Arthroscopic Management of Glenoid Fracture and Shoulder Dislocation: Surgical Technique

Rajkumar S. Amaravathi, MBBS, DNB, MNAMS, FRCS, INDIA Jerin Jeevo, MS, DNB Ortho, INDIA Vadhiraj Krishna, MS, DNB Ortho, INDIA Gaurav Kumar Gupta, MS, DNB Ortho, INDIA Allen Kavalakkatt, MBBS, INDIA Karthik Shyam, MD, INDIA

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ABSTRACT

Surgical reconstruction of intra-articular displaced glenoid rim fractures remains a clinical challenge. Historically, open approaches to the glenohumeral joint have been used to treat these fractures; however, arthroscopic procedures may lessen the morbidity linked to open surgery. Clamps and Kirschner wires (K-wires) are frequently used to achieve and maintain temporary fixation during various arthroscopic procedures. In the present report, we outline our method of arthroscopic fixation of displaced glenoid rim fractures, which involves using the labrum to achieve fracture reduction followed by the insertion of an extra-articular screw for final fixation. This technique can be applied to a range of intra-articular glenoid fractures and is safe, effective, and dependable.

INTRODUCTION

The yearly incidence of scapular fractures is only 10 per 100,000, making these injuries very uncommon. Roughly 30% of them involve the glenoid cavity. While nonoperative treatment is frequently used for extra-articular scapular fractures, surgical intervention is usually recommended for displaced, intra-articular glenoid fractures, especially when the articular step-off is >5 mm. In order to achieve direct visibility and anatomic reduction, open reduction (that is, internal fixation through an arthrotomy) has historically been used to treat displaced, intra-articular glenoid fractures. However, open reduction is associated with a number of possible complications, such as infection, postoperative stiffness, injury to neurovascular structures, and a protracted recovery period. As a result, arthroscopic methods for treating glenoid fractures have gained popularity, and numerous methods have been documented in the literature.

In order to achieve and hold temporary fixation, the majority of these arthroscopic procedures require the use of clamps and/or K-wires.

The purpose of the present article is to offer an alternative method for arthroscopic fixation of glenoid rim fractures by employing labral repair as an indirect reduction technique and an extra-articular screw for final fixation. This technique can minimize the hazards associated with an open approach while achieving anatomic reduction and reliable fixation of the glenoid.

CASE

A 37-year-old man presented to our institution 1 week after having sustained a dislocation of the right shoulder as the result of a fall. The dislocation had spontaneously reduced during positioning for radiographs at a nearby hospital. The patient had no history of a similar dislocation. Shoulder assessment could not be done because of severe pain; however, the Beighton score was <5. Radiographs showed a possible glenoid fracture. CT showed displaced anterior glenoid rim fracture (Figs. 1A and 1B). MRI showed a glenoid rim fracture with an intact labrum at the fracture fragment and a torn middle glenohumeral ligament (MGHL) (Figs. 1C and 1D). On the basis of the fracture pattern, the glenoid rim fracture was classified as AO type F1-1b.

Figs. 1A and 1B CT scans with 3D reconstruction. The blue arrow indicates the displaced glenoid rim fracture fragment. Fig. 1C Axial MRI section, with blue arrows depicting the displaced glenoid fragment. Fig. 1D Sagittal MRI section, with blue arrow showing the torn MGHL.

SURGICAL TECHNIQUE

With the patient under general anaesthesia and in the lateral decubitus position, diagnostic arthroscopy was done with a standard 30° arthroscope through a posterior portal into the glenohumeral joint. Arthroscopy showed the glenoid fracture site, a labral tear at the 7 o’clock position, a torn MGHL, and a small Hill-Sach lesion at posterolateral part of the humeral head. We mainly used the posterior portal for viewing and the anterior portal for working. An arthroscopic shaver was used to locate and gently debride the glenoid fracture line. As this process could have damaged any remaining labral tissue, care was taken not to displace the fracture too much. With use of a probe, the labrum next to the intact glenoid and fracture fragment was carefully examined. The fracture fragment was subsequently mobilized to achieve anatomical reduction.

