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Address correspondence to Dr. Ivan Wong, Orthopaedic Surgery – Sports Medicine, QEII Health Sciences Centre – Veterans Memorial Site, 2106-5955 Veterans Memorial Lane, Halifax, Nova Scotia, Canada, B3H 2E1.
Recurrent shoulder instability is associated with bone loss. Distal tibial allograft reconstruction of the glenoid is an accepted technique for managing bone loss. Bone remodeling occurs within the first 2 years postoperatively. This can lead to prominent instrumentation, particularly anteriorly near the subscapularis tendon, causing pain and weakness. We provide a description of arthroscopic instrumentation removal for prominent anterior screws following anatomic glenoid reconstruction with distal tibial allograft.
See video under supplementary data.
The surgical management of shoulder instability in the presence of bone loss is a challenging scenario. Many surgical options exist, and what constitutes significant bone loss is a constant topic of debate. Historically, glenoid bone loss of more than 20% would require bony stabilization
Each of these techniques has its own unique safety profiles and complications.
The technique of arthroscopic distal tibial allograft reconstruction for the management of anterior glenoid bone loss has demonstrated an excellent safety profile in a report of 42 patients with no neurovascular injury.
However, in a follow-up study reporting on 2-year outcomes of the arthroscopic anatomic glenoid reconstruction with distal tibial allograft, it was shown that 5 of 73 (6.8%) patients had hardware complications necessitating removal of instrumentation.
the typical open deltopectoral approach for hardware removal may cause unnecessary damage to the musculotendinous structures for removal of instrumentation. Revision arthroscopic shoulder surgery in the context of scar tissue and previous instability can be difficult. The authors present a step-by-step technique for the preservation of native anatomy with an arthroscopic removal of hardware following an arthroscopic anatomic glenoid reconstruction with distal tibial allograft.
Surgical Technique (With Video Illustration)
The patient is assessed in the clinic with a full history of preceding events, including events surrounding the surgery. A standard physical examination of the shoulder is completed. Both passive and active range of motion are recorded. Anterior instability is assessed via the anterior apprehension, Jobe relocation, and surprise test. Other tests of instability include the sulcus test, load-and-shift test, and jerk test. Rotator cuff musculature is evaluated with the empty can test, external rotation in position one, external rotation in position two, lift-off test, bear hug test, and belly press test. Hypermobility is assessed with the Beighton score and examination of other joints. Signs and symptoms of infection must be ruled out. Full examination of the uninvolved side should provide comparison values.
Appropriate imaging includes anteroposterior glenoid (Grashey) views, transscapular Y-view, and axillary views. To assess bony remodeling and graft integration, a computed tomography (CT) scan is recommended. Three-dimensional reconstruction images including isolated humeral and scapular reformats are helpful to assess both articulations in the glenohumeral joint.
Anterior shoulder pain in the context of weakness of the subscapularis or worsened pain with isolated subscapularis testing should raise suspicion for prominent hardware, specifically when there is evidence of bony remodeling around the distal tibial allograft causing screw prominence on the CT scan.
Positioning and Preparation
The patient is positioned in 30° of semilateral decubitus with beanbag support as previously described.
The arm is supported by a pneumatic arm positioner (SPIDER 2; Smith & Nephew, Memphis, TN) with balanced traction in 60° of abduction with neutral rotation. Skin landmarks (coracoid, lateral acromion, acromioclavicular joint, clavicle, and scapular spine) and previous portals are identified (Fig 1). Previous arthroscopic portals are used, including posterior, anterosuperior, anteroinferior, and medial (Halifax) portals.
Evaluation and Debridement
The critical steps of the operation are summarized in Table 1 and demonstrated in our technique video (Video 1). The posterior portal is established slightly medial to its typical entry point to provide a parallel path relative to the glenoid articular surface. Anterosuperior and anteroinferior arthroscopic portals are found with an outside-in technique while viewing from the posterior portal. Cannulas (CONMED/Linvatec, Largo, FL) are placed in each portal for instrument passage and outflow management to maintain low intraarticular pressures. Diagnostic arthroscopy is performed from the posterior viewing portal and the anterosuperior viewing portal as described by Snyder.
Using the anteroinferior portal as a working portal, open the rotator interval widely and place a traction stitch within anterior capsule at 3-o'clock position. Release the labrum between the traction suture and the biceps tendon and elevate the anterior–inferior labrum as a sleeve to identify the underlying graft and screw fixation. The traction stitch and a labral elevator can assist in release of remaining capsule, scar tissue, and adhesions from the screws. Assess underlying bone stock. Release adhesions around screw head. Establish the medial (Halifax) portal with a switching stick from posterior portal. The planned trajectory is parallel to the glenoid articular surface passing superior to subscapularis, through the rotator interval, and lateral to conjoint tendon. Flexion of the elbow and adduction of arm will assist in passage of the switching stick as the conjoint tendon relaxes and can be displaced medially with ease.
