The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 9

Scientific Articles | September 01, 2005

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.

Figures in this Article

Multiple pathoanatomic conditions contribute to recurrent anterior instability of the shoulder^1-10. The glenoid fossa plays a major role in stabilizing the humeral head. Loss of this osteochondral concavity can contribute to recurrent instability and to the failure of soft-tissue repair^11-15. It has been suggested that a bone defect involving 30% of the surface area of the glenoid face leads to recurrent anterior instability requiring bone-grafting¹⁶. Itoi et al. recently showed that when the width of an anteroinferior glenoid defect involved 21% of the length of the glenoid face, recurrent instability is likely to occur despite Bankart repair¹⁷.

Several authors have presented methods for reconstituting anteroinferior bone loss^6,10,18-22. Bone-grafting the anteroinferior defect with use of iliac crest graft is a well-known method of restoring the lost glenoid bone, glenoid concavity, and shoulder stability^23,24. The shape and positioning of the graft are critical: a graft that encroaches on the extrapolated glenoid curvature may prevent the head from seating in the glenoid, whereas a graft that is too far from the curvature may not restore the glenoid contribution to stability. Observations of axillary radiographs and computerized tomographic scans after anterior bone-graft surgery reveal that the graft often is placed either prominently (extending beyond the extrapolated contour of the glenoid) or, conversely, recessed on the glenoid neck (medial to the extrapolated contour of the glenoid). Optimizing glenohumeral stability with bone-grafting during surgery is more complicated than may be apparent initially. The purpose of the present study was to use a cadaveric model involving a "critical" sized glenoid defect (as defined previously in the literature^6,10,17) to test the hypotheses that (1) the osseous glenoid defect substantially compromises the stability provided by the socket and (2) reconstruction with a bone graft can enhance the contribution of the glenoid to stability. We also sought to determine the effect of different graft configurations on the stability provided by the glenoid fossa.

Materials and Methods

Materials and Methods | Results | Discussion | References

Specimens

Four fresh-frozen cadaveric shoulders were obtained from two eighty-five-year-old male donors. These specimens demonstrated no evidence of arthritis or other abnormalities of the glenoid fossa. The shoulders were thawed for twenty-four hours prior to use, and all soft tissues, including the labrum, were removed. The glenoids were then potted in plaster within a metal frame. The glenoid face was oriented parallel to the floor in all quadrants, and the orientation was confirmed with use of a level.

Stability

For the purpose of the present study, the stability of the glenoid specimens was measured by determining the maximal angle that the glenoid could be tipped in the anteroinferior direction (from an initial position with the glenoid facing vertically upward) before a ball placed in the concavity dislocated over the lip. We refer to the maximal angle of tip achieved before dislocation as the "balance stability angle." Previous studies have shown this to be a reproducible method for documenting the contribution of the glenoid concavity to stability^25,26. It also has been demonstrated that the balance stability angle is not affected by the size of the ball as long as its radius of curvature is not larger than that of the glenoid²⁶. This condition was met in all of the glenoids studied in this investigation. A motorized device was used to tip the glenoid from the initial face-upward position at a rate of 9° per second while the angle of tip was recorded with use of an inclinometer. The angle at which the ball rolled from the glenoid was the balance stability angle.

In a preliminary trial, four balls with a diameter of 5.08 cm (including one made of plastic and weighing 0.075 kg, one made of aluminum and weighing 0.18 kg, one made of steel and weighing 0.52 kg, and one made of carbonate and weighing 1.1 kg) were subject to three trials each involving the same glenoid to ensure that the weight of the ball had no effect on the balance stability angle. All measurements in all trials among all four balls of different weights were within 1° of each other; therefore, for the definitive experiments, the aluminum ball weighing 0.18 kg was utilized.

Defect Protocol

Defect size and orientation were standardized with use of the parameters suggested by Itoi et al.¹⁷. The superoinferior glenoid length was measured for each glenoid. The length measurement was then multiplied by 0.21 to determine the defect size to be 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, depending on whether a right or left glenoid was utilized. The lengths of the glenoids ranged from 32 to 34 mm. All defects created were 7 mm in maximal width (comprising 20.6% to 21.9% of the glenoid face length) (Figs. 1-A, 1-B, and 1-C).

