Anterior glenoid reconstruction for unstable dislocating shoulders. Surgery to restore lost anterior glenoid bone and deep the socket with a bone graft can restore shoulder anatomy and lessen pain and improve function.
Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Friday, October 16, 2009
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Figure 1 - Anatomically Contoured Extracapsular Iliac Crest Bone Graft: Bone graft inserted at the front of the glenoid socket helps restore shoulder stability
Figure 2 - Deficiency of the rim of the glenoid socket: Repeated dislocations can wear away the front lip of the socket of the shoulder
Figure 3 - Previous fracture of the lip of the socket: A previous fracture of the rim of the glenoid socket lessens its ability to stabilize the head of the humerus
Figure 4 - Separating the subscapularis tendon from the underlying capsule provides access to the site where the graft will be placed
Figure 5 - The graft is harvested from the iliac rest (hip beltline) on the same side as the shoulder reconstruction
Figure 6 - The bone graft is taken from the upper outer aspect of the iliac crest at the beltline. After the harvest, the muscle attachments are repaired.
Figure 7 - Drilling and then screwing the graft to the glenoid provides firm fixation in the desired location
Figure 8 - Extra capsular graft placement: Screw fixation of the graft outside the capsule allows the capsule to protect the humeral head from the graft. Once fixed in position, the graft can be finely contoured.
Figure 8 - Extra capsular graft placement: Screw fixation of the graft outside the capsule allows the capsule to protect the humeral head from the graft. Once fixed in position, the graft can be finely contoured.
Summary
Overview
A Bankart repair is usually successful in stabilizing a shoulder
with recurring dislocations. However, sometimes surgery can fail to
stabilize the shoulder, either because the repair is not strong enough
or because the socket of the shoulder is compromised. In these
situations, a contoured bone graft may provide the needed stability by
deepening the socket.
After performing a careful history and a clinical examination, a
surgeon experienced in complex reconstructions for instability can
determine if socket deficiency is contributing to the recurrent
dislocations of the shoulder. Patients are most likely to benefit from
this surgery if they are well motivated, in good health and have not
been smoking.
The goal of the bone graft surgery is to build up the socket so that it provides more stability for the joint.
The bone graft is harvested from the iliac crest (hip bone at the
belt line), shaped, and then screwed to the front of the socket. It is
placed outside the capsule of the shoulder so that the bone graft does
not rub directly on the cartilage of the humeral head (the ball of the
shoulder joint).
Anatomically contoured iliac crest grafting is a highly technical
procedure and is best performed by a surgical team who performs this
surgery often. Such a team can maximize the benefit and minimize the
risks. The two-hour procedure is performed under general (or nerve
block) anesthesia. If a shoulder nerve block is used, additional
anesthesia is needed for the graft donor site.
Shoulder motion is started
immediately after the
procedure. Patients learn to do
their own physical therapy and
are usually discharged three
days after surgery if they are
comfortable and have a good
range of passive motion. The
recovery of strength and
function may continue for up to
a year after surgery.
Articles of interest on Anterior inferior Bone Grafting (PDF) (1.45 MB)
Characteristics of failed surgery for anterior dislocation
After failed surgery for anterior dislocation there is often a
deficiency of the normal lip of the glenoid (shoulder socket) as well
as a deficiency in the glenoid labrum and capsule (the soft tissues in
front of the shoulder socket). These deficiencies make another try at a
routine repair less likely to succeed.
Individuals with failed shoulder repairs usually notice that the
ball slips forward out of the socket, sometimes with the arm relaxed at
the side and sometimes when the arm is raised backwards. The shoulder
may dislocate at night as well.
There may be a grinding feeling as the arm is moved.
Once the surgery has failed, dislocation of the joint may become easier and easier.
Similar conditions
Failed surgery for instability is usually not difficult for the patient
to recognize. Commonly, the symtoms are similar to those before the
surgery--sometimes they are even worse.Incidence and risk factors
Surgery for anterior dislocation of the shoulder fails in one out of
ten to one out of twenty cases. There is a higher incidence of failure
when the repair has been done arthroscopically. There is also a higher
incidence of failure in individuals who smoke, those who begin using
their shoulder vigorously very early after the repair, and those with
very loose ligaments. If part of the lip of the socket is missing,
conventional repairs have a higher chance of failure.Diagnosis
The shoulder surgeon diagnoses failure of surgery for anterior
dislocation from the patient's history, performing a thorough physical
examination of the joint, and taking the proper X-rays.
