Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures

doi:10.1016/j.jse.2015.09.012

Journal of Shoulder and Elbow Surgery

Volume 25, Issue 5, May 2016, Pages 781-790

https://doi.org/10.1016/j.jse.2015.09.012 Get rights and content

Background

The optimal treatment of large anterior glenoid rim fractures is still a matter of debate. The purpose of this study was to evaluate the clinical and radiologic results of an arthroscopic reduction and fixation of acute displaced large solitary or multifragmented anterior glenoid rim fractures using anchors or bioabsorbable compression screws.

Methods

Twenty-three consecutive patients (7 women, 16 men; mean age, 47.9 [15-74] years) were treated. The patients were followed up clinically (range of motion, instability testing, and shoulder outcome scores) and with conventional radiographs (true anterior-posterior, axillary, and Bernageau views).

Results

With a minimum follow-up of 24 months, 21 patients could be evaluated. The average Constant score was 84.5 points, the Rowe score was 90.8 points, the Melbourne Instability Shoulder Score was 96.2 points, the Western Ontario Shoulder Instability Index was 89.2%, and the subjective shoulder value averaged 92.1%. No patient had suffered recurrent instability. The radiologic evaluation revealed signs of osteoarthritis in 7 cases, which was pre-existing in 1 patient. Patients with osteoarthritis were on average 10 years older at the time of surgery compared with patients without osteoarthritis. A postoperative step-off of the glenoid was detected in 7 cases and averaged 2 (1-3) mm. We could not find a correlation between the step-off and the presence of osteoarthritis.

Conclusion

Arthroscopic reconstruction of acute large solitary and multifragmented fractures of the glenoid rim shows good and excellent clinical results. In the majority of cases, an anatomic reduction and healing of the glenoid fracture can be achieved. The rate of osteoarthritis needs further investigation.

Section snippets

Materials and methods

In this retrospective case series, we treated 23 consecutive patients with an acute large solitary or multifragmented anterior glenoid rim fracture through an arthroscopic approach. All procedures were performed by a single surgeon (M.S.).

There were 7 women and 16 men with a mean age of 47.9 (range, 15-74) years at the time of surgery. The average time from injury to surgical treatment was 12.4 (0-17) days. The most common reason for the time interval between trauma and intervention of >14 days

Results

After an average follow-up of 33.2 (range, 24-59) months, 21 patients were available for final evaluation (follow-up rate, 91.3%). We were not able to contact 1 patient, and 1 patient refused to participate in this study.

Complications

We could not detect specific complications like neurovascular lesions, postoperative hematoma, infections, or postoperative shoulder stiffness related to the surgical technique.

Discussion

The treatment of anterior glenoid rim fractures and the indications for an operative intervention are still a matter of debate. This study shows good and excellent clinical results and a high patient satisfaction after arthroscopic glenoid fracture reconstruction in cases of large solitary and multifragmented anterior glenoid rim fractures. To our knowledge, this is the largest case series of arthroscopically treated glenoid fractures with an average of 27.5% of the glenoid length according to

Conclusion

Arthroscopic reconstruction of acute large solitary and multifragmented fractures of the glenoid rim using anchors or compression screws showed good and excellent clinical results. In the majority of cases, we could achieve an anatomic reduction and healing of the glenoid fracture. The post-traumatic rate of osteoarthritis needs further investigation.

