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Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-017-4757-6
SHOULDER
Bone grafts used for arthroscopic glenoid reconstruction restore
the native glenoid anatomy
Benjamin Bockmann1 · Arne Johannes Venjakob1 · Rolf Gebing2 · Frank Reichwein1 ·
Marthe Hagenacker1 · Wolfgang Nebelung1 Received: 14 May 2017 / Accepted: 6 October 2017
© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017
Abstract Purpose Recurrent anterior instability of the glenohumeral
joint is a demanding condition, especially in cases of glenoid
bone loss. Various treatment options have been described,
such as arthroscopic grafting techniques and the Latarjet
procedure. In this study, the degree to which an arthroscopically applied iliac crest graft restores the glenoid anatomy
was evalutated.
Methods Nine patients (three women and six men) with an
average age of 31 ± 9 years (21–46 years) who were treated
with an arthroscopic iliac crest graft technique were included
in this study. After a mean follow up of 34 ± 10 months (19–
50 months) after the procedure, MRI scans of both shoulders
were performed and the glenoid width, Glenoid Index (GI),
Pixel Signal intensity (PSI), thickness of the tissue covering
the articular aspect of the graft, inclination, version, concavity and balance stability angle were measured.
Results All scans showed the cultivation of tissue on the
graft, which visually resembled the cartilage of the native
ipsilateral glenoid. Additionally, reshaping of the graft to
repair the glenoid configuration could be observed. Glenoid
width (p = 0.022) and GI (p < 0.001) increased significantly
through surgery. The tissue examined on the graft showed
a significant pixel intensity gap (p = 0.017) but comparable thickness (n.s.) in relation to native cartilage. The
* Benjamin Bockmann
benjamin_bockmann@hotmail.com
1
Department of Rheumatology and Arthroscopy,
Marienkrankenhaus Düsseldorf-Kaiserswerth, An St
Swidbert 17, Düsseldorf, Germany
Department of Diagnostic Radiology, St. Vinzenz Hospital,
Schloßstraße 85, Düsseldorf, Germany
2
remaining parameters did not differ significantly between
both shoulders.
Conclusion In the cohort presented, iliac crest grafts were
able to restore the glenoid configuration, and the glenoid
was re-shaped to its native contour. Additionally, cartilagelike scar tissue with similar thickness as healthy cartilage
was formed on the articular side of the graft. These results
suggest that glenoid reconstruction is not only important
for prevention of recurrence, but also for restoration of the
native glenoid anatomy.
Level of evidence Level III—retrospective cohort study.
Keywords Shoulder instability · Glenoid deficit ·
Arthroscopic stabilization · Iliac crest graft · Bone
remodeling
Introduction
Recurrent shoulder instability is a demanding disorder of
the shoulder, which is commonly seen in younger patients
[1, 5]. When labral tears are accompanied by relevant bone
loss, high failure rates are observed when the osseous deficit
is not addressed properly [10, 17, 20]. To restore native glenoid configuration, both open and arthroscopic procedures
have been described [13, 16, 21]. Regarding arthroscopic
techniques, bone graft procedures using iliac crest and the
Latarjet procedure are well-established options [4, 5, 8, 13].
The common goal of these concepts is to reconstruct the
glenoid anatomy to prevent recurrence, since incorrect graft
fixation can be accompanied with early osteoarthritis [22]. In
other cases, graft remodeling and cartilage formation on iliac
crest grafts have been observed [8]. Thus, it was hypothesized that cartilage-like tissue can be found on iliac crest
grafts and that reshaping of the graft leads to native glenoid
13
Vol.:(0123456789)
13
27
25
2
1
1
2
1
1
2
1
2
No
Yes (due to contralateral shoulder
pain)
Hill–Sachs lesion (on-track)
Yes (12/day) Yes (sporadic use)
Impingenment + SLAP-lesion Subacromial decompression No
No
No
No
Hill–Sachs lesion (on-track)
Yes (15/day) No
Loose bodies + Hill–Sachs
Yes (4/day) No
lesion (on-track)
ALPSA-lesion
No
No
Hill–Sachs lesion (on-track)
Yes (15/day) No
No
No
Filling of Hill–Sachs lesion
2
0
0
0
Bio
Bio
8 ♂ 29 years WN
9 ♂ 29 years WN
100
70
Bio
Bio
Bio
Bio
Bio
WN
WN
FR
FR
FR
3 ♂ 21 years
4 ♂ 46 years
5 ♀ 33 years
6 ♀ 26 years
7 ♂ 23 years
145
105
93
110
110
0
0
0
0
0
0
2
3
0
4
SLAP-lesion
Hill–Sachs lesion (off-track)
2
0
0
0
105
120
Titan
Bio
Additive procedures
Findings
Cartilage
degeneration:
glenoid
Surgeon Screw Length of Cartilage degenprocedure eration: humeral
head
The MRI scans were performed after a mean follow-up of
34 ± 10 months (19–50 months) after the procedure. Preoperatively, bone loss had been quantified in CT scans and
concomitant injuries had been detected in MRI scans of
the injured shoulder. The loss was defined as relevant if the
anterior–posterior diameter exceeded 20% of the glenoid
Patient no.