The examination often reveals that the shoulder slips easily out of
the front of the socket, even when it is pressed into it. This is
called the "load and shift test." It is similar to checking the
adequacy of a golf tee by pressing the golf ball into it and seeing how
easily the golf ball can slide out of the tee.
X-rays of the shoulder may reveal that bony lip of the glenoid
socket is rounded or deficient. They may also reveal that the humeral
head (ball) is not centered in the glenoid (socket).
Medications
Medications are usually not helpful in improving the stability of the shoulder joint after failed surgery.Exercises
Exercises can help to stabilize the shoulder. Particularly internal
and external rotation strengthening exercises and exercise that develop
coordinated movements may increase the joint's stability.
However, if the shoulder is unstable at rest or at night, exercises may not be of benefit.
Possible benefits of surgery to deepen the socket of anteriorly dislocating shoulders (using an anterior iliac crest bone graft)
If the cause of recurrent instability after a previous repair for
anterior dislocation is a deficiency of the lip of the socket or lack
of soft tissues of sufficient strength, an anatomically contoured
extracapsular bone graft harvested from the iliac crest (hip at the
beltline) may restore stability by deepening the socket. In experienced
hands, this procedure may help restore function of the unstable
shoulder.
While this surgery can improve stability, it cannot make the joint
as good as it was before the onset of dislocations. In many cases, the
tendons and muscles around the shoulder have been weakened from
prolonged disuse and recurring dislocations.
After the surgery, it may take months of gentle exercises before the
shoulder achieves maximum improvement in comfort and function.
The effectiveness of the procedure depends on the health and motivation
of the patient, the condition of the shoulder, and the experience of
the surgeon.
Types of surgery recommended
When the anterior soft tissues of the shoulder are deficient,
particularly if there is loss of the bone from the front of the socket,
iliac crest grafting to the anterior glenoid lip provides the most
robust of reconstruction techniques.
Other procedures, such as a repeat Bankart repair, may be of benefit
if the bony anatomy is normal and if adequate quantity and quality of
soft tissues remain.
Shoulder fusion can stabilize the shoulder, but takes away the mobility at the ball and socket joint.
Who should consider surgery to deepen the socket of anteriorly dislocating shoulders (using an anterior iliac crest bone graft)?
Iliac crest graft surgery is considered when dislocations or
instability of the shoulder have recurred after previous surgery for
dislocations.
If the patient and doctor decide to use this surgical procedure, it is important that:
- the instability is the problem,
- the patient is sufficiently healthy to undergo the procedure,
- the patient understands and accepts the risks and alternatives,
- the surgeon is experienced in shoulder reconstructive surgery, and
- the patient is dedicated to the rehabilitation program after the surgery.
What happens without surgery?
If the shoulder dislocates repeatedly, the dislocations tend to become more frequent and to require less force.
Recurrent dislocations may cause risk to the bone, the rotator cuff and to the nerves and blood vessels in front of the joint.
Surgical options
Several options exist for the patient with failed shoulder instability surgery.
One is to accept the tendency for dislocation and to control it with careful positioning of the shoulder and with exercises.
A second option is for the surgeon to attempt a repeat soft tissue
repair, assuming there is sufficient and sufficiently strong tissue.
The third option is to perform an anatomically contoured extracapsular iliac crest bone graft to the anterior glenoid lip.
A final option is to perform a fusion of the shoulder.
Effectiveness
If the problem is recurrent anterior glenohumeral instability after
surgery, anterior iliac crest grafting is usually very effective in
restoring stability. Once the glenoid graft is healed solidly (usually
after 3 months) the stability should not be lost with time unless a new
injury occurs.
Urgency
Surgery for failed instability surgery is an elective procedure that
can be scheduled when circumstances are optimal. It is not an urgent
procedure. The patient has plenty of time to become informed and to
select an experienced surgeon.
