The Effects of Combined Bony Defects on Anterior...
Transcript of The Effects of Combined Bony Defects on Anterior...
The Effects of Combined Bony
Defects on Anterior Glenohumeral
Stability: A Cadaveric Study
Lionel Gottschalk, MD
Piyush Walia, MS
Ronak M. Patel, MD
Matthew Kuklis, MS
Morgan H. Jones, MD, MPH
Steve D. Fening, PhD
Anthony Miniaci, MD
Disclosure
• No personal/individual disclosures
• Supported by a research grant from NFL
Medical Charities and Cleveland Clinic
Research Program Committee Grant
Shoulder Injury
• Approximately 1.7% of the general population will experience a glenohumeraldislocation
• Approximately 95% of patients with anterior shoulder instability have a humeral head defect, a glenoid defect, or both
• Radiographic studies on shoulders with chronic anterior instability have shown • 90% incidence of humeral head defects
• 87% incidence of glenoid defects
• 54% incidence of combined defects
Clinical Significance of Bony
Defects
• Burkhart and De Beer reported a 10.8% recurrence rate following arthroscopic Bankart repair• 67% recurrence with significant bone defects
• 4% recurrence in patients without significant bone defects
• Boileau et al. performed arthroscopic stabilization for recurrent anterior instability• 15.3% recurrence rate
• Strong association with defects >25% glenoid surface (p=0.01)
• Voos et al. performed arthroscopic Bankart for anterior instability• 18% recurrence rate
• 3.9 risk ratio with large humeral head defect (>250mm3)
Biomechanical Significance
of Bony Defects
• Itoi et al. showed a decrease in
glenohumeral stability with anteroinferior
glenoid defects >25% of glenoid width
• Yamamoto et al. showed a decrease in
glenohumeral stability with with glenoid
defects >26% of glenoid width
• Kaar et al. showed a decrease in
glenohumeral stability with humeral head
defects greater than 5/8 of the humeral head
radius
Study Aim
Investigate the effects of combined
humeral head and glenoid defects on
anterior glenohumeral stability across a
range of arm positions
Hypothesis
Combined bony defects will lead to
increased instability compared to an
isolated defect
The “critical” size of humeral head and
glenoid defects that need to be addressed
to restore stability will be smaller when
combined rather than isolated
Methods
• 18 Fresh-Frozen shoulder
specimens
• All soft tissues dissected
Sizes of Lesions
• Humeral head defect sizes:• Intact condition (no defect)
• 6% humeral head diameter
• 19% humeral head diameter
• 31% humeral head diameter
• 44% humeral head diameter
• Glenoid defect sizes:
• Intact condition (no defect)
• 10% glenoid width
• 20% glenoid width
• 30% glenoid width
Testing Protocol
Custom shoulder dislocation simulator
was used:
• Seating (home) position for humerus
defined
• Translate glenoid at constant velocity
under compressive force to cause a
controlled anterior dislocation
• Compressive load: 50N
50 N
Outcome Measures
• Percent of Intact Stability Ratio • Stability ratio for a given trial divided by the
stability ratio in the intact state at that arm
position for that specimen
• Percent of Intact Translation• Distance to dislocation for a given trial
divided by the distance to dislocation in the
intact state at that arm position for that
specimen
Combined Defects in the
Position of Apprehension
Decrease in Percent ISR as Humeral Head defect size increases
Decrease in Percent ISR as Glenoid defect size increases at each Humeral Head defect size
Combined Defects in the
Position of Apprehension
65%
85%84%
Decrease in Percent ISR with
- Humeral Head defects of 44%
- Glenoid defects of 30%
- Combined defect with 19% HH and 20% Glenoid
Percent ISR for combined 19% HH and 10% Glenoid nearly equal to isolated 20% Glenoid defect
Combined Defects in the
Position of Apprehension
Decrease in Percent IT as Humeral Head defect size increases
Decrease in Percent IT as Glenoid defect size increases at each Humeral Head defect size
69%74
%
Combined Defects in the
Position of Apprehension
Decrease in Percent IT with
- Humeral Head defects ≥ 31%
- Glenoid defects ≥ 20%
- Combined defect with 19% HH and 10% Glenoid
Percent IT for combined 19% HH and 10% Glenoid lower than isolated 20% Glenoid defect
Additional Findings
• There was a notable difference in baseline stability ratio between specimens
• Not explained by differences in glenoid or humeral head sizes
• Large variance in glenoid concavity depth in the Intact State
• Range 0.3mm to 2.5mm
• Linear Regression provided the following relationship for the Intact State
Stability Ratio = 10.7 + 8.9 x Glenoid Concavity Depth (R2 = 0.74)
• Previously reported by Lippitt et al.:Stability Ratio = 9.7 + 10.3 x Glenoid Concavity Depth
Additional Findings
• With a 10% loss of glenoid width
• Loss of glenoid concavity depth ranged from 3% to 42%
• With a 20% loss of glenoid width
• Loss of glenoid concavity depth ranged from 17% to 76%.
Conclusion
• Stability decreased due to
smaller combined defects
• % Intact translation for 10%
GD + 19% HH was lower
than isolated GD.
18
Conclusions
• Combined humeral head and glenoid defects produce
greater instability than either defect found alone
• In shoulders with combined humeral head and glenoid
defects, bony reconstruction may be indicated for humeral
head defects as small as 19% of the humeral head
diameter and glenoid defects as small as 10% of the
glenoid width, especially if the glenoid defect produces a
significant loss of glenoid concavity depth
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