Matthew T. Provencher

Arthroscopic Stabilization in Patients With an Inverted Pear Glenoid: Results in Patients With Bone Loss of the Anterior Glenoid

Background Recent literature has demonstrated that the success rates of arthroscopic stabilization of glenohumeral instability deteriorate in patients with an anteroinferior glenoid bone deficiency, also known as the “inverted pear” glenoid. Purpose This study was conducted to assess the outcomes of arthroscopic stabilization for recurrent anterior shoulder instability in patients with a mean anteroinferior glenoid bone deficiency of 25% (range, 20%-30%). Study Design Cohort study; Level of evidence, 3. Methods Twenty-one of 23 patients (91% follow-up) undergoing arthroscopic stabilization surgery and noted to have a bony deficiency of the anteroinferior glenoid of 20% to 30% were reviewed at a mean follow-up of 34 months (range, 26-47). The mean age was 25 years (range, 20-34); 2 patients were female and 19 were male. All patients were treated with a primary anterior arthroscopic stabilization using a mean of 3.2 suture anchors (range, 3-4). Eleven patients had a bony Bankart that was incorporated into the repair; 10 had no bone fragment and were considered attritional bone loss. Outcomes were assessed using the Rowe score, the American Shoulder and Elbow Surgeons (ASES) Score, the Single Assessment Numeric Evaluation (SANE), and the Western Ontario Shoulder Instability (WOSI) Index. Findings of recurrent instability and dislocation events were documented. Results Two patients (9.5%) experienced symptoms of recurrent subluxation, and 1 (4.8%) sustained a recurrent dislocation that required revision open surgery. The mean postoperative outcomes scores were as follows SANE = 88.1 (range, 65-100; standard deviation [SD] 9.0); Rowe = 85.2 (range, 55-100; SD 14.1); ASES Score = 93.1 (range, 78-100; SD 5.3); and WOSI Index = 398 (82% of normal; range, 30-1175; SD 264). No patient with a bony fragment experienced a recurrent subluxation or dislocation, and mean outcomes scores for patients with a bony fragment were better than those with no bony fragment (P = .08). No patient required medical discharge from the military for his or her shoulder condition. Conclusions Arthroscopic stabilization for recurrent instability, even in the presence of a significant bony defect of the glenoid, can yield a stable shoulder; however, outcomes are not as predictable especially in attritional bone loss cases. Longer-term follow-up is needed to see if these results hold up over time.

Anatomic Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability With Glenoid Deficiency Using a Distal Tibia Allograft

The treatment of glenoid bone loss in the setting of recurrent shoulder instability remains a challenge. This is because of the nonanatomic nature and resultant incongruous joint resulting from most bony augmentation procedures. We present a novel technique for the management of glenoid bone deficiency by using a fresh osteochondral distal tibial allograft. We have found that the distal tibia has excellent articular conformity to unmatched humeral heads, fits nearly anatomically on the distal two thirds of the glenoid, is composed of dense weight-bearing cortical and metaphyseal distal tibia bone, and provides for a cartilaginous surface for which the humeral head to articulate. This article describes the technique, initial results, and postoperative findings with the use of a distal tibia allograft (the lateral portion of the distal tibia) for the treatment of glenoid bone deficiency (mean loss of 30%) in a series of 3 patients.

The Modified Bristow Procedure for Anterior Shoulder Instability 26-Year Outcomes in Naval Academy Midshipmen