Disclaimer

Markus Scheibel received royalties and consultant payments from Arthrex that are related to this work. All other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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The purpose of the present study was to investigate the characteristics of unrecognized glenoid fracture in opposite shoulders with symptomatic anterior instability.
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Among the asymptomatic shoulders, 16 had a single traumatic event and 22 had no history of trauma. The glenoid morphology was normal in 6, erosion in 12 and bony Bankart in 20 on the symptomatic side, whereas the respective shoulders were 0, 16 and 22 on the asymptomatic side. Bone union of bony Bankart was complete in 9, partial in 3 and non-union in 8 on the symptomatic side, whereas the respective shoulders were 18, 3 and 1 on the asymptomatic side. The mean glenoid defect size was 10.4% and 7.8%, and the mean bone fragment size was 5.0% and 4.5%, respectively. The mean medial displacement of bone fragments was 2.6 mm and 1.0 mm, respectively (p < 0.001). A larger glenoid defect (≥10%) was recognized in 19 symptomatic shoulders and 10 asymptomatic shoulders. Among them, erosion was solely recognized in 5 symptomatic shoulders. In shoulders with bony Bankart, all 10 asymptomatic shoulders had a completely or partially united fragment with less than 2 mm displacement. On the other hand, among 14 symptomatic shoulders, united fragment was solely recognized in 8 shoulders, in which medial displacement was less than 2 mm in 3 shoulders.
Even if a glenoid fracture occurred, symptom such as instability or pain was not always recognized by all patients. Regardless of glenoid defect size, shoulders with a completely or partially united bone fragment and with less than 2 mm displacement were found to be asymptomatic.
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Patients with recurrent anterior shoulder instability and glenoid bone loss are diagnosed according to a previously published classification by Scheibel et al.15 (Table 1).
Anterior bone grafting is an established and frequently used treatment option for recurrent anterior shoulder instability in combination with significant glenoid bone loss. Several open and arthroscopic fixation techniques have been presented to this field in recent years. Some of these techniques are associated with different peri- and postoperative problems or complications. Therefore, the technical gold standard for anterior bone grafting has not been determined, resulting in an ongoing evolvement of bone-grafting techniques. Arthroscopic, metal-free fixation procedures were introduced to the field bone grafting to overcome previous problems of screw fixation. These metal-free techniques frequently include surgically challenging transglenoidal drilling and are placing anterior soft tissues and neurovascular structures at risk. We therefore present an arthroscopic anterior, PEEK (polyether ether ketone)–anchor based, interconnecting bone-grafting technique bypassing previous challenges to restore the anterior glenoid bone stock with adequate positioning and fixation of the bone graft.
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An arthroscopic technique for the reduction and stable fixation of an articular glenoid fracture with a 2-button compression system, originally designed for the treatment of shoulder instability with bone deficiency in the anterior glenoid, is presented. This technique allows direct visualization of the joint, reduction of the fracture, precise placement of the buttons according to the fracture line, and stable fixation. It is a safe and reproducible technique, using the standard shoulder arthroscopy portals.
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This mobilization happens because suture tensioning and knot tying create a fulcrum at the anchor entry point when it is more central on the articular surface, unbalancing the compression forces acting on the fragment so that its lateral portion is more compressed than the medial, which then is lifted from its fracture bed. This could also be one of the reasons that fragment size is a limitation for other techniques.2,3,6,7 Along with the direct stabilization provided by the kissing anchors construct, the standard repair of the remaining detached labrum offers and an additional, yet indirect, stabilization effect owing to ligamentotaxis, it being attached to the fracture's fragment.3,7
Up to one fifth of glenoid fractures are intra-articular and associated with recurrent anterior dislocation. Surgery is often the indicated treatment, and as with many other articular fractures, it aims for a perfectly congruent and flush reconstruction of the articular surface to avoid the onset of secondary degenerative joint diseases. The purpose of this paper is to describe a reproducible, simple arthroscopic technique that uses suture anchors to fix the glenoid fragment with a strong and stable construct called “kissing anchors.” This method provides the advantages of both direct and indirect stabilizing effects. It applies 2 anchors, one inside the fragment and the other inside the fracture bed, to stabilize and fix the fragment, and is adequately associated with labrum refixation, which provides the construct with increased stability. However, a surgeon willing to apply it should already be confident with basic shoulder arthroscopy and should have performed an appropriate amount of arthroscopic shoulder stabilizations.
Arthroscopic, Nonrigid Fixation of a Displaced Glenoid Fracture After Anterior Shoulder Dislocation
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With a trend toward minimally invasive approaches, proposed arthroscopic techniques have included the Bristow–Laterjet procedure, as well as several more anatomic reconstructions using materials such as glenoid allograft, distal tibial allograft, or iliac crest autograft.3 In cases in which a large, displaced bony Bankart fracture is identified, fragment fixation also can be performed with screws or suture anchors, avoiding the need for graft material.4 Recently, anatomic glenoid reconstruction with distal tibial allograft has been described using arthroscopic transglenoid suture fixation.5
Glenoid rim fractures are recognized as a risk factor for recurrent instability after anterior shoulder dislocation. In addition to traditional open treatments of bony Bankart lesions, several arthroscopic techniques of fixation and reconstruction recently have been described. We present a technique of arthroscopic nonrigid fixation for large glenoid rim fractures, as an alternative to existing procedures.

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: This study was approved by the local Ethical Committee (EA2/167/13).

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ShoulderArthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Complications

Discussion

Conclusion

Disclaimer

Arthroscopy

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Injury

Arthroscopy

J Shoulder Elbow Surg

Dislocation of the shoulder with significant fracture of the glenoid

J Bone Joint Surg Am

Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder

Am J Sports Med

Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors

Am J Sports Med

A clinical method of functional assessment of the shoulder

Clin Orthop Relat Res

Posterior-inferior capsular shift for the treatment of recurrent, voluntary posterior subluxation of the shoulder

J Bone Joint Surg Am

Fractures of the scapula: diagnosis and treatment

Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients

AJR Am J Roentgenol

Fractures of the scapula involving the glenoid fossa

Shoulder
Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures