Shoulder and Elbow Cases to Consider.

Last updated Friday, August 29, 2008

Figure 1

Figure 2

Anterior-inferior glenoid reconstruction for recur

Clinical presentation

This is the radiograph of a 25 year old male with a history of recurrent anterior dislocations of his right shoulder (see figure 1). His original dislocation occurred 5 years ago following a seizure. Unfortunately over the ensuing two years his seizures were poorly controlled resulting in further dislocations. Over the last three years he has had two surgical procedures (a Bankart repair and a revision Bankart repair with soft tissue augmentation), but continues to have instability whenever his arm is brought into abduction and minimal external rotation. Due to the dislocations he is unable to work or perform normal daily activities above shoulder level. His epilepsy is well controlled on medication.

On examination the patient was very apprehensive with his arm in abduction and in thirty degrees of external rotation. With his arm by the side he could externally rotate to sixty degrees without discomfort in comparison to eighty degrees on the other side.He had a functioning rotator cuff and subscapularis. He had no evidence of ligamentous laxity,a negative sulcus sign and a negative jerk test.

Our concerns include:

1. Significant deficiency of the anterior / inferior glenoid.
2. Early degenerative change of the glenohumeral joint.
3. The history of seizures.
4. The failure of two previous repairs.

Management

Despite early degenerative changes on X-ray, the patient's primary functional problem was instability. Examination under anesthesia revealed that there was no effective anterior glenoid lip on the load and shift test. Surgical findings confirmed the lack of an anterior inferior glenoid lip, a large recurrent Bankart lesion, a large Hill-Sachs defect, and early degenerative changes. The subscapularis was intact.

We concluded that a robust reconstruction of the anterior glenoid was essential to stabilizing this shoulder and that the patient's history demonstrated that this could not be accomplished with soft tissue procedures. Thus we reconstructed the anterior glenoid using a contoured iliac crest graft with capsule interposed between the graft and the humeral head.

One year following surgery, the bone graft remains stable (see figure 2) and the patient uses the shoulder for daily activities without apprehension, instability, or complaints of pain.

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