Risks
The risks of iliac crest grafting to the anterior glenoid lip include but are not limited to the following:
- infection,
- injury to nerves and blood vessels,
- fracture,
- stiffness or instability of the joint,
- loosening or wear of the bone graft,
-
- screw loosening,
- arthritis,
- and problems at the bonegraft harvest site.
There are also risks to anesthesia.
A blood transfusion is only rarely required.
An experienced shoulder replacement team will use special techniques
to minimize these risks, but cannot totally eliminate them.
Managing risk
Most of the risks of iliac crest graft surgery can be effectively
managed if they are identified promptly and treated.
Infections may require a wash out in the operating room, possibility
with removal of the graft. Blood vessel or nerve injury may require
repair. Fracture may require surgical fixation. Stiffness or
instability may require exercises or additional surgery. Loosening of
hardware or wear of the graft may require surgical revision. Arthritis
of the shoulder may require joint reconstruction. If the patient has
questions or concerns about the course after surgery, the surgeon
should be informed as soon as possible.
Preparation
Iliac crest graft surgery is considered for healthy and motivated
individuals in whom instability after a previous repair interferes with
shoulder function.
Successful reconstructive surgery depends on a partnership between the
patient and the experienced shoulder surgeon. Patients should optimize
their health so that they will be in the best possible condition for
this procedure. Smoking should be stopped a month before surgery and
not resumed for at least three months afterwards. Any heart, lung,
kidney, bladder, tooth, or gum problems should be managed before
surgery. Any infection may be a reason to delay the operation. The
shoulder surgeon needs to be aware of all health issues, including
allergies and the non-prescription and prescription medications being
taken. Some of these may need to be modified or stopped. For instance,
aspirin and anti-inflammatory medication may affect the way the blood
clots.
The area of the skin incision over the shoulder and hip must be
clean and free from sores and scratches.
Before surgery, patients should consider the limitations,
alternatives and risks of surgery. Patients should also recognize that
the result of surgery depends in large part on their efforts in
rehabilitation after surgery.
The patient needs to plan on being less functional than usual for
six to twelve weeks after the procedure. Driving, shopping and
performing usual work or chores may be difficult during this time.
Plans for necessary assistance need to be made before surgery. For
individuals who live alone or those without readily available help,
arrangements for home help should be made well in advance.
Timing
Shoulder reconstruction with an iliac crest graft can be delayed until
the time that is best for the patient's overall well-being. However, in
the case of recurrent dislocations, excessive delays can result in the
loss of bone and tendon tissue. These losses can compromise the quality
of the surgery and its result.Costs
The surgeon's office should provide a reasonable estimate of:
- the surgeon's fee and
- the hospital fee
Surgical team
Revision instability surgery is a technically demanding procedure that
should be performed by an experienced surgeon in a medical center
accustomed to performing these reconstructions frequently. Patients
should inquire as to the number of similar shoulder procedures that the
surgeon performs each year and the number of these procedures performed
in the medical center each year.Finding an experienced surgeon
Because these procedures
are performed infrequently in the United States each year, it is
unlikely that every community has a shoulder surgeon who performs many
of these procedures each year. Surgeons specializing in shoulder joint
reconstruction may be located through university schools of medicine,
county medical societies, or state orthopedic societies. Other
resources include local rheumatologists or professional societies such
as the American Shoulder and Elbow Surgeons Society, which offers a worldwide directory of shoulder and elbow surgeons on its web site.
Facilities
Shoulder reconstruction is usually performed in a major medical center
that performs these procedures on a regular basis. These centers have
surgical teams and facilities specially designed for this type of
surgery. They also have nurses and therapists who are accustomed to
assisting patients in their recovery from shoulder reconstruction
surgery.
Technical details
Revision surgery for shoulder instability is a highly technical
procedure; each step plays a critical role in the outcome.
After the anesthetic has been administered and the shoulder and hip are
prepared, an incision is made across the front of the shoulder. The
incision from a previous repair may be used for this procedure.
Otherwise an incision is made in the anterior skin crease of the
shoulder.
The hip incision is made just below the beltline near the front of the hip.
The shoulder incision allows access to the joint without damaging
the important deltoid or pectoralis muscles that are responsible for a
significant portion of the shoulder's power.