The previous surgical incision is the preferred location for placement of the medial (Halifax) portal. A slotted cannula and a channel dilater (DePuy Synthes) are used to bluntly dissect over the switching stick. The slotted cannulas are used through the medial portal to deliver the prominent screw heads (Fig 3). Use Kirschner wires from the cannulated screw set to engage each screw individually. Using the cannulated screwdriver, engage each screw with a clockwise turn to ensure appropriate seating of the driver within the screw head (Fig 4). Remove each screw under direct visualization from the anterosuperior portal (Fig 5).
Anterior Soft-Tissue Stabilization
Once the screws are removed, assess the integration of your distal tibial allograft. Perform careful debridement to initiate a healing response with an arthroscopic shaver. Perform a standard soft-tissue stabilization with inferior to superior capsular shift
on the native glenoid with all-knot suture anchors (Q-FIX 1.8 mm; Smith & Nephew) (Fig 6). Assess stability of the shoulder following the procedure. Close incisions, apply postoperative bandages, and place the patient into a sling.
The postoperative rehabilitation is similar to previously described protocols for arthroscopic anatomic glenoid reconstruction with anterior soft-tissue stabilization.
The patient is initially immobilized in a sling for the first 6 weeks. During the first 2 weeks, elbow, wrist, and hand motion is encouraged, with very limited passive range of motion exercises of the operative shoulder. From 2 to 6 weeks, pendular exercises are introduced to the operative shoulder while out of the sling. At 6 weeks, the use of a sling is discontinued. Active-assisted and active motion of the operative shoulder is now permitted. When satisfactory range of motion is achieved, the patient may begin gentle, progressive strengthening. This typically occurs between 10 and 12 weeks' postoperatively.
This paper describes a technique for all-arthroscopic removal of instrumentation from an anatomic glenoid reconstruction with distal tibial allograft after development of symptomatic instrumentation. In addition to providing a more cosmetic result, this technique avoids the added morbidity of an open approach to the shoulder with a subscapularis split while also allowing concurrent intra-articular pathology to be treated as well as repeating anterior shoulder stabilization (Tables 2 and 3).
Table 2Pearls and Pitfalls of the Surgical Technique
All-arthroscopic technique provides a minimally invasive option for patients
Cost of distal tibial allograft
Use of a medial (Halifax) portal avoids splitting of subscapularis tendon
Learning curve of new technique
Arthroscopic assessment allows concomitant management of intra-articular pathology
Requires anterior capsular release to access instrumentation
Arthroscopic technique allows soft-tissue stabilization and capsular shift to tension anterior stabilizing structures
There are also additional risks that are specific to this procedure. Recurrent instability is possible, as the previous anterior shoulder stabilization is released during exposure of the symptomatic instrumentation. In this technique, this is managed with a revision inferior-to-superior capsular shift at the end of the procedure. The historic recurrence rate for instability following revision arthroscopic Bankart repair is 12.7%.
There has been no recurrent instability in the patients who had hardware removal after AAGR. In addition, although neurovascular injury was a concern with the development of the medial portal, no neurologic injuries were reported in the mid-range follow-up series.
With the increased popularity of the distal tibial allograft for shoulder instability associated with glenoid bone loss, the reader should be aware of the risk of hardware prominence. Mid-range follow up demonstrates a hardware prominence rate of 6.8% requiring instrumentation removal.
The key symptoms are dull anterior shoulder pain associated with subscapularis pain and weakness with CT imaging evidence of graft resorption. This technique provides an all-arthroscopic approach to assessment of bone graft integration, revision stabilization, and removal of instrumentation utilizing previously established portals.
Technical video demonstrating arthroscopic removal of prominent anterior hardware from a previous arthroscopic anatomic glenoid reconstruction. The patient is placed in the lateral decubitus position. The operative site is the patient's right shoulder. The posterior portal is the viewing portal for the diagnostic arthroscopy and the anterosuperior portal is the viewing portal for the duration of the removal of instrumentation.
The effect of glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study.
The authors report the following potential conflicts of interest or sources of funding: I.W. reports consulting fees from DePuy Mitek, Smith & Nephew, CONMED Corp., and Bioventus LLC, outside the submitted work; is an editorial board member for the American Journal of Sports Medicine and Arthroscopy: The Journal of Arthroscopic and Related Surgery; and is a board or committee member for Arthroscopic Association of North America (AANA), International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), and the Arthroscopy Association of Canada (AAC). Full ICMJE author disclosure forms are available for this article online, as supplementary material.