Background Many procedures have been proposed for the correction of anterior shoulder instability. Some of these procedures address the problem anatomically, such as the Bankart procedure, and some prevent instability nonanatomically, such as the Bristow-Latarjet procedure. A modified Bristow procedure was the procedure of choice for anterior shoulder instability among midshipmen at the United States Naval Academy from 1975 to 1979. Hypothesis The modified Bristow procedure for anterior shoulder instability provides good shoulder function and stability in the long term. Study Design Case series; Level of evidence, 4. Methods There were 52 shoulders in 49 patients reviewed at a mean follow-up of 26.4 years. The Rowe score, Single Assessment Numeric Evaluation, and Western Ontario Shoulder Instability Index were used to assess outcomes. Results The mean Rowe score was 81.8 (range, 5-100), and the mean Single Assessment Numeric Evaluation score was 82.9 (range, 30-100), with an overall Single Assessment Numeric Evaluation of 71.2% (37 of 52 shoulders) rated as good and excellent. The mean Western Ontario Shoulder Instability Index was 376 of 2100 (range, 0-1560). Overall, recurrent instability occurred in 8 of 52 shoulders (15.4%), with recurrent dislocation in 5 shoulders (9.6%) and recurrent subluxation in 3 shoulders (5.8%). The mean time to recurrent dislocation was 7.0 years. Conclusion This study represents the longest follow-up in the literature of the modified Bristow procedure. The authors have shown nearly 70% good and excellent results and recurrent instability comparable with other long-term follow-up studies of open instability procedures.

Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management

&NA; Recurrent anterior shoulder instability may result from a spectrum of overlapping, often coexistent factors, one of which is glenoid bone loss. Untreated, glenoid bone loss may lead to recurrent instability and poor patient satisfaction. Recent studies suggest that the glenoid rim is altered in up to 90% of shoulders with recurrent instability, thus underscoring the need for careful diagnosis, quantification, and preoperative evaluation. Biomechanical and clinical studies offer criteria that may be used in both primary and revision settings to judge whether shoulder stability is compromised by a bony defect. Along with patient activity level, these criteria can help guide the surgeon in selecting treatment options, which range from nonsurgical care to isolated soft‐tissue repair as well as various means of bony reconstitution.

Overview of existing cartilage repair technology.

Currently, autologous chondrocyte implantation and osteochondral grafting bridge the gap between palliation of cartilage injury and resurfacing via arthroplasty. Emerging technologies seek to advance first generation techniques and accomplish several goals including predictable outcomes, cost-effective technology, single-stage procedures, and creation of durable repair tissue. The biologic pipeline represents a variety of technologies including synthetics, scaffolds, cell therapy, and cell-infused matrices. Synthetic constructs, an alternative to biologic repair, resurface a focal chondral defect rather than the entire joint surface. Scaffolds are cell-free constructs designed as a biologic “net” to augment marrow stimulation techniques. Minced cartilage technology uses stabilized autologous or allogeneic fragments in 1-stage transplantation. Second and third generation cell-based methods include alternative membranes, chondrocyte seeding, and culturing onto scaffolds. Despite the promising early results of these products, significant technical obstacles remain along with unknown long-term durability. The vast array of developing technologies has exceptional promise and the potential to revolutionize the cartilage treatment algorithm within the next decade.

Does the Literature Confirm Superior Clinical Results in Radiographically Healed Rotator Cuffs After Rotator Cuff Repair

PURPOSE Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies. METHODS Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies. RESULTS Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies. CONCLUSIONS The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes. LEVEL OF EVIDENCE Level IV, systematic review.

The outcomes of lumbar microdiscectomy in a young, active population: correlation by herniation type and level.

