Treatment of recurrent anterior inferior instability associated with glenoid bone loss: Iliac crest

OVERVIEW

Chapter synopsis

The J-bone graft procedure is indicated in patients suffering from anterior shoulder instability and critical glenoid bone loss. An autologous iliac crest bone graft is shaped to resemble the letter “J” and is press-fit impacted into a scapula neck osteotomy, thus allowing for implant-free anatomic glenoid reconstruction.

Important points

Indications: Anterior shoulder instability with critical glenoid bone loss
Contraindications: Untreated neuromuscular pathologies (e.g., seizure disorders), progressed degenerative changes, chronic glenohumeral joint infection
Symptoms: Chronic feeling of instability, recurrent anterior dislocations, discomfort and pain with the arm in external rotation and abduction
Surgical technique: Open deltopectoral and subscapularis splitting approach to visualize the glenoid defect, graft harvesting from the ipsilateral iliac crest, J-shaped graft trimming, osteotomy of the scapular neck, implant-free press-fit impaction of the graft into the osteotomy, modeling of the graft to restore the glenoid concavity

Clinical/surgical pearls

Bicortical bone block harvesting involving the outer and upper cortex of the iliac crest
Preparation of the graft leaving a cortico-cancellous bone block and a long keel of cortical bone similar to the shape of the letter “J”
Scapular neck osteotomy 5 mm medial and in 20 degrees of angulation to the articular surface
Implant-free press-fit impaction of the graft into the osteotomy with force applied strictly on the medial/keel side of the graft
Final graft contouring to match the exact radius of curvature of the articular surface

Clinical/surgical pitfalls

Fracture of the glenoid articular surface during the osteotomy if the angulation and distance to the articular surface is not respected
Graft fracture during incorrect impaction or inadequate graft stability may require additional screw fixation
Persistent pain or wound-related complications of the harvesting site at the iliac crest
Similar to other stabilization techniques, progression of instability arthropathy cannot be prevented with this procedure

Video available

: Surgical video of the J-bone graft procedure (7:39 min)

Introduction

Shoulder stability relies on intact anatomic constraints of the glenohumeral joint. Substantial osseous defects of the glenoid rim are a major risk for recurrent anterior shoulder instability. In the presence of significant bony defects of the anterior glenoid concavity, soft tissue stabilization procedures have been associated with a high rate of recurrent instability. Based on the bone graft concept of Eden and Hybinette, various glenoid restoration surgeries have been proposed, including open and arthroscopic bone block augmentation techniques with distinctive fixation methods to re-establish shoulder stability. In contrast to the Latarjet procedure where a coracoid transfer with attached conjoined tendons serve as a mechanical barrier, iliac crest bone grafting techniques aim for anatomic restoration of the glenoid concavity and demonstrate a comparable clinical outcome in patients with critical glenoid bone loss. The aim of the J-bone graft procedure is to re-establish glenoid morphology in patients suffering from anterior shoulder instability with critical glenoid bone loss by means of an implant-free iliac crest bone grafting technique.

Preoperative considerations

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