Follow‑up design and ethical approval
Table 1 Baseline data and intraoperative findings of patient cohort
In this study, standardized MRI scans of both shoulders were
performed after arthroscopic glenoid reconstruction using
iliac crest bone grafts as described before [13]. Briefly, the
patient is positioned in lateral decubitus position and secured
with pads and attachments. A short diagnostic arthroscopy
is performed through the standard posterior portal to focus
on further pathologies as well (s. Table 1). Cartilage degeneration is staged using the Outerbridge classification [15].
Preparation of the anterior glenoid is performed with the
arthroscope inserted through the suprabicipital portal. A
2 × 1 × 1 cm sized bone graft is harvested from the iliac crest
of the same side, which is then carved with a burr according
to the approximate defect size. The bone block is penetrated
with a 1 mm hole and a 2.4 mm K-wire is passed through the
glenoid, entering at 5 o’clock position and exiting into the
infraspinatus fossa. A FiberWire, size 2 (Arthrex, Naples,
FL, USA) is retrieved through this tunnel and the bone graft
is attached to its anterior ending using a stopper knot. The
posterior end of the FiberWire is then pulled, thus carefully
dragging the graft through the rotator interval to the anterior glenoid. Through an antero-inferior portal, two screws
(either titanium 3–4-mm screws or bioresorbable 3 × 26 mm
Bio-Compression screws, Arthrex) are used to fixate the
graft. Finally, standard arthroscopic anchors pull the capsule
and labrum to the antero-inferior aspect of the graft.
Between 2009 and 2015, 42 patients had been treated
with this procedure; all of these patients were invited to
the MRI examination via mail. The first nine patients who
answered the invitation were included. Three women and six
men with an average age of 31 ± 9 years (21–46 years) and
a glenoid deficit of 23 ± 6% (13–29%) at the day of surgery
were included. Four patients showed a Hill–Sachs lesion
during surgery, whereas one was considered an off-track
lesion [3] and filled with additionally harvested bone from
the iliac crest. Further information about the cohort including intraoperative findings can be found in Table 1.
Smoking
Materials and methods
1 ♂ 46 years WN
2 ♀ 30 years WN
NSAR consume
ASA BMI
configuration at mid-term follow up. This is a relevant problem concerning this pathology, since anatomical reconstruction is the main goal of this procedure, and no study has been
able to show these processes on MRI scans before.
27
28
22
19
29
Knee Surg Sports Traumatol Arthrosc
25
29
Knee Surg Sports Traumatol Arthrosc
width as described by Kraus et al. [8]. All CT scans were
performed with 128 slice scanners with patients in head
first position, reconstructing 3 mm slices from 1 cm inferior
to the scapula to 1 cm superior to the shoulder. At follow
up, all patients completed a short questionnaire evaluating
re-dislocations.
MRI scans were then performed of both the injured
shoulder and the contralateral side. For the examination, a
1.5 T MRI scanner (Vantage Titan, Toshiba Medical Systems GmbH, Neuss, Germany) was used. The respective
shoulder was immobilized in the associated shoulder array
coil. All shoulders were positioned in neutral rotation. The
injured side was scanned using fat saturated T2 sequences
similar to previously described protocols [7, 14] (image size
210 × 300 mm, slice thickness 1.5 mm, repetition time (TR)
2016.0 ms; echo time (TE) 30.0 ms) and coronal, axial and
parasagittal reformats were built. Afterwards, the contralateral side was scanned, using the same standard T2 protocol
from daily clinical routine that was used for the preoperative
scans (image size 190 × 190 mm, slice thickness 3 mm, TR
2016.0 ms; TE 30.0 ms). Again, coronal, axial and parasagittal reformats were built.
