgical management strategies to avoid superior tilt. Adequate exposure with a superior approach can be achieved but requires not just proper surgical technique but also careful patient selection. We propose that the superior approach be considered only for acute proximal humerus fractures or in patients when the following criteria are met: no prior open surgery on the shoulder; more than 30° of passive external rotation at 0° of abduction; no medial humeral osteophytes; and any superior migration must be reducible with a sulcus test during examination under anesthesia. Avoiding superior tilt when there is significant superior glenoid erosion can be accomplished with humeral head autograft, most easily performed through a deltopectoral approach. Preoperative templating is critical to determine proper graft thickness, inclination, reaming depth, and harvest technique.

Structural bone grafting for glenoid deficiency in primary total shoulder arthroplasty.

BACKGROUND: Glenoid bone grafting can be useful to restore an asymmetrically eroded glenoid to better support the glenoid component and improve positioning. The purpose of this study was to evaluate the clinical and radiographic results of patients undergoing structural bone grafting for glenoid deficiency with placement of a cemented glenoid component during primary total shoulder arthroplasty. METHODS: Between January 1, 1976, and December 31, 2008, 24 patients (25 shoulders) of 2607 shoulders undergoing primary total shoulder arthroplasty (0.96%) had structural bone grafting with a humeral head autograft and screw fixation. The mean clinical follow-up was 8.7 years, and the mean radiographic follow-up was 7.6 years. RESULTS: Twenty-three shoulders experienced pain relief, and patients expressed satisfaction with the operation in these shoulders. Postoperative active elevation averaged 148°, and external rotation with the arm at the side averaged 60°. On radiographic evaluation, 10 shoulders had glenoids at risk for component loosening. Two of these shoulders were symptomatic and underwent revision surgery to address glenoid component loosening. The Neer result rating was excellent in 18 shoulders, satisfactory in 5, and unsatisfactory in the 2 shoulders undergoing revision. CONCLUSION: Structural bone grafting in primary total shoulder arthroplasty is uncommonly necessary. When it is performed, the clinical outcomes are favorable; however, radiographic analysis shows a moderate rate of failure of glenoid component fixation. It seems likely that alternative treatment methods may prove to be more effective in addressing glenoid wear.

Recurrent, locked posterior glenohumeral dislocation requiring hemiarthroplasty and posterior bone block with humeral head autograft.

This article describes the case of a 77-year-old man with a recurrent posterior shoulder dislocation, treated with humeral hemiarthroplasty and reconstruction of a large posteroinferior glenoid defect with a bone block created from humeral head autograft. On examination, the patient's left arm was held in internal rotation against his stomach, with minimal swelling about the deltoid. His shoulder was nontender to palpation; however, he had substantial motion restrictions, and attempted motion was painful. He could forward elevate to 30°, extend to 0°, internally rotate to belly, and passive external rotation was limited to -30°. He maintained full elbow, wrist, and hand range of motion, and his neurovascular examination was intact. Radiographs revealed a recurrent posterior glenohumeral dislocation, with a large reverse Hill-Sachs defect involving the lesser turberosity and humeral head. Computed tomography with 3-D reconstruction revealed the humeral head defect involving the lesser tuberosity and approximately 40% of the humeral head and a large comminuted posteroinferior glenoid fracture measuring 2.7×0.8 cm, encompassing approximately 30% of the posteroinferior glenoid surface. Standard fixation was not possible; therefore, the resected humeral head was fashioned into an elliptical piece mirroring the size of the defect of the posteroinferior glenoid. Rough measurements of the defect were made and marked on the humeral head, which was then cut with an oscillating saw to approximate the size and shape of the defect. The glenoid graft provided an extension to the glenoid and prevented posterior subluxation with no block to motion. One year postoperatively, he had full strength (5/5) with external rotation, forward elevation, and internal rotation, 140° of active forward elevation, 30° of external rotation, internal rotation to T7, and no episodes of instability. To our knowledge. this is the first report of this technique in the literature. It is an alternative to total shoulder arthroplasty.