The muscles and other tissues near the shoulder are mobilized by
removing any scar tissue that may restrict their motion. This may be
difficult if previous surgery has resulted in excessive scarring or if
implants or sutures need to be removed and dissected from the normal
tissues.
The subscapularis tendon is cut to allow access to the joint and
then split from the capsule that lies beneath it. This split reveals
the front of the bone of the socket where the bone graft will be placed
and secured.
The graft is then harvested from the iliac crest by detaching the
muscles that attach there. A segment of bone measuring about 4 cm by 4
cm by 1 cm is harvested. The muscles are then reattached.
This bone graft is then shaped to fit on the front of the glenoid
and fixed there with two screws. The graft is placed so that the
capsule lies between the humeral head and the graft. After the graft
has been secured in position, its contour can be finely adjusted.
After the graft is in position, the stability of the shoulder is
examined. At the conclusion of the procedure, the subscapularis tendon
and capsule are repaired.
Anesthetic
Revision instability surgery may be performed under a general
anesthetic or under a brachial plexus nerve block. A brachial plexus
block can provide anesthesia for several hours after the surgery. If a
plexus block is used, additional anesthesia is necessary for the iliac
crest harvest. The patient may wish to discuss their preferences with
the anesthesiologist before surgery.Length of surgery to deepen the socket of anteriorly dislocating shoulders (using an anterior iliac crest bone graft)
The procedure usually takes approximately two hours, however the
preoperative preparation and the postoperative recovery may add several
hours to this time. Patients often spend two hours in the recovery room
and two to four days in the hospital after surgery
Pain and pain management
The shoulder and hip are painful after the surgery. Pain in the hip
area may make walking uncomfortable for several weeks after surgery. A
cane held in the opposite hand may be helpful in walking afterwards.
For this reason, the bone graft is usually harvested from the same side
as the shoulder surgery. Recovery of comfort and function after
shoulder reconstruction continues for the first year after surgery.Use of medications
Initially pain medication is usually administered intravenously or
intramuscularly. Sometimes patient controlled analgesia (PCA) is used
to allow the patient to administer the medication as it is needed.
Hydrocodone or Tylenol with codeine are taken by mouth. Intravenous
pain medications are usually needed only for the first day or two after
the procedure. Oral pain medications are usually needed only for the
first two weeks after the procedure.Effectiveness of medications
Pain medications can be very powerful and effective. Their proper use
lies in the balancing of their pain relieving effect and their other,
less desirable effects. Good pain control is an important part of the
postoperative management.Important side effects
Pain medications can cause drowsiness, slowness of breathing,
difficulties in emptying the bladder and bowel, nausea, vomiting and
allergic reactions. Patients who have taken substantial narcotic
medications in the recent past may find that usual doses of pain
medication are less effective. For some patients, balancing the benefit
and the side effects of pain medication is challenging. Patients should
notify their surgeon if they have had previous difficulties with pain
medication or pain control.Hospital stay
After surgery the patient spends an hour or so in the recovery room.
Drainage tubes are usually used to remove excess fluid from the
surgical areas. The drains are usually removed on the second day after
surgery. Bandages cover the incisions. They are usually changed the
second day after surgery.
Patients are discharged as soon as the incisions are dry, the shoulder
and hip are comfortable with oral pain medications, the patient can
perform the range of motion exercises, the patient can walk
independently and the home support systems for the patient are in
place. Discharge is usually on the third or fourth day after surgery.
Recovery and rehabilitation in the hospital
Early motion after shoulder reconstruction helps achieve the best
possible shoulder function. Initially, the patient is encouraged to
rotate the arm through a limited range that is defined by the surgeon.
During the hospitalization, the patient learns the simple
rehabilitation program that will be used for maintaining the range of
motion at home after discharge. On the day of surgery or the day after,
the physical therapist teaches the patient gentle range of motion
exercises. Walking and use of the arm for gentle activities are
encouraged soon after surgery.
Hospital discharge
At the time of discharge, the patient should be relatively
comfortable on oral medications, have dry incisions, understand their
exercises, and feel comfortable with the plans for managing the
shoulder and the hip. For the first month or so after this procedure,
the operated arm may be less useful than it was immediately beforehand.