Evaluation of data
All scans were examined by the first author (BB) and reevaluated by two experienced surgeons on the fellowship
level (AJV and WN). From each patient, three MRI scans
were evaluated: The injured shoulder pre- and post-surgery
as well as the uninjured shoulder post-surgery, leading to
a total of 27 scans. Picture analysis included the following
parameters and angles:
• Glenoid height and width on parasagittal scans to cal-
culate the glenoid index (GI) of the injured shoulder
pre-and post-surgery as described by Chuang [2]. The
maximum inferior glenoid width of the affected shoulder
was evaluated using parasagittal MRI scans. The glenoid
width was then compared both between the uninjured
and the operated injured shoulder as well as the injured
shoulder pre- and post-surgery.
• Pixel Signal Intensity (PSI) of the glenoid cartilage in the
injured shoulder was measured by drawing a Region of
Interest (ROI) through all cartilage layers in the center of
the glenoid in T2-weighted coronal formats as described
by Kang and Choi [7] (s. Fig. 1a). Then, a ROI of similar
size was drawn on the surface of the graft using the same
slice. The PSI of both ROIs was noted and compared.
• Thickness of the tissue on the graft was measured (s.
Fig. 1b) and compared to healthy cartilage on the contralateral side (s. Fig. 1c). To correlate similar locations
on the respective glenoids, the antero–inferior cartilage was localized in both shoulders and measured as
described by Schleich et al. [19].
• Glenoid version and glenoid inclincation were measured
on the injured shoulder post-surgery and compared to the
healthy side as described by Hohmann et al. [6].
The version was measured by selecting the axial image
just inferior to the supraspinatus muscle. Then, a line was
drawn along the articular surface of the glenoid. The axis
of the scapula was then defined as a line posteriorly to the
glenoid neck and medially to the scapular body. Glenoid
version was calculated by subtracting 90° from the angle
built by these two lines. Anteversion was expressed as a
positive angle while retroversion was defined as a negative angle.
For inclination, a coronal MRI image that showed
the most inferior point of the supraspinatus fossa was
identified. From this point, a line was drawn through the
whole supraspinatus fossa. Another line was then drawn
Fig. 1 Measuring the Pixel Signal Intensity (PSI, a) and cartilage thickness in the injured (b1) and healthy (b2) shoulder according to a standardized protocol
13
along the articular surface of the glenoid. Again, the
angle between these lines was subtracted from 90°. A
downward-pointed glenoid surface was defined as a positive angle, while negative angles expressed an upwardpointed glenoid.
• Glenoid concavity and the balance stability angle
were evaluated as proposed by Matsen et al. [9]. The
glenoid concavity was evaluated by measuring the distance between two parallel lines, whereas the first line
connected the tip of the ventral and dorsal labrum. The
second line ran along the glenoid surface. The balance
stability angle was examined as the angle between the
lines connecting the center of the humeral head with
the glenoid center on the one hand and the center of
the humeral head and the ventral labrum on the other.
Both parameters were examined in the axial images of
the healthy shoulder as well as the injured shoulder post
surgery.
The study protocol was reviewed and approved by the
ethics committee of the Medical Association of North
Rhine (file number 2016324), and all patients gave written
informed consent.
Statistical evaluation
All results were registered in an Excel database (Microsoft
Excel 2012 for Mac, Microsoft, Redmont, USA). For data
analysis, IBM SPSS statistics 22 (Statistical Package for the
Social Science, IBM Cooperation, Armonk, N.Y., USA) was
employed. The Kolmogorov–Smirnov-test was used to evaluate normal distribution. Analysis of means was performed
using t tests for dependent samples. If normal distribution
was not given, sign tests for paired samples were used. A p
value < 0.05 was considered statistically significant. A posthoc analysis was performed based on the Mantel–Haenszel
Test as described by Rosner [18].
Results
The questionnaire completed by all patients prior to scanning revealed no complications, and none of the individuals
had suffered from a re-dislocation in the interval between
surgery and follow-up. One patient reported several dislocations on the contralateral side, but no significant bone loss
could be found in the corresponding scan that would have
hindered further investigation.
All scans showed the cultivation of tissue on the graft,
which visually resembled the cartilage of the native ipsilateral glenoid. Additionally, reshaping of the graft thus
adapting to the glenoid configuration could be observed.
