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Technical Note| Volume 12, ISSUE 2, e217-e221, February 2023

Arthroscopic Anatomic Glenoid Reconstruction Hardware Removal

Open AccessPublished:January 18, 2023DOI:https://doi.org/10.1016/j.eats.2022.10.011

      Abstract

      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.

      Technique Video

      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
      • Itoi E.
      • Lee S.
      • Berglund L.
      The effect of glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study.
      ,
      • Burkhart S.S.
      • De Beer J.F.
      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.
      ; however, the concept of subcritical bone loss has led some authors to lower the threshold to 13.5% to 17.3% of glenoid bone loss in selected patients.
      • Shin S.J.
      • Kim R.G.
      • Jeon Y.S.
      • Kwon T.H.
      Critical value of anterior glenoid bone loss that leads to recurrent glenohumeral instability after arthroscopic Bankart repair.
      Bony stabilization procedures range from either a Latarjet,
      • Burkhart S.S.
      • De Beer J.F.
      • Barth J.R.
      • Cresswell T.
      • Roberts C.
      • Richards D.P.
      Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss.
      ,
      • Matton D.
      • Van Looy F.
      • Geens S.
      Recurrent anterior dislocations of the shoulder joint treated by the Bristow–Latarjet procedure. Historical review, operative technique and results.
      glenoid open reduction internal fixation, iliac crest bone grafting,
      • Warner J.J.
      • Gill T.J.
      • O'Hollerhan J.D.
      • Pathare N.
      • Millett P.J.
      Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft.
      or distal tibial allograft.
      • Provencher M.T.
      • Frank R.M.
      • Golijanin P.
      • et al.
      Distal tibia allograft glenoid reconstruction in recurrent anterior shoulder instability: Clinical and radiographic outcomes.
      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.
      • Amar E.
      • Konstantinidis G.
      • Coady C.
      • Wong I.H.
      Arthroscopic treatment of shoulder instability with glenoid bone loss using distal tibial allograft augmentation: Safety profile and short-term radiological outcomes.
      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.
      • Wong I.H.
      • John R.
      • Ma J.
      • Coady C.
      Arthroscopic anatomic glenoid reconstruction using distal tibial allograft for recurrent shoulder instability: Clinical and radiographic outcomes.
      The main symptoms of hardware-related complications were commonly a dull aching anterior shoulder pain with subscapularis weakness.
      Alternatives to screw fixation have been studied, including nonrigid fixation with an ENDOBUTTON
      • Ravipati A.
      • Ali M.
      • Wong I.
      Arthroscopic anatomic glenoid reconstruction in the setting of a failed Latarjet using distal tibial allograft.
      ,
      • McNeil D.
      • Coady C.
      • Wong I.
      Arthroscopic anatomic glenoid reconstruction in lateral decubitus position using allograft with nonrigid fixation.
      and hybrid fixation with compressive screw and suspensory fixation
      • Campos-Mendez A.
      • Rayes J.
      • Wong I.
      Arthroscopic anatomic glenoid reconstruction with distal tibial allograft and hybrid fixation.
      ; however, biomechanical studies demonstrate concerns about fixation strength at the interface of the native glenoid and graft.
      • Williams R.
      • Morris R.
      • El Beaino M.
      • Maassen N.
      Cortical suture button fixation vs. bicortical screw fixation in the Latarjet procedure: A biomechanical comparison.
      As the arthroscopic anatomic glenoid reconstruction with distal tibial allograft technique avoids a subscapularis split and preserves native anatomy,
      • Wong I.H.
      • Urquhart N.
      Arthroscopic anatomic glenoid reconstruction without subscapularis split.
      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)

      Preoperative Assessment

      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.
      • Wong I.H.
      • Urquhart N.
      Arthroscopic anatomic glenoid reconstruction without subscapularis split.
      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.
      Figure thumbnail gr1
      Fig 1The patient is positioned in balanced traction in the lateral decubitus position with skin landmarks for the arthroscopic portals identified on the right shoulder. (AI, anteroinferior portal; AS, anterosuperior portal; M, medial portal; P, posterior portal.)