Fig. 2A The fracture site was mobilized and debrided. Fig. 2B Fibre wire was passed through the labrum and was attached to the fracture fragment as a racking stich to aid in reduction. Fig. 2C Fibre wire was manipulated to provide temporary reduction.

Fibre wire was then passed through the anterior portal and was used to manipulate the fracture fragment (Figs. 2B and 2C). Once reduction had been achieved, guidewires were passed though the jig (transglenoid drill guide hook AR-7800PGH and drill guide sleeve AR-7800DGS; Arthrex, Munich, Germany), which was placed via the posterior portal under fluoroscopic guidance. Then, 2.4-mm cannulated drill bits were used to drill over the guidewires under fluoroscopic guidance using the same Arthrex jig, and final fixation was achieved with use of extra-articular screws of appropriate size (in this case, 30 mm). After fixation, fluoroscopy was used to check the fracture reduction and the position of the screws (Figs. 3A and 3B).

Figs. 3A and 3B Fluoroscopic images showing glenoid fracture fixation with partially threaded cancellous screws. Figs. 3C and 3D Radiographic images after fracture reduction and fixation with partially threaded cancellous screws.

After fracture fixation, labral repair at 7 o’ clock was performed with use of a single loaded suture anchor (1.4 mm) (ICONIX; San Jose, California, USA) (Fig 4A). Anterior subscapularis augmentation was performed, and the torn MGHL was repaired with use of a double-loaded suture anchor (2.3 mm) (ICONIX; San Jose, California, USA) to provide additional anterior support to the head of humerus and to reduce the volume of the rotator interval (Fig 4B).

The Hill-Sachs lesion was then treated with remplissage with use of two double-loaded suture anchors (2.3 mm) (ICONIX; San Jose, California, USA) to reduce the stress on the glenoid fixation, repaired labrum, and MGHL (Figs. 4C and 4D). Finally, fracture stability was assessed. The wound was irrigated and sutured.

Fig. 4A Labral repair at 7’o clock with a single loaded suture anchor. Fig. 4B MGHL repair and anterior subscapularis augmentation. Fig. 4C Suture anchor placement at the Hill-Sachs lesion for remplissage. Fig. 4D Capsulotenodesis of the infraspinatus over the Hill-Sachs lesion.

Essential Points

• The fracture pattern should be characterized and other injuries should be ruled out with use of preoperative radiographs and CT scans.

• Prior to starting the procedure, fluoroscopy views should be taken after patient positioning.

• Gravity is removed as a deforming force on the fracture fragment by placing the patient in the lateral decubitus position.

• Prior to reduction, the hematoma and callus at the fracture site should be completely debrided.

• Intraoperative fluoroscopy should be used to verify fracture reduction and screw trajectory.

Following surgery, the patient was managed with a sling and was not allowed to stress the fracture site for 3 weeks. Immediately after surgery, supervised gentle range-of-motion exercises were started to avoid postoperative stiffness. We advised the patient to return for follow-up at 3 weeks, 6 weeks, and 16 weeks. Follow-up radiographs were made every 3 weeks to assess healing and to ensure that there was no fracture displacement. At 16 weeks, the patient resumed full activity (Figs. 5A, 5B, and 5C) and CT scans were used to assess union Figs. 5D, 5E, and 5F).

Figs. 5A, 5B, and 5C Clinical follow up at 16 weeks. Figs. 5D, 5E, and 5F Postoperative CT scans showing fracture union.