An exemplary case is shown in Fig. 2.
13
Knee Surg Sports Traumatol Arthrosc
The results for averages and standard deviations of the
parameters measured are shown in Table 2. The glenoid
width increased significantly (p = 0.022) through surgery,
and at follow-up, it did not differ compared to the healthy
side (n.s.). As a consequence, GI increased significantly after
the procedure (p < 0.001).
Regarding PSI, the tissue examined on the graft showed
a significant disparity concerning pixel intensity (p = 0.017)
compared to native cartilage. However, the scar tissue examined showed a thickness comparable to native cartilage from
the contralateral side (n.s.).
Glenoid version (n.s.), inclination (n.s.), concavity (n.s.)
and balance stability angle (n.s.) did not differ between the
injured and the healthy shoulder at final follow-up, either.
The post-hoc power analysis revealed high statistical
power for the calculation of the GI (1 − ß = 1.0), while less
power was observed for the remaining parameters (PSI,
1 − ß = 0.17; cartilage thickness, 1 − ß = 0.035; glenoid
version, 1 − ß = 0.033; glenoid inclination, 1 − ß = 0.025;
glenoid concavity, 1 − ß = 0.08; balance stability angle,
1 − ß = 0.098).
Discussion
Two important findings were revealed through this study.
The first one is the restoration of the glenoid shape by the
graft. Steffen and Hertel [21], who performed CT scans in
40 patients at long-term follow-up after open glenoid reconstruction using iliac crest autografts, have also described
this aspect. In their study, the bone graft consolidated in
all cases. In five cases, 3D reconstruction was performed
and revealed a restoration of the glenoid shape. Supporting
these findings, Kraus et al. [8] performed all- arthroscopic
procedures using iliac crest grafts in their study cohort.
They followed 15 patients over a period of 20.6 months and
demonstrated a complete re-formation of the anterior sclerotic glenoid line in 13 cases. Furthermore, the GI of the
injured side approximated to the healthy side throughout
the examinations. Mizuno et al. [11] presented long-term
results of 68 patients 20 years after Latarjet procedure. In
their study cohort, pseudarthrosis of the graft and omarthrosis were accompanied with poor outcome. Even screw
breakage in one case was not associated with poor outcome,
since the graft had healed in conveniently. These findings
lead us to believe that a proper reshaping of the graft enables
the shoulder to readopt its native functionality and avoid
degeneration. However, Moroder et al. [12] were able to
show that a suitable amount of bone loss is a prerequisite
for good results. In their cohort, 11 patients with a maximum
bone loss of 5% were followed after a minimum follow-up
of 12 months. The performed follow-up CT scans showed
extensive and in some patients even subtotal osteolysis of the
Knee Surg Sports Traumatol Arthrosc
Fig. 2 Reshaping and formation of cartilage-like scar tissue (red arrows) in a male patient, 19 months post surgery. Parasagittal CT scan (a) and
3D reconstruction (b) before surgery; a.p. radiograph 2 days post-surgery (c); coronal (d), axial (e) and parasagittal (f) reformats at follow up
Table 2 Glenoid width (­WGl), Glenoid Index (GI), pixel signal intensity (PSI), thickness of cartilage/cartilage-like scar tissue as well as glenoid-related angles and concavity
N
Minimum
Maximum
Average
95% CI
WGl (contralateral) (mm)
WGl (before surgery) (mm)
WGl (after surgery) (mm)
GI (before surgery)
GI (after surgery)
PSI (glenoid)
PSI (graft)
Thickness (graft) (mm)
Thickness (contralateral) (mm)
9
9
9
9
9
9
9
9
9
20
17
17
68
135
976
725
1.7
1.6
37
24
34
103
170
3949
2857
2.4
2.7
27.0
21.3
25.4
80.2
156.0
2442.0
2012.7
1.9
1.9
23.2–30.8
19.3–23.4
20.5–30.4
72.1–88.4
148.0–164.0
1684.3–3200.0
1384.0–2641.3
1.8–2.1
1.6–2.2
Glenoid version (after surgery) (°)
Glenoid version (contralateral) (°)
Glenoid inclincation (after surgery) (°)
Glenoid inclincation (contralateral) (°)
Glenoid concavity (after surgery) (mm)
Glenoid concavity (contralateral) (mm)
Balance stability angle (after surgery) (°)
Balance stability angle (contralateral) (°)
9
9
9
9
9
9
9
9
-9
-11
-6
-3
2
2
26
28
7
7
8
7
6
6
48
46
0.6
0.2
1.2
1.2
4
4
36
36
-3.8–4.9
-4.3–4.7
-2.4–4.9
-1.4–3.9
3–5
3–5
30–41
32–41
13
grafts. In our study, no difference could be found between
the glenoid width of the healthy and the injured side after
almost 3 years. Additionally, the GI did not differ between
both shoulders at final follow-up. This is an important finding, indicating that healing of the graft includes the whole
graft body and not only the articular aspect. This is also
indicated by the fact that no statistical difference could be
found for glenoid version, inclination and concavity as well
as the balance stability angle between the operated and the
contralateral shoulder at final follow-up. The restoration of
native glenoid configuration seems to be important since
glenoid inclination and version have shown to have relevant
influence on shoulder stability [6]. This finding is clinically
relevant, since the restoration of the pear-shaped glenoid has
been in the center of attention in previous works.