Study Design. Prospective longitudinal clinical study. Objective. The purpose of our article was to investigate the clinical outcomes with type and level of disc herniation in a young, active population undergoing lumbar microdiscectomy. Summary of Background Data. There are few reported outcomes studies on the relationship between disc herniation level, type of disc herniation, and surgical outcomes of lumbar microdiscectomy in a young, active population. Methods. One hundred ninety-seven (197) consecutive single-level lumbar microdiscectomies performed by a single surgeon were prospectively followed over a 3-year period. All patients had failed a period of nonoperative care including physical therapy and/or transforaminal epidural steroid injections. One hundred eighty-three patients (139 males, 44 females) with a mean age of 27.0 years (range 19–46 years) were prospectively followed for a mean of 26 months (range, 12–38 months). Outcomes were assessed using Visual Analog Scale (VAS), Oswestry disability index, patient satisfaction, return to military duty, and need for additional surgery. The type of disc herniation (contained, extruded, or sequestered) and the lumbar level of herniation were also recorded. Results. At final follow-up, 84% (154 of 183) of patients had returned to unrestricted military duty; 16% (29) had been medically discharged. The mean decrease in VAS leg pain score was 4.7 points (from mean preoperative 7.2 to mean postoperative 2.5); 80% (146) reported a decrease of greater than 2 points. The mean Oswestry index improved from 53.6 before surgery to 21.2 at final follow-up. Overall, 85% (156) were satisfied with their surgery. Six patients had recurrent herniations (3%) with 4 of the 6 undergoing additional surgery. Patients with preoperative VAS scores consistent with a preponderance of radicular leg pain versus back pain demonstrated better surgical outcomes in all categories (P < 0.001) When classified by disc herniation type, sequestered discs at all levels demonstrated better Oswestry and VAS scores versus extruded or contained disc herniations. (P < 0.001) Disc herniations at the L5–S1 level had significantly greater improvements in both mean VAS leg and Oswestry outcome scores than disc herniations at the L4–L5 level. (P < 0.001) Preexisting restricted duty status at time of first surgical consultation was associated with poorer outcomes. Smokers had a significantly lower return to full active military duty (P = 0.037). Conclusion. Microdiscectomy for symptomatic lumbar disc herniations in young, active patients with a preponderance of leg pain who have failed nonoperative treatment demonstrated a high success rate based on validated outcome measures, patient satisfaction, and return to active duty. Patients with disc herniations at the L5–S1 level had significantly better outcomes than did those at the L4–L5 level. Patients with sequestered or extruded lumbar disc herniations had significantly better outcomes than did those contained herniations. Patients with contained disc herniations, a predominance of back pain, on restricted duty and smoking should be counseled before surgery of the potential for less satisfaction, poorer outcomes scores, and decreased return to duty rates.

Arthroscopic Treatment of Posterior Shoulder Instability: Results in 33 Patients

Background Posterior shoulder instability is a relatively rare condition and a surgical challenge. Arthroscopic techniques have allowed for a potential improvement as well as diagnosis and management of this condition. Purpose To evaluate the outcomes of arthroscopic posterior shoulder stabilization and to evaluate preoperative and intraoperative variables as predictors of success. Study Design Case series; Level of evidence, 4. Methods Thirty-three consecutive patients with a mean age of 25 years (range, 19-34 years) who underwent posterior arthroscopic shoulder stabilization with suture anchors (mean, 3 anchors) or suture capsulolabral plication (mean, 5.3 stitches) or both were reviewed at a mean follow-up of 39.1 months (range, 22-60 months). Shoulder outcomes rating scores were determined using the American Shoulder and Elbow Surgeons Rating Scale, the Western Ontario Shoulder Instability Index, the Subjective Patient Shoulder Evaluation, and the Single Assessment Numeric Evaluation. Results There were 7 failures: 4 for recurrent instability and 3 for symptoms of pain. Overall, outcomes scores demonstrated mean values of the American Shoulder and Elbow Surgeons Rating Scale of 94.6, Subjective Patient Shoulder Evaluation of 20.0, Western Ontario Shoulder Instability Index of 389.4 (81.5% of normal), and Single Assessment Numeric Evaluation of 87.5. Patients with voluntary instability demonstrated worse outcomes (P=. 025), and those with prior surgery of the shoulder also did worse (P=. 02). Conclusion Arthroscopic treatment of posterior shoulder instability is an effective means to improve symptoms associated with recurrent posterior subluxation of the shoulder. It can provide predictable success in the setting of unidirectional, nonvoluntary posterior instability without prior surgery.

