Arthroscopy journal: Technique for arthroscopic fixation of glenoid fractures

Abstract

Jump to SectionTechnique  Preoperative Workup  Patient Positioning and SetupProcedure  Step 1: Portal Placement  Step 2: Fracture Evaluation and Debridement of Fracture Hematoma  Step 3: Fracture Manipulation, Reduction, and Insertion of Cannulated Screw Guidewires  Step 4: Insertion of the Cannulated Lag ScrewsRehabilitation ProtocolDiscussionSupplementary DataReferences

The most common procedure to address transverse glenoid fractures that are characterized by intra-articular step-off or gapping is open reduction and internal fixation. Disadvantages of open surgery are delay in regaining full range of motion, increased approach morbidity, neurovascular complications, and the need for capsulotomy, which delays healing and increases the risk of stiffness. An arthroscopically assisted fracture fixation, as described in this article, is characterized by better visualization of the glenoid articular surface and reduction of the intra-articular fragments under direct vision, which diminishes the chances of residual step-off after fixation. Furthermore, arthroscopic fixation provides the advantages of minimal surgical trauma, which speeds up the recovery time, decreased morbidity as there is less blood loss compared with the open technique, lower chance of neurologic injury as there is less dissection around the spinoglenoid or suprascapular notch, less trauma to the joint capsule, and lower chances of stiffness and capsulorrhaphy arthropathy.

Anastasios Papadonikolakis, MD, PhD, Arthroscopy Techniques June 2017

Reverse shoulder replacement for chronic non union of the proximal humerus

The use of the reverse shoulder arthroplasty in the elderly is valuable not only for the treatment of rotator cuff arthropathy but also for the treatment of painful non union of the proximal humerus. My experience has been that open reduction and internal fixation is not a predictable solution in these cases due to the osteoporosis, poor nutrition and blow flow to the bone. This case below illustrates that the reverse total shoulder replacement provides solutions for problems that we did not have a solution before.

I prefer to use large glenospheres for those cases as instability can be a problem

I also prefer to use eccentric glenospheres which minimize the risk of impingement and scapular notching especially when the neck shaft angle of the humeral stem is more than 135 degrees. Those stems bring the humerus closer to the glenoid and can impinge. Impingement can be avoided by implanting a glenosphere with a 2-3 mm of inferior eccentricity.

The preoperative and postoperative images are shown below. This patient is in his 80s.

Dissection can be challenging especially when the proximal humerus is migrated in the axilla where the axillary a. and nerve can be traumatized at the time of surgery. Caution and patience is recommended during the dissection.

Arthroscopic findings after a ream and run shoulder hemiarthroplasty

Although the ream and run procedure has been a matter of debate among shoulder and elbow surgeons, it seems that for the young individual with glenohumeral arthritis there are not many alternative options. Glenoid components fail 10-15 years after surgery and some of these require difficult revision surgery as there is no bone left at the glenoid for reconstruction. The principle of ream and run surgery as developed by Dr Frederick Matsen at the University of Washington is that by reaming the glenoid to a smooth surface there is fibrocartilage regeneration, redistribution of the load and contact pressures to the entire glenoid and decrease in pain.

As reported by Dr Matsen:

"Earlier studies on hip and knee arthroplasty have provided encouraging evidence that reamed bone articulating with a convex metal prosthesis can remodel to a functional and durable arthroplasty concavity, sometimes lasting over four decades. Notably, the majority of so-called mold arthroplasty failures of the hip were on the femoral side and not on the acetabular side of the articulation. An analysis of pelvic specimens retrieved post mortem revealed that the concave acetabular joint surface was often covered with a smooth regenerated surface and had reestablished homogeneous and stable subsurface bone. Moreover, the tissue covering the acetabular concavity was found to resemble dermis and meniscus in terms of glycosaminoglycan content."


The case illustrated below is a of patient 1 year after a ream and run. During arthroscopy we found patchy formation of fibrocartilage on the glenoid side which probably accounts for the pain relief seen at the ream and run surgery. Pictures and video are demonstrated below.