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• W3158502795 abstract "Where Are We Now? Posterior instability in patients with increased glenoid retroversion remains a challenging treatment problem. Though posterior instability represents less than 10% [10, 11] of patients with unidirectional instability, and most of these patients will respond well to posterior labral repair and/or capsular imbrication, it is generally felt that shoulders with bony glenoid insufficiency will not be rendered stable with soft tissue stabilization procedures alone, as one recent study again demonstrated [6]. Recurrent instability can damage the articular surface, which may cause early arthritis. And among those patients who progress to advanced arthritis and undergo arthroplasty, those procedures are made more challenging because of those glenoid version abnormalities, some of which should be corrected. This adds risk and complexity to a group of patients who already have too much of both, since they’re often younger at the time of the index arthroplasty [2, 3]. Techniques for treating instability in this group of patients include glenoid osteotomy, osteochondral allograft, the reverse Putti-Platt, the McLaughlin procedure and its modifications, staple capsulorrhaphy, thermal capsulorrhaphy, humeral rotational osteotomy, labral repair, and capsular shift. All have their limitations and advantages [3, 5, 7, 12]. In this study, Ernstbrunner and colleagues [4] present the results of a novel technique using a “J”-shaped iliac crest graft inserted into a posterior glenoid osteotomy. It is similar to the technique described for anterior instability and modifies the traditional Scott osteotomy to use the J-shaped graft, which also helps restore the glenoid concavity and does not employ hardware. The technique is clever and offers the potential advantage of restoring the glenoid concavity without implants, which saves expense and potential hardware complications, and it may help to preserve the joint surfaces. It may also slow the development of degenerative disease. Where Do We Need To Go? While using a J-shaped iliac crest graft inserted into a posterior glenoid osteotomy offers an additional treatment option for a tough problem, it is important to note that despite the generally good results of the current study, four of seven patients had persistent apprehension, and some continued to have pain [4]. Indeed, these results are not necessarily equal or superior to older techniques. Therefore, future comparative studies are needed to determine which treatment results in the best clinical outcomes for recurrent instability as well as over long-term follow-up in terms of risk of development of arthritis. Additionally, the senior surgeon in the current study has a wealth of surgical experience. Would a less experienced surgeon obtain the same results? In particular, the opening wedge osteotomy “hinge” formation is technically demanding for a less-experienced surgeon, and there is a very real risk of iatrogenic bicortical glenoid neck fracture. Training future surgeons to do this procedure may be difficult given the rarity of the procedure. Future studies are needed to determine how best to teach the procedure. There are complications specific to previously published posterior instability procedures as well. Thermal capsulorrhaphy has been strongly associated with chondrolysis [9], which can be catastrophic, but other less severe yet still important complications can occur. The original Scott osteotomy, for instance, was associated with subcoracoid impingement [7]. Other techniques were ineffective at preventing recurrent instability and/or resulted in motion loss [3]. Any procedure involving autogenous iliac crest bone graft has some inherent donor site morbidity. With this small series and only an average of 2.3 years follow-up, many complications, especially recurrent instability or development of arthritis, may not yet be identified. The patients who did worse in this study were those on the older end of the participating age range. Additional evaluation including middle-aged to older patients with this condition would also be helpful to determine whether there is an age range beyond which this procedure may not be recommended. While there is a study comparing nonoperative and operative treatment for posterior shoulder instability [2], we do not yet have a study that directly compares types of operative treatment for this condition. Finally, like any good study, this one leaves us with more questions than answers. Some additional questions future studies will need to answer include: Does the restoration of the glenoid concavity help protect the patient against the development of arthritis and need for future arthroplasty? Do the increased contact pressures accelerate the degeneration of the glenohumeral joint? If the patient does go on to arthroplasty, is it easier to perform or more successful because glenoid version has been corrected with an osteotomy, as opposed to a soft tissue stabilization procedure? How Do We Get There? Longer term follow-up of these patients is needed to determine the future incidence of recurrent instability or development of arthritis. Future studies to determine the best method of teaching this procedure to surgeons are also warranted. With the increasing use of simulation in training, perhaps there is a role in assisting other surgeons with learning the “feel” of the appropriate amount of force and depth with the osteotomy when performing the opening wedge as well as with fashioning the graft. Virtual reality is also being used now to allow remote surgeons to “visit” other centers virtually and may increase the opportunity to participate in less common cases, where the options to see them locally may be limited. Larger series of patients undergoing this procedure are likely needed to refine the indications, as there appeared to be a tendency in this study toward poorer outcomes in patients at the higher end of the participating age range. Also, larger studies with different treatment arms are needed to determine whether one technique is superior to another. Only by comparing results between techniques can one be definitively determined to be superior to another. It may also be difficult to obtain enough patients with abnormal glenoid retroversion to enroll at a single center. Multicenter studies may allow for greater enrollment, but do have other limitations, such as increased cost and administrative complexity, as well and decreased ability to keep other variables consistent, such as postoperative protocols for physical therapy and sling use. Still, there may be opportunities to work with certain patient populations, such as professional baseball players [8] (perhaps with the cooperation of their leagues) or soldiers and recruits [1, 13], who have been shown to have a higher incidence of posterior glenoid dysplasia and posterior instability, respectively, than the population at large. Additionally, the age range in the current series was 16 to 45 years of age. Long-term follow-up is certainly needed to determine the consequences of the alteration of joint mechanics. As discussed by the authors, biomechanical data can better elucidate the effect of the glenoid osteotomy procedure they have described on glenohumeral contact pressures." @default.
• W3158502795 created "2021-05-10" @default.
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• W3158502795 date "2021-05-05" @default.
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• W3158502795 title "CORR Insights®: Posterior Open-wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-free, J-shaped Iliac Crest Bone Graft in Atraumatic Posterior Instability with Pathologic Glenoid Retroversion and Dysplasia: A Preliminary Report" @default.
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