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Treatment of Recurrent Anterior Glenohumeral Instability: J-plasty Procedure

January 01, 2013

Contributors: Celeste Bertone, MD; Dario Petriccioli, MD; Giacomo Marchi, MD; Giacomo Marchi, MD

Keywords: Bony Procedure

Peer review has expired on this program. It is the viewer’s responsibility to determine the educational value of this historical content.
Peer review has expired on this program. It is the viewer’s responsibility to determine the educational value of this historical content.

Traumatic anterior instability is one of the most commonly diagnosed and treated conditions of the shoulder. It is often associated with bone loss from the glenoid, the humerus, or both. A significant glenoid bone defect limits the effectiveness of arthroscopic repairs of anteroinferior shoulder instability. The critical size of the defect is estimated by Itoi et al. to be approximately 6.8 mm, or 21% of the glenoid length. Above that size, an arthroscopic Bankart repair becomes ineffective. In our practice, arthroscopic Bankart repair is the primary treatment for refractory anterior instability with small glenoid bone defect (or medium size in elderly low-demand patients). We use an open technique (Latarjet) when the bone loss appears to have approached 20-25% (large defect) of the surface area of the native glenoid or when the impression injury to the humeral head appears to engage the anterior glenoid rim within a functional arc of motion. Generally, we treat defects involve about 30% or greater of the glenoid articular surface with open bone grafting (autograft or allograft). To reconstruct the anterior-inferior glenoid, we use structural bone grafting according to the Eden-Hybbinette procedure. We present an alternative to these common bone block procedures where a J-shaped bicortical iliac crest bone graft is anatomically modeled onto the glenoid rim and held in place without screw fixation. The video shows the technical details of this procedure. Initially, the authors discussed indications, including recurrent anteroinferior glenohumeral instability with glenoid bone loss > 30% and failure of other types of bone grafting for anterior stabilization, such as a Bristow or a Latarjet. However, the authors now suggest no absolute indications for this procedure. They consider anterior glenoid bicortical iliac crest bone grafting only for informed patients who the surgeon believes are acceptable surgical candidates, specifically in whom a previous bone graft has failed and a soft-tissue repair is not likely to succeed. Contraindications include active infection in the operative area, a high risk of poor patient compliance (especially due to substance abuse), an elderly patient with a rotator cuff deficiency, and glenohumeral arthropathy. A very large humeral head defect is a relative contraindication; glenoid grafting still may be useful in conjunction with a humeral hemiarthroplasty in selected circumstances.

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