The specific limitations can be specified only by the surgeon
who performed the procedure. It is important that the repaired tendons
not be challenged until they have had a chance to heal. Usually the
patient is asked to lift nothing heavier than a cup of coffee for six
weeks after the surgery. Management of these limitations requires
advance planning to accomplish the activities of daily living during
the period of recovery.
Convalescent assistance
Patients usually require some assistance with self-care, activities
of daily living, shopping, and driving for approximately six weeks
after surgery. Patients usually go home after this surgery, especially
if there are people at home who can provide the necessary assistance,
or if such assistance can be arranged through an agency. In the absence
of home support, a convalescent facility may provide a safe environment
for recovery.
Recovery of comfort and function after shoulder reconstruction
continues for many months after the surgery. Improvement in some
activities may be evident as early as six weeks. With persistent
effort, patients make progress for as long as a year after surgery.
Physical therapy
Early motion after shoulder reconstruction is critical for achieving
optimal shoulder function. One of the major goals of shoulder
reconstruction surgery is to maintain the range of motion while
achieving stability.
After surgery, scar tissue tends to limit movement unless motion is
started immediately. Later on, once the shoulder is comfortable and
flexible, strengthening exercises and additional activities are started.
Rehabilitation options
It is often most effective for the patient to carry out their own
exercises so that they are done frequently, effectively and
comfortably. Usually, a physical therapist or the surgeon instructs the
patient in the exercise program and advances it at a rate that is
comfortable for the patient. For the first six weeks after surgery,
emphasis is placed on optimizing the flexibility and range of motion of
the shoulder through gentle stretching exercises. After six weeks,
these stretching exercises are continued and strengthening exercises
may be added.Can rehabilitation be done at home?
In general the exercises are best performed by the patient at home.
Occasional visits to the surgeon or therapist may be useful to check
the progress and to review the program.Usual response
Patients are almost always satisfied with the increases in range of
motion, comfort and function that they achieve with the exercise
program. If the exercises are uncomfortable, difficult, or painful, the
patient should contact the surgeon promptly.Risks
The primary risk is that the patient may exceed the limitations suggested by the surgeon after the reconstruction.Duration of rehabilitation
Once the range of motion and strength goals are achieved, the
exercise program can be cut back to a minimal level. However, gentle
stretching is recommended on an ongoing basis.
Returning to ordinary daily activities
In general, patients are able to perform gentle activities of daily
living using the operated arm from two to six weeks after surgery.
Walking is strongly encouraged. Driving should wait until the patient
can perform the necessary functions comfortably and confidently.
Recovery of driving ability may take six weeks if the surgery has been
performed on the right shoulder, because of the increased demands on
the right shoulder for shifting gears.
With the consent of their surgeon, patients can often return to
activities such as swimming and golf at six months after their surgery.
Long-term patient limitations
Until the surgeon determines that the shoulder is healed and strong,
patients should avoid sudden, heavy or forceful activities with the
shoulder.The surgeon and therapist should provide the information on the usual
cost of the rehabilitation program. The program is quite
cost-effective, because it is based heavily on home exercises.Costs
The surgeon and therapist should provide the information on the usual
cost of the rehabilitation program. The program is quite
cost-effective, because it is based heavily on home exercises.
Summary of surgery to deepen the socket of anteriorly dislocating shoulders (using an anterior iliac crest bone graft) for failed surgery for anterior dislocation
After a procedure for anterior shoulder dislocation fails, the
tissues may be compromised so that another routine repair may not be
dependable.
In such a situation, especially if there is a loss of the normal lip
of the socket and deficiency of the normal soft tissues, consideration
can be given to a shoulder reconstruction using a contoured iliac crest
graft placed outside the shoulder capsule.
This reconstruction is best performed by a surgeon familiar with complex shoulder revision surgery.
The iliac crest graft can provide excellent stability of the shoulder.
Other options include accepting the limitations of instability,
attempting a repeat soft tissue procedure, and a shoulder fusion.
Surgery for failed surgery for anterior dislocation at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington
If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-BONE (2663) to make an appointment. Our clinical center is located in Seattle Washington, USA