Reconstruction

Reconstruction of the glenoid defect with a bone block was accomplished with use of a block measuring 20 mm in length × 25 mm in height × 8 mm in width. This graft was harvested from the tip of the scapula for convenience, with the recognition that in the clinical situation the graft is harvested from the iliac crest or an allograft is used. Each glenoid was grafted with bone harvested from the ipsilateral scapula. Once the stability was quantitated for the normal glenoid and for the glenoid with the standardized defect, the reconstruction was performed. The uncontoured bone block was secured to the defect with use of two 3.5-mm cannulated screws that were placed through the graft and into the native glenoid subchondral bone (Fig. 1-C). The graft initially was placed at a height of 8 mm above the glenoid face and was left uncontoured.

Experimental Protocol

The anteroinferior balance stability angle was measured three times for each of the four glenoids for each preparation: the native state, after creation of the defect, and in the presence of an 8-mm graft (uncontoured) (Fig. 2-A), an 8-mm graft (contoured), a 6-mm graft (contoured) (Fig. 2-B), a 4-mm graft (contoured), a 2-mm graft (contoured), and a graft that was flush with the glenoid face. For each preparation for each glenoid, the three trials were averaged. Contouring was performed as a surgeon would perform it in the operating room, with the bone graft being shaped by eye to match the curvature of the ball with use of a pinecone burr. The contouring of the graft was performed in situ without removal of the screws. Physiologic saline solution was applied to the glenoid face between trials to prevent desiccation. The glenoids also were observed to confirm the graft height at which contact of the ball with the graft was eliminated, allowing the ball to seat in the reconstructed glenoid.

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Figs. 1-A, 1-B, and 1-C: Photographs illustrating the creation of the anteroinferior glenoid defect. Fig. 1-A A normal glenoid.

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Fig. 1-B: A glenoid with the standard defect.

Data Analysis

Paired t tests were utilized to compare the stability angle for each preparation with that of (1) the native glenoid, (2) the glenoid with the standardized defect, and (3) the glenoid after different configurations of bone-grafting. The level of significance was set at p < 0.05.

Results

Materials and Methods | Results | Discussion | References

The results of the tests are shown in Table I. The balance stability angles were reproducible (within 1°) across all trials for each preparation of each glenoid. The average balance stability angle of the native glenoids (and standard deviation) was 26° ± 2°, with a significant decrement to 14° ± 2° when the defect was created (p = 0.006). An uncontoured 8-mm graft was associated with an average balance stability angle of 31° ± 9°; when the 8-mm graft was contoured, the average stability angle increased to 46° ± 4°. The ball was noted to roll around (rather than roll over) the 8-mm uncontoured graft when the construct was tipped in the cases of three of the four glenoids (the exception being glenoid number 4).

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TABLE I Balance Stability Angles of Differing Glenoid States

	Balance Stability Angle (°)
	Native	Defect	8 mm Uncontoured	8 mm Contoured	6 mm Contoured	4 mm Contoured	2 mm Contoured	Flat
Glenoid 1	29	11	23	42	32	31	28	24
Glenoid 2	24	13	32	49	38	34	27	21
Glenoid 3	28	17	26	49	36	32	24	21
Glenoid 4	24	15	44	44	33	27	25	22
Average and standard deviation	26 ± 2	14 ± 2	31 ± 9	46 ± 4	35 ± 3	31 ± 3	26 ± 2	22 ± 1
P value for difference from initial (native) angle		0.006	0.473	0.004	0.027	0.062	0.790	0.018
P value for difference from defect angle			0.033	<0.0001	0.001	0.004	0.012	0.021

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TABLE I Balance Stability Angles of Differing Glenoid States

	Balance Stability Angle (°)
	Native	Defect	8 mm Uncontoured	8 mm Contoured	6 mm Contoured	4 mm Contoured	2 mm Contoured	Flat
Glenoid 1	29	11	23	42	32	31	28	24
Glenoid 2	24	13	32	49	38	34	27	21
Glenoid 3	28	17	26	49	36	32	24	21
Glenoid 4	24	15	44	44	33	27	25	22
Average and standard deviation	26 ± 2	14 ± 2	31 ± 9	46 ± 4	35 ± 3	31 ± 3	26 ± 2	22 ± 1
P value for difference from initial (native) angle		0.006	0.473	0.004	0.027	0.062	0.790	0.018
P value for difference from defect angle			0.033	<0.0001	0.001	0.004	0.012	0.021

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Fig. 1-C: A glenoid with a graft.