      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.
      • Snyder S.J.
      Shoulder arthroscopy.
      Evaluation of previous soft-tissue stabilization is a critical step (Fig 2).
      Table 1Surgical Steps for Arthroscopic Removal of Hardware From Previous Anatomic Glenoid Reconstruction With Distal Tibial Allograft
      1.Place Patient in 30° Semilateral Decubitus Position
      2.Suspend arm with pneumatic arm holder with balanced traction in 60° of abduction and neutral forearm rotation (Fig 1)
      3.Establish posterior viewing portal parallel to glenoid face, as well as anteroinferior and anterosuperior portals with outside-in technique.
      4.Perform diagnostic arthroscopy from posterior portal and anterosuperior portal
      5.Assess glenoid articular surface and integrity of anterior soft-tissue repair from anterosuperior viewing portal (Fig 2)
      6.Open the rotator interval with electrocautery from anteroinferior working portal
      7.Place traction stitch at 3 o'clock within anterior capsule for visualization and assistance with later inferior to superior capsular shift
      8.Incise the labrum between traction stitch and biceps tendon to expose underlying tibial bone block
      9.Identify screw heads for both compression screws
      10.Establish the medial (Halifax) portal through an inside-out approach from posterior portal
      • Place a large switching stick parallel to the glenoid, superior to the subscapularis, and lateral to the conjoint tendon
      • Adduction of arm with flexion of elbow will assist in development of this portal
      11.Bluntly dissect and dilate tissue through medial (Halifax) portal with half-pipe instruments and deliver the head of each screw (Fig 3)
      12.Slide a Kirschner wire into the cannulated screw, Advance cannulated screw driver over the Kirschner wire and engage the screw (Fig 4)
      13.Carefully remove screw, releasing any soft-tissue adhesions
      14.Debride bone block for stimulation of healing response and perform standard soft-tissue repair of anteroinferior capsule to native glenoid with all suture anchors (Figs 5 and 6)
      • Perform inferior to superior capsular shift moving your traction stitch to 12 o'clock
      Figure thumbnail gr2
      Fig 2Anterosuperior viewing portal of the right shoulder demonstrating healed anterior soft-tissue stabilization from prior arthroscopic anatomic glenoid reconstruction. Lateral decubitus position of the right shoulder.
      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.

      Screw Removal

      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).
      Figure thumbnail gr3
      Fig 3Anterosuperior viewing portal of the right shoulder demonstrating a half-pipe instrument isolating the prominent anterior screw head from the previous arthroscopic anatomic glenoid reconstruction. The patient is in the lateral decubitus position.
      Figure thumbnail gr4
      Fig 4Anterosuperior view of the right shoulder demonstrating a cannulated screwdriver engaging the anterior prominent screw head in lateral decubitus position.
      Figure thumbnail gr5
      Fig 5Anterosuperior view of the right shoulder demonstrating an all-suture suture anchor placement for an anterior soft-tissue stabilization following instrumentation removal in the lateral decubitus position.

      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
      • Power L.
      • Wong I.H.
      Arthroscopic anatomic glenoid repair using distal tibial allograft and an 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.
      Figure thumbnail gr6
      Fig 6Anterosuperior view of the right shoulder demonstrating a completed anterior soft-tissue stabilization with a centered humeral head on the glenoid articular surface in the lateral decubitus position.

      Postoperative Rehabilitation

      The postoperative rehabilitation is similar to previously described protocols for arthroscopic anatomic glenoid reconstruction with anterior soft-tissue stabilization.
      • McNeil D.
      • Coady C.
      • Wong I.
      Arthroscopic anatomic glenoid reconstruction in lateral decubitus position using allograft with nonrigid fixation.
      ,
      • Campos-Mendez A.
      • Rayes J.
      • Wong I.
      Arthroscopic anatomic glenoid reconstruction with distal tibial allograft and hybrid fixation.
      ,
      • Buckley A.
      • Wong I.
      Arthroscopic Bankart repair with inferior to superior capsular shift in lateral decubitus position.
      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.

      Discussion

      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
      PearlsPitfalls
      All-arthroscopic technique provides a minimally invasive option for patientsCost of distal tibial allograft
      Use of a medial (Halifax) portal avoids splitting of subscapularis tendonLearning curve of new technique
      Arthroscopic assessment allows concomitant management of intra-articular pathologyRequires anterior capsular release to access instrumentation
      Arthroscopic technique allows soft-tissue stabilization and capsular shift to tension anterior stabilizing structures
      Table 3Additional Risks and Limitations of the Surgical Technique
      RisksLimitations
      Recurrent instability due to revision anterior stabilizationRequires proficiency in arthroscopic evaluation and management of shoulder pathology to achieve all-arthroscopic technique
      The risks associated with any shoulder arthroscopy apply to this technique.
      • Moen T.C.
      • Rudolph G.H.
      • Caswell K.
      • Espinoza C.
      • Burkhead Jr., W.Z.
      • Krishnan S.G.
      Complications of shoulder arthroscopy.
      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%.
      • Abouali K.
      • Hatzantoni K.
      • Holtby R.
      • Veillette C.
      • Theodoropoulos J.
      Revision arthroscopic Bankart repair.
      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.
      • Wong I.H.
      • John R.
      • Ma J.
      • Coady C.
      Arthroscopic anatomic glenoid reconstruction using distal tibial allograft for recurrent shoulder instability: Clinical and radiographic outcomes.
      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.
      • Wong I.H.
      • John R.
      • Ma J.
      • Coady C.
      Arthroscopic anatomic glenoid reconstruction using distal tibial allograft for recurrent shoulder instability: Clinical and radiographic outcomes.
      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.

      Supplementary Data

      References

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