Arthroscopic Anterior and Posterior Glenoid Bone Augmentation With Capsular Plication for Ehlers-Danlos Syndrome With Multidirectional Instability

Abstract

Recurrent multidirectional shoulder instability is a difficult clinical problem. This can be compounded in patients with connective tissue diseases such as Ehlers-Danlos syndrome. We present an all-arthroscopic technique involving extra-articular anterior and posterior glenoid bone grafting to augment a capsular repair in a patient with Ehlers-Danlos syndrome and recurrent multidirectional shoulder instability. Graft options include either distal tibial allograft or iliac crest autograft. Anterior graft placement uses a dilated far medial portal using an inside-out technique. The posterior graft is placed through a dilated posterior portal. A 1-mm edge of anterior and posterior glenoid rim is denuded of cartilage for later capsular repair, and grafts are secured flush to the osseous surface. A capsular plication is then completed and repaired to the prepared native glenoid surface, using the grafts as extra-articular osseous bumpers.

Fig 1

Patient is placed in the lateral decubitus position and rolled 30° posteriorly with the ipsilateral hip prepped for iliac crest tricortical graft harvest. A standard posterior portal is created and kept slightly medial in order to stay parallel with the glenoid face.

Fig 2

Standard arthroscopic portals are made. Portal 1, standard posterior portal; portal 2, posterolateral portal; portal 3, direct medial portal; portal 4, anterosuperior