The role of bone in glenohumeral stability

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Abstract

Shoulder stability depends on several factors, either anatomical or functional. Anatomical factors can be further subclassified under soft tissue (shoulder capsule, glenoid rim, glenohumeral ligaments etc) and bony structures (glenoid cavity and humeral head).
Normal glenohumeral stability is maintained through factors mostly pertaining to the scapular side: glenoid version, depth and inclination, along with scapular dynamic positioning, can potentially cause decreased stability depending on the direction of said variables in the different planes. No significant factors in normal humeral anatomy seem to play a tangible role in affecting glenohumeral stability.
When the glenohumeral joint suffers an episode of acute dislocation, either anterior (more frequent) or posterior, bony lesions often develop on both sides: a compression fracture of the humeral head (or Hill–Sachs lesion) and a bone loss of the glenoid rim. Interaction of such lesions can determine ‘re-engagement’ and recurrence.
The concept of ‘glenoid track’ can help quantify an increased risk of recurrence: when the Hill–Sachs lesion engages the anterior glenoid rim, it is defined as ‘off-track’; if it does not, it is an ‘on-track’ lesion. The position of the Hill–Sachs lesion and the percentage of glenoid bone loss are critical factors in determining the likelihood of recurrent instability and in managing treatment.
In terms of posterior glenohumeral instability, the ‘gamma angle concept’ can help ascertain which lesions are prone to recurrence based on the sum of specific angles and millimetres of posterior glenoid bone loss, in a similar fashion to what happens in anterior shoulder instability.

Cite this article: EFORT Open Rev 2018;3:632-640. DOI: 10.1302/2058-5241.3.180028

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Most cited references 84

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Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging" lesion to "on-track/off-track" lesion.

Giovanni Di Giacomo, Eiji Itoi, Stephen S Burkhart (2014)

For anterior instability with glenoid bone loss comprising 25% or more of the inferior glenoid diameter (inverted-pear glenoid), the consensus of recent authors is that glenoid bone grafting should be performed. Although the engaging Hill-Sachs lesion has been recognized as a risk factor for recurrent anterior instability, there has been no generally accepted method for quantifying the Hill-Sachs lesion and then integrating that quantification into treatment recommendations, taking into account the geometric interplay of various sizes and various orientations of bipolar (humeral-sided plus glenoid-sided) bone loss. We have developed a method (both radiographic and arthroscopic) that uses the concept of the glenoid track to determine whether a Hill-Sachs lesion will engage the anterior glenoid rim, whether or not there is concomitant anterior glenoid bone loss. If the Hill-Sachs lesion engages, it is called an "off-track" Hill-Sachs lesion; if it does not engage, it is an "on-track" lesion. On the basis of our quantitative method, we have developed a treatment paradigm with specific surgical criteria for all patients with anterior instability, both with and without bipolar bone loss.

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Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.

Pascal Boileau, Matias Villalba, Jean-Yves Héry … (2006)

The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability. Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers. At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03). In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization.

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Glenoid rim morphology in recurrent anterior glenohumeral instability.

Hiroyuki Sugaya, Joji Moriishi, Michiko Dohi … (2003)

Knowledge regarding the morphology of the glenoid rim is important when patients with recurrent anterior glenohumeral instability are assessed. Ordinary imaging techniques are not always sensitive enough to demonstrate the morphology of the glenoid rim accurately. We developed a method of three-dimensionally reconstructed computed tomography with elimination of the humeral head to evaluate glenoid morphology. The purpose of the present study was to quantify glenoid osseous defects and to define their characteristics in patients with recurrent anterior instability. The morphology of the glenoid rim in 100 consecutive shoulders with recurrent unilateral anterior glenohumeral instability was evaluated on three-dimensionally reconstructed computed tomography images with the humeral head eliminated. The configuration of the glenoid rim was evaluated on both en face and oblique views. Concurrently, we also investigated seventy-five normal glenoids, including both glenoids in ten normal volunteers. Shoulders without an osseous fragment at the anteroinferior portion of the glenoid were compared with the contralateral shoulder in the same patient to determine if the glenoid morphology was normal. In shoulders with an osseous fragment, the fragment was evaluated quantitatively and its size was classified as large (>20% of the glenoid fossa), medium (5% to 20%), or small (<5%). Finally, all 100 shoulders were evaluated arthroscopically to confirm the presence of the lesion at the glenoid rim that had been identified with three-dimensionally reconstructed computed tomography. Investigation of the normal glenoids revealed no side-to-side differences. Investigation of the affected glenoids revealed an abnormal configuration in ninety shoulders. Fifty glenoids had an osseous fragment. One fragment was large (26.9% of the glenoid fossa), twenty-seven fragments were medium (10.6% of the glenoid fossa, on the average), and twenty-two were small (2.9% of the glenoid fossa, on the average). In the forty shoulders without an osseous fragment, the anteroinferior portion of the glenoid appeared straight on the en face view and it appeared obtuse or slightly rounded, compared with the normally sharp contour of the normal glenoid rim, on the oblique view, suggesting erosion or a mild compression fracture at this site. Arthroscopic investigation revealed a Bankart lesion in ninety-seven of the 100 shoulders and an osseous fragment in forty-five of the fifty shoulders in which an osseous Bankart lesion had been identified with the three-dimensionally reconstructed computed tomography. In the shoulders with distinctly abnormal morphology on three-dimensionally reconstructed computed tomography, the arthroscopic appearance of the anteroinferior portion of the glenoid rim was compatible with the appearance demonstrated by the three-dimensionally reconstructed computed tomography. We introduced a method to evaluate the morphology of the glenoid rim and to quantify the osseous defect in a simple and practical manner with three-dimensionally reconstructed computed tomography with elimination of the humeral head. Fifty percent of the shoulders with recurrent anterior glenohumeral instability had an osseous Bankart lesion; 40% did not have an osseous fragment but demonstrated loss of the normal circular configuration on the en face view and an obtuse contour on the oblique view, suggesting erosion or compression of the glenoid rim.

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Journal

Journal ID (nlm-ta): EFORT Open Rev

Journal ID (iso-abbrev): EFORT Open Rev

Title: EFORT Open Reviews

Publisher: British Editorial Society of Bone and Joint Surgery

ISSN (Electronic): 2058-5241

Publication date Collection: December 2018

Publication date (Electronic): 20 December 2018

Volume: 3

Issue: 12

Pages: 632-640

Affiliations

[1 ]Concordia Hospital for Special Surgery Rome, Italy

[2 ]Università degli Studi di Roma La Sapienza, Dipartimento di Medicina Sperimentale, Trauma and Orthopaedics, Rome, Italy

Author notes

[*]M. Pugliese, Università degli Studi di Roma La Sapienza, Dipartimento di Medicina Sperimentale, Trauma and Orthopaedics, Piazzale Aldo Moro 5, 00185 Rome, Italy. Email: mattiapugliese@ 123456outlook.com

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Publisher ID: 10.1302_2058-5241.3.180028

DOI: 10.1302/2058-5241.3.180028

PMC ID: 6335605

PubMed ID: 30697443

SO-VID: 2ade1bd2-f15f-4462-92d4-715196f0d961

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This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence ( https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.

The role of bone in glenohumeral stability

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EFORT Open Reviews

Most cited references 84

Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging" lesion to "on-track/off-track" lesion.

Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.

Glenoid rim morphology in recurrent anterior glenohumeral instability.

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