In comparison with the glenoid defect preparation, each of the glenoid reconstruction preparations demonstrated significantly enhanced stability, with the balance stability angle measuring 46° ± 4° for the 8-mm contoured graft (p < 0.0001), 35° ± 3° for the 6-mm contoured graft (p = 0.001), 31° ± 3° for the 4-mm contoured graft (p = 0.004), 26° ± 2° for the 2-mm contoured graft (p = 0.012), and 22° ± 1° for the flat graft (p = 0.021).

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Figs. 2-A and 2-B: Photographs showing the relationship of the raft to the contour of the glenoid and the ball. Fig. 2-A An 8-mm uncontoured graft.

The balance stability angles associated with the glenoids that had been reconstructed with contoured graft heights of 8 mm and 6 mm were significantly greater than the initial stability angle of the native glenoid (p = 0.004 and p = 0.027), while the balance stability angle associated with the glenoids that had been reconstructed with a graft height of 4 mm approached a significant difference compared with the initial angle (p = 0.062). The average stability angle of the glenoids with the contoured graft placed at 4 mm was almost 5° greater than that of the native glenoid, whereas the average stability angle of the glenoids with a graft height of 2 mm was within 0.4° of that of the native glenoid. The ball was observed to be perched on the graft and posterior glenoid at graft heights of 6 mm.

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Fig. 2-B: A 6-mm contoured graft.

Discussion

Materials and Methods | Results | Discussion | References

Traumatic anterior instability of the glenohumeral joint is most commonly associated with a Bankart lesion, which can be successfully reconstructed either arthroscopically^27-29 or with open surgical methods^12,30-33. However, the orthopaedic surgeon must carefully evaluate the glenoid concavity with radiographs before undertaking a soft-tissue reconstruction because bone defects can play an important role in the failure of a Bankart repair^6,10,17,24. Osteochondral defects of the glenoid may be subtle, can be easily missed, and are best evaluated with special radiographic views, such as the West Point view, for a higher diagnostic yield^34-36. Computed tomography also may be of use for quantifying and characterizing the amount of glenoid bone loss^34,37.

Osseous lesions of the anteroinferior part of the glenoid have been reported to occur in association with 5.4% to 78.8% of shoulders with recurrent anterior dislocation^3,9,16,38-41. Glenoid bone loss narrows the range of positions in which bone can support the net humeral joint-reaction force, placing the shoulder at greater risk for dislocation in the unsupported positions. Reestablishing the lost anteroinferior bone with a well-contoured bone graft expands the surface area of the glenoid and restores the glenoid concavity, allowing for the restoration of stabilizing mechanisms. In addition to restoring stability, bone-grafting allows for a more even distribution of contact pressures. Greis et al. found that a 30% loss of glenoid face surface area increases anteroinferior contact pressures by 300% to 400%, suggesting that early osteoarthritis could result from neglect of the lesion⁴².

Numerous procedures have been performed to treat such bone loss, with variable results and long-term consequences¹⁸-22,⁴³. Restoring glenoid concavity through the use of iliac crest autografting appears to provide a strong, durable construct that can help to restore shoulder stability²⁴. However, we are not aware of any previous reports in the literature that have discussed the optimal configuration for the graft. In the present study, we documented the effects of a standardized glenoid defect and the degree of restoration of stability with different graft configurations. We also noted that when the graft was placed in a high position, it had the potential to push the ball posteriorly on the glenoid. In vivo, such an occurrence could both compromise stability and place the shoulder at risk for degenerative joint disease.

The results of our study should be interpreted in light of several limitations. First, the balance stability angle examines the contribution of the glenoid fossa to shoulder stability without consideration of the role played by ligaments, labrum, and capsule. However, it is the contribution of the socket to glenohumeral stability that is in question in cases of glenoid deficiency. Second, the load applied to the glenoid in our experiments did not represent the range of loads encountered in vivo. However, the stability provided by the glenoid was not observed to be load-dependent in our pilot study. Third, while glenoid defects occur clinically in many different dimensions, we studied only one size of defect. However, this is the size of defect that has been identified as critical by Itoi et al.¹⁷, Burkhart and De Beer⁶, and Lo et al.¹⁰. Fourth, we created a consistent defect and a consistent reconstruction. Clinically, there is variability in defect size and in graft width and height, all of which may affect the resulting change in stability. However, the present study demonstrated the potential effectiveness of grafting for the treatment of a glenoid defect. Fifth, we used only four specimens from two cadavera. However, the results were so uniform and significant, it is unlikely that the conclusions of the present study would have been changed by the inclusion of additional specimens. Finally, we, along with some other authors, often perform a modification of the grafting procedure that is designed to render the graft extracapsular either by placing the graft medial to the intact capsule or by repairing the capsule to the edge of the remaining portion of the glenoid lip after the graft has been placed²⁴. This modification of the grafting procedure was not explored in the present study.

