Patient History and Presentation:
A 25 year-old male presented with a complaint of significant recurrent shoulder instability and severe glenoid bone loss. Imaging revealed significant (50 percent) glenoid bone loss (Figures 1, 2). The patient reported multiple, recurrent dislocations related to recreational athletic activity. He was otherwise physically healthy.
April Armstrong, M.D., Penn State Hershey Bone and Joint Institute, says: “Given the patient’s young age, baseline high level of physical activity and overall good health and significant glenoid bone loss, glenoid reconstruction using a fresh distal tibia allograft was chosen. With significant bone loss, such as in these cases, other traditional reconstructive options are not feasible, including traditional open instability or arthroscopic instability repair. The latarjet reconstruction is an option if there is less than 30 percent glenoid bone loss. However, these larger bone loss cases require either an iliac crest bone graft or this newer approach. The fresh distal tibial allograft is a good option in that it also has articular cartilage, but we don’t have long-term data to know if this is truly a clinical advantage. For a very young, athletic patient, this seemed the most desirable solution.”
The reconstruction technique was originally described by Mathew Provencher, M.D. and his team in 2009.¹ The patient is placed in the beach chair position with the head elevated about 40 degrees. The surgical approach and dissection is generally similar to that for other, more widely used glenoid reconstruction techniques, such as iliac crest bone graft. Dr. Armstrong says, “We obtained fresh tibial allograft (fewer than seven days since harvest), also containing cartilage, which we cut to fit to the glenoid surface. K wires were temporarily placed in the periphery of the graft to act as a joystick, to accurately guide the graft into place. We ensured the face of the socket was leveled and bleeding, [to encourage good graft integration with native, healthy bone].” Dr. Armstrong also notes, “With the fresh tibial allograft glenoid reconstruction, soft tissue reconstruction is also challenging. One needs to achieve the correct tension for the capsule and muscle that need to drape over the graft.”
At three months post-reconstruction, the shoulder is stable. X-rays reveal a concentric joint space between the humeral head and glenoid. The CT scan shows boney incorporation of the graft (Figures 3, 4). Clinically the patient reports no sensations of instability and elevates his arm to 140 degrees and can achieve 30 degrees of rotation at his side. Longer-term follow-up is required to determine the degree and durability of recovery.
Armstrong comments, “Patients like this present a major challenge because traditional, widely-used treatment options don’t yield optimal long-term outcomes; iliac crest isn’t the same shape and lacks cartilage; the Latarjet technique cannot accommodate this degree of bone loss; and glenoid allograft is expensive and difficult to obtain.”
April Dawn Armstrong, BSc(PT), M.Sc., M.D., FRCSC
Professor, Orthopaedics and Rehabilitation
Chief, Shoulder and Elbow Orthopaedic Surgery
FELLOWSHIPS: Orthopaedic surgery, shoulder and elbow, Washington University Barnes-Jewish Hospital, St. Louis, Mo. and Orthopaedic surgery, hand and upper extremity, London Health Sciences Centre, London, Ontario
RESIDENCY: Orthopaedic surgery, hand and upper extremity, London Health Sciences Centre, London, Ontario
MEDICAL SCHOOL: University of Western Ontario Schulich School of Medicine and Dentistry, London, Ontario