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




• Glenoid defect sizes:

• Intact condition (no defect)

• 10% 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



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



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

%



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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