In conclusion, the present study demonstrates that a highly significant loss of stability results from the creation of a standardized anteroinferior glenoid defect. It further shows that the lost stability can be significantly restored by an appropriately contoured bone graft. The ideal graft would restore stability while preserving the centered position of the humeral head in the glenoid fossa. In this model, uncontoured and contoured 8-mm grafts caused undesirable posterior displacement of the humeral head from the center of the glenoid, whereas contoured grafts of 2, 4, or 6 mm significantly restored or even increased the stability provided by the glenoid without displacing the humeral head from the glenoid center. ?

References

Materials and Methods | Results | Discussion | References

Robinson CM, Kelly M, Wakefield AE. Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: risk factors and results of treatment. J Bone Joint Surg Am.2002;84: 1552-9.841552 2002 [PubMed]

Bankart ASB. Recurrent or habitual dislocation of the shoulder-joint. Br Med J.1923;2: 1132-3.21132 1923 [PubMed][CrossRef]

Bigliani LU, Newton PM, Steinmann SP, Connor PM, McIlveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med.1998;26: 41-5.2641 1998 [PubMed]

Aston JW Jr, Gregory CF. Dislocation of the shoulder with significant fracture of the glenoid. J Bone Joint Surg Am.1973;55: 1531-3.551531 1973

Kummel BM. Fractures of the glenoid causing chronic dislocation of the shoulder. Clin Orthop Relat Res.1970;69: 189-91.69189 1970

Burkhart SS, De Beer JF. 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. Arthroscopy.2000;16: 677-94.16677 2000 [PubMed][CrossRef]

Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am.1956;38: 957-77.38957 1956 [PubMed]

McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. II. A comparative study. J Trauma.1967;7: 191-201.7191 1967 [CrossRef]

Rowe CR, Sakellarides HT. Factors related to recurrences of anterior dislocations of the shoulder. Clin Orthop Relat Res.1961;20: 40-8.2040 1961

Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy.2004;20: 169-74.20169 2004 [PubMed][CrossRef]

Lazarus MD, Sidles JA, Harryman DT 2nd, Matsen FA 3rd. Effect of a chondral-labral defect on glenoid concavity and glenohumeral stability. A cadaveric model. J Bone Joint Surg Am.1996;78: 94-102.7894 1996

Matsen FA 3rd, Titelman RM, Lippitt SB, Rockwood CA Jr, Wirth MA. Glenohumeral instability. In: Rockwood CA Jr, Matsen FA 3rd, Wirth MA, Lippitt SB, editors. The shoulder. 3rd ed. Volume 2. Philadelphia: Saunders; 2004. p 655-794.2655 2004

Hayashida K, Yoneda M, Nakagawa S, Okamura K, Fukushima S. Arthroscopic Bankart suture repair for traumatic anterior shoulder instability: analysis of the causes of a recurrence. Arthroscopy.1998;14: 295-301.14295 1998 [PubMed][CrossRef]

Gill TJ, Zarins B. Open repairs for the treatment of anterior shoulder instability. Am J Sports Med.2003;31: 142-53.31142 2003 [PubMed]

Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. Clin Orthop Relat Res.2002;400: 65-76.40065 2002 [PubMed][CrossRef]

Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am.1978;60: 1-16.601 1978

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: 35-46.8235 2000

Latarjet M. [Treatment of recurrent dislocation of the shoulder]. Lyon Chir.1954;49: 994-7.49994 1954 [PubMed]

Hybbinette S. De la transplantation d'un fragment osseux pour remedier aux luxations recidivantes de l'epaule: constatations et resultats operatoires. Acta Chir Scand.1932;71: 411-45.71411 1932

Palmer I, Widen A. The bone block method for recurrent dislocation of the shoulder joint. J Bone Joint Surg Br.1948;30: 53-8.3053 1948

Eden R. Zur Operation der habituellen Schulterluxation unter Mitteilung eines neuen Verfahrens bei Abriß am inneren Pfannenrande. Deutsche Zeitschrift Chirurgie.1918;144: 269-80.144269 1918

Oudard M. La luxation récidivante de l'epaule (variété antéro-interne). Procédé opératoire. J Chir.1924;23: 13-25.2313 1924