DISCUSSION

Intra-articular glenoid fractures have been a clinical dilemma for surgeons. Historically, these fractures have been treated openly; however, the extensive exposure that is needed to achieve an anatomic reduction and stable fixation through an arthrotomy may result in a prolonged recovery period, infection, postoperative stiffness, and neurovascular damage. As a result, arthroscopic methods have become more popular for reducing and fixing intra-articular glenoid fractures. Compared with open surgery, the arthroscopic approach substantially reduces severe soft-tissue trauma, which lowers the possibility of complications. Any additional intra-articular diseases may be treated concurrently. Furthermore, the arthroscopic method allows for considerably greater vision and control of fracture reduction because the fracture line is located deep within the glenohumeral joint.

The primary objective of surgical therapy for a glenoid rim fracture is to restore the anatomy of the normal joint surface in order to obtain firm fixation, promote bone-healing, and avoid repeated shoulder instability. Currently, there is no gold standard for the treatment of large glenoid rim fractures. New surgical options for the treatment of these lesions have been made possible by the development of shoulder arthroscopy.

Clamps and/or K-wires are commonly used in various arthroscopic procedures for glenoid fracture reconstruction in order to achieve and maintain temporary fixation prior to final screw fixation. It may be challenging to position clamps and K-wires appropriately because of the constraints presented by the osseous structure of the shoulder. Furthermore, the positioning of these temporary fixation devices may endanger nearby neurovascular systems1.

Marsland and Ahmad, in a cadaveric study, showed that fixation devices positioned anteriorly to posteriorly caused damage to the cephalic vein in 30% of specimens, putting the musculocutaneous nerve and the inferior branch of the suprascapular nerve at serious risk2.

In the case of our patient, all of the guides were introduced posteriorly; this technique has the tremendous advantage of being safe, utilizing normal arthroscopic portals, and avoiding the important neurovascular systems at the front region of the shoulder.

Porcellini et al. described an arthroscopic method for stabilizing acute Bankart fractures by placing the suture anchors along the glenoid rim fracture site and passing the sutures around the fracture fragment with the adjacent capsular-labral complex3. This method was refined by Sugaya et al., who used augmentation sutures that are run through or around the fragment after stabilizing it with labral fixation alone4.

In our experience, arthroscopic reconstruction of glenoid rim fractures has resulted in excellent clinical outcomes and, in the majority of cases, anatomic reduction and healing of the glenoid fracture was achieved. Using arthroscopic methods to stabilize the shoulder surgically has several advantages, such as reduced soft-tissue dissection, enhanced visualization of joint abnormalities, faster rehabilitation, and greater accessibility5 (Table 1).

Table 1. Advantages and Disadvantages of the Arthroscopic Approach for Reduction and Fixation of Glenoid Fractures

CONCLUSION

Arthroscopic methods that lower the risks and morbidity of open procedures are a viable option for treating intra-articular glenoid fractures. Prior to final screw fixation, labral fixation is a reliable method for achieving and maintaining an anatomic reduction. This method reduces the risk of injuring the neurovascular structures as all of the fixation guides are used in a posterior-to-anterior direction. Numerous intra-articular glenoid fractures can be treated with this method with good radiographic and functional outcomes and little risk to the patient.

References

1. Cameron S. Case Report Arthroscopic reduction and internal fixation of an anterior glenoid fracture. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1998 Oct;14(7):743–6.
2. Marsland D, Ahmed HA. Arthroscopically assisted fixation of glenoid fractures: A cadaver study to show potential applications of percutaneous screw insertion and anatomic risks. J Shoulder Elbow Surg. 2011 Apr;20(3):481–90.
3. Porcellini G, Campi F, Paladini P. Arthroscopic approach to acute bony Bankart lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2002 Sep;18(7):764–9.
4. Sugaya H, Kon Y, Tsuchiya A. Arthroscopic Repair of Glenoid Fractures Using Suture Anchors. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2005 May;21(5):635.e1-635.e5.
5. Scheibel M, Hug K, Gerhardt C, Krueger D. Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures. J Shoulder Elbow Surg. 2016 May;25(5):781–90.

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