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Anteroinferior Bone-Grafting Can Restore Stability in Osseous Glenoid Defects
William H. MontgomeryJr., MD, MPH1; Melvin Wahl, MD1; Carolyn Hettrich, MD1; Eiji Itoi, MD2; Steven B. Lippitt, MD3; Frederick A. MatsenIII, MD1
1 Departments of Orthopaedics and Sports Medicine (W.H.M. Jr., M.W., F.A.M. III) and Medicine (C.H.), University of Washington Medical Center, Box 356500 (W.H.M. Jr., M.W., F.A.M. III) and Box 356420 (C.H.), 1959 N.E. Pacific Street, Seattle, WA 98195. E-mail address for F.A. Matsen III: matsen@u.washington.edu
2 Department of Orthopedic Surgery, Akita University School of Medicine, Hondo 1-1-1, Akita 010-8543, Japan
3 Akron General Medical Center, 224 West Exchange Street, Suite 440, Akron, OH 44302
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Sep 01;87(9):1972-1977. doi: 10.2106/JBJS.D.02573
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Abstract

Background: Glenohumeral instability associated with a large osseous defect of the glenoid can be treated with bone graft to restore the glenoid concavity. The shape and positioning of the graft is critical: a graft that encroaches on the extrapolated glenoid curvature can prevent the head from seating completely in the glenoid, whereas a graft that is too far from the curvature does not restore the glenoid concavity. The purpose of the present study was to investigate how the intrinsic stability that is provided by the glenoid is affected by (1) a standardized anteroinferior glenoid defect and (2) different configurations of anteroinferior glenoid bone graft.

Methods: The anteroinferior stability provided by the glenoid was quantitated by measuring the balance stability angle in that direction. The balance stability angle is the maximal angle that the direction of the net humeral joint-reaction force can make with the glenoid centerline before dislocation takes place. The anteroinferior stability was assessed in each of four fresh-frozen, grossly normal cadaveric glenoids in (1) the unaltered state, (2) after the creation of a standardized defect of a magnitude that has been reported by other investigators to be sufficient to require a bone graft, and (3) after each step of a series of bone-grafting procedures involving grafts of varying height and contour.

Results: The anteroinferior glenoid defect significantly diminished the anteroinferior stability by almost 50% (p = 0.006). Bone-grafting significantly increased the stability provided by the glenoid. The increase in stability as compared with that of the glenoid with the standardized defect was particularly marked for contoured graft heights of 6 and 8 mm, for which the increases were 150% (p = 0.0001) and 229% (p < 0.00025), respectively. Contouring of the graft minimized the potential for unwanted contact between the ball and the graft.

Conclusions: Anteroinferior shoulder instability caused by an osseous defect in the glenoid can be corrected with bone-grafting. The effectiveness of the graft in restoring the lost stability is related both to its height and to the extent to which it is contoured as long as the graft is not so prominent that it forces the ball posteriorly from the center of the glenoid.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Frederick A. Matsen III, M.D.
    Posted on February 13, 2006
    Dr. Matsen replies to Dr. Barchilon & Dr. Meir
    Depts. of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA

    We concur with Drs. Barchilon and Meir that the actual defect in patients can range from vertical to oblique. In our cadaver study, we chose to emulate the lesion described by Itoi in JBJS.

    Vidal S. Barchilon
    Posted on February 05, 2006
    Location of the glenoid defect in recurrent anterior dislocations of the shoulder
    Sapir Medical Center, Kfar-Saba, ISRAEL

    To The Editor:

    We read with interest the article by Montgomery et al, "Anteroinferior Bone-Grafting Can Restore Stability in Osseous Glenoid Defects." We would like to draw attention to the fact that the defect size was created along a line inclined 45° from the centerline to the anteroinferior border of the glenoid with the apex at the 4:30 or 7:30 position, as suggested by Itoi, et al. (1)

    The glenoid defect is located almost anterior to the glenoid in patients with recurrent anterior dislocations of the shoulder. The mean orientation of the defect pointing toward 3:01 on the clock face of the glenoid, at a mean angle of 90.5° ± 10.4° from the 12-o'clock direction, as decribed by Saito, et al. (2)

    The model described by Itoi may need to be updated as it does not reflect the actual pathological anatomy of the glenoid in patients with recurrent anterior dislocations of the shoulder.

    References:

    1. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000; 82:35-46.

    2. Saito H, , Itoi E, Sugaya H, Minagawa H, Yamamoto N, Tuoheti Y, The American Journal of Sports Medicine, Vol. 33, No.Vol. 33, No. 6, 2005 Location of the Glenoid Defect in Shoulders With Recurrent Anterior Dislocation Hidetomo

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