Churchill RS, Moskal MJ, Lippitt SB, Matsen FA 3rd. Extracapsular anatomically contoured anterior glenoid bone grafting for complex glenohumeral instability. Tech Shoulder Elbow Surg.2001;2: 210-8.2210 2001 [CrossRef]

Matsen FA 3rd, Lippitt SB, editors. Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2004. Procedure: reconstruction of a deficient anterior glenoid lip using an extracapsular anatomically contoured iliac crest graft. p 150-74.150 2004

Weldon EJ 3rd, Scarlat MM, Lee SB, Matsen FA 3rd. Instrinsic stability of unused and retrieved polyethylene glenoid components. J Shoulder Elbow Surg.2001;10: 474-81.10474 2001 [PubMed][CrossRef]

Weldon EJ 3rd, Boorman RS, Smith KL, Matsen FA 3rd. Optimizing the glenoid contribution to the stability of a humeral hemiarthroplasty without a prosthetic glenoid. J Bone Joint Surg Am.2004;86: 2022-9.862022 2004

Bacilla P, Field LD, Savoie FH 3rd. Arthroscopic Bankart repair in a high demand patient population. Arthroscopy.1997;13: 51-60.1351 1997 [PubMed][CrossRef]

Morgan CD, Bodenstab AB. Arthroscopic Bankart suture repair: technique and early results. Arthroscopy.1987;3: 111-22.3111 1987 [PubMed][CrossRef]

McIntyre LF, Caspari RB. The rationale and technique for arthroscopic reconstruction of anterior shoulder instability using multiple sutures. Orthop Clin North Am.1993;24: 55-8.2455 1993 [PubMed]

Gill TJ, Micheli LJ, Gebhard F, Binder C. Bankart repair for anterior instability of the shoulder. Long-term outcome. J Bone Joint Surg Am.1997;79: 850-7.79850 1997 [PubMed]

Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am.1996;78: 1677-84.781677 1996

Bankart ASB. The pathology and treatment of recurrent dislocation of the shoulder-joint. Br J Surg.1938;26: 23-9.2623 1938 [CrossRef]

Uhorchak JM, Arciero RA, Huggard D, Taylor DC. Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports. Am J Sports Med.2000;28: 794-9.28794 2000

Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med.2003;31: 112-8.31112 2003 [PubMed]

Pavlov H, Warren RF, Weiss CB Jr, Dines DM. The roentgenographic evaluation of anterior shoulder instability. Clin Orthop Relat Res.1985;194: 153-8.194153 1985 [PubMed]

Rokous JR, Feagin JA, Abbott HG. Modified axillary roentgenogram. A useful adjunct in the diagnosis of recurrent instability of the shoulder. Clin Orthop Relat Res.1972;82: 84-6.8284 1972 [PubMed]

Seltzer SE, Weissman BN. CT findings in normal and dislocating shoulders. J Can Assoc Radiol.1985;36: 41-6.3641 1985 [PubMed]

Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy.2003;19: 732-9.19732 2003 [PubMed][CrossRef]

Hovelius L, Eriksson K, Fredin H, Hagberg G, Hussenius A, Lind B, Thorling J, Weckstrom J. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am.1983;65: 343-9.65343 1983 [PubMed]

Norlin R. Use of Mitek anchoring for Bankart repair: a comparative, randomized, prospective study with traditional bone sutures. J Shoulder Elbow Surg.1994;3: 381-5.3381 1994 [CrossRef]

Liu SH, Henry MH. Anterior shoulder instability. Current review. Clin Orthop Relat Res.1996;323: 327-37.323327 1996 [PubMed][CrossRef]

Greis PE, Scuderi MG, Mohr A, Bachus KN, Burks RT. Glenohumeral articular contact areas and pressures following labral and osseous injury to the anteroinferior quadrant of the glenoid. J Shoulder Elbow Surg.2002;11: 442-51.11442 2002 [CrossRef]

Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br.1958;40: 198-202.40198 1958 [PubMed]

Topics

bone transplantation ; reconstructive surgical procedures ; tissue transplants

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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 45Â° 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 90.5Â° Â± 10.4Â° 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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William H. MontgomeryJr., Melvin Wahl, Carolyn Hettrich, Eiji Itoi, Steven B. Lippitt, Frederick A. MatsenIII; Anteroinferior Bone-Grafting Can Restore Stability in Osseous Glenoid Defects. The Journal of Bone & Joint Surgery. 2005 Sep;87(9):1972-1977.

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