The Hill-Sachs lesion: diagnosis, classification, and management.

The Hill‐Sachs lesion is an osseous defect of the humeral head that is typically associated with anterior shoulder instability. The incidence of these lesions in the setting of glenohumeral instability is relatively high and approaches 100% in persons with recurrent anterior shoulder instability. Reverse Hill‐Sachs lesion has been described in patients with posterior shoulder instability. Glenoid bone loss is typically associated with the Hill‐Sachs lesion in patients with recurrent anterior shoulder instability. The lesion is a bipolar injury, and identification of concomitant glenoid bone loss is essential to optimize clinical outcome. Other pathology (eg, Bankart tear, labral or capsular injuries) must be identified, as well. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. Nonsurgical management, including focused rehabilitation, is acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.

Normalization of Glenohumeral Articular Contact Pressures After Latarjet or Iliac Crest Bone-Grafting

BACKGROUND Multiple bone-grafting procedures have been described for patients with glenoid bone loss and shoulder instability. The purpose of this study was to investigate the alterations in glenohumeral contact pressure associated with the placement and orientation of Latarjet or iliac crest bone graft augmentation and to compare the amount of glenoid bone reconstruction with two coracoid face orientations. METHODS Twelve fresh-frozen cadaver shoulders were tested in static positions of humeral abduction (30 degrees , 60 degrees , and 60 degrees with 90 degrees of external rotation) with a 440-N compressive load. Glenohumeral contact pressure and area were determined sequentially for (1) the intact glenoid; (2) a glenoid with an anterior bone defect involving 15% or 30% of the glenoid surface area; (3) a 30% glenoid defect treated with a Latarjet or iliac crest bone graft placed 2 mm proud, placed flush, or recessed 2 mm in relation to the level of the glenoid; and (4) a Latarjet bone block placed flush and oriented with either the lateral (Latarjet-LAT) or the inferior (Latarjet-INF) surface of the coracoid as the glenoid face. The amount of glenoid bone reconstructed was compared between the Latarjet-LAT and Latarjet-INF conditions. RESULTS Bone grafts in the flush position restored the mean peak contact pressure to 116% of normal when the iliac crest bone graft was used (p < 0.03 compared with the pressure with the 30% defect), 120% when the Latarjet-INF bone block was used (p < 0.03), and 137% when the Latarjet-LAT bone block was used (p < 0.04). Use of the Latarjet-LAT bone block resulted in mean peak pressures that were significantly higher than those associated with the iliac crest bone graft (p < 0.02) or the Latarjet-INF bone block (p < 0.03) at 60 degrees of abduction and 90 degrees of external rotation. With the bone grafts placed in a proud position, peak contact pressure increased to 250% of normal (p < 0.01) in the anteroinferior quadrant and there was a concomitant increase in the posterosuperior glenoid pressure to 200% of normal (p < 0.02), indicating a shift posteriorly. Peak contact pressures of bone grafts placed in a recessed position revealed high edge-loading. Augmentation with the Latarjet-LAT bone block led to restoration of the glenoid articular contact surface from the 30% defect state to a 5% defect state. Augmentation of the 30% glenoid defect with the Latarjet-INF bone block resulted in complete restoration to the intact glenoid articular surface area. CONCLUSIONS Glenohumeral contact pressure is optimally restored with a flush iliac crest bone graft or with a flush Latarjet bone block with the inferior aspect of the coracoid becoming the glenoid surface. Bone grafts placed in a proud position not only increase the peak pressure anteroinferiorly, but also shift the articular contact pressure to the posterosuperior quadrant. Glenoid bone augmentation with a Latarjet bone block with the inferior aspect of the coracoid as the glenoid surface resulted in complete restoration of the 30% anterior glenoid defect to the intact state. These findings indicate the clinical utility of a flush iliac crest bone graft and utilization of the inferior surface of the coracoid as the glenoid face for glenoid bone augmentation with a Latarjet graft.