The second important finding is formation of cartilagelike scar tissue on the articular surface. Nevertheless, a significant difference in PSI could be found between the tissue
on the graft and native cartilage while reaching the same
thickness as the healthy side. Olivier et al. [14] examined the
correlation between pixel intensity and the structural properties of articular cartilage. Their group found that concentration of matrix constituents, collagen network formation and
hydratation are the three decisive factors in pixel intensity
of cartilage in bovine patellae. In younger animals, different
collagen arrangements and varying concentrations of matrix
constituents played a decisive role in defining pixel intensity.
In relation to our patients, who are young individuals with
an average age of 31 ± 9 years, these differences might have
a higher impact on the pixel intensity than the hydratation of
the tissue. As a consequence, different mechanical properties
of the tissue on the graft must be expected when compared
to native cartilage. The mechanical properties of the scar
tissue cannot be explained with our data. However, it can
be hypothesized that this layer is a mechanical protection of
the graft against osteoarthritis, since it forms one common
articular-sided layer of same thickness compared to native
cartilage. If this cartilage-like scar tissue reduces its differences to native cartilage concerning PSI in the long run can
only be shown in further follow-up investigations.
The authors are aware that this study has some limitations. In general, there always is a lack of accuracy in
free-hand measurements analysing imaging data. More
specifically, only MRI imaging was performed, and only
two different sequences were analyzed. Histological and
biochemical evaluation of the scar tissue would have been
more illuminating in this case. In addition, the GI [2] was
first described in CT scans, while it was assigned to MRI
scans in our study. Furthermore, a longer and more homogenous follow-up period with a larger group of patients would
have improved the feasibility of our work. When looking
at our data, it cannot be excluded that the cohort size was
too small to detect differences for certain parameters with
13
Knee Surg Sports Traumatol Arthrosc
rather similar results between both shoulders, like cartilage thickness or glenoid width. This can be seen in our
post-hoc power analysis, where some of the parameters are
underpowered.
However, this is the first work to analyze the reshaping
and tissue formation of autologous iliac crest grafts used for
glenoid restoration, thus confirming our initial hypothesis.
Conclusion
In the cohort presented, iliac crest grafts were able to restore
the glenoid configuration, and the glenoid was re-shaped
to its native contour. Additionally, cartilage-like scar tissue
with similar thickness as healthy cartilage was formed on the
articular side of the graft. These results suggest that glenoid
reconstruction is not only important for prevention of recurrence, but also for restoration of the native glenoid anatomy.
Acknowledgements We thank Mrs Bettina Eßer from the Department of Diagnostic Radiology, St. Vinzenz hospital Düsseldorf, for
her technical advice while conducting the study.
Authors’ contributions BB conducted the measurements, wrote
the manuscript and calculated the statistics. AJV participated in the
study’s design and coordination and helped to draft the manuscript. RG
performed the MRI scans. FR participated in the study’s design and
coordination and helped to draft the manuscript. MH helped to draft
the manuscript and was involved in data collection. WN conceived of
the study, and participated in its design and coordination and helped
to draft the manuscript.
Compliance with ethical standards Conflict of interest The authors declare that they have no conflict
of interest.
Funding The authors received no financial support for the research,
authorship, and/or publication of this article.
Ethical approval The study was approved by the ethics committee
of the Medical Association of North Rhine (file number 2016324).
Informed consent All patients gave written informed consent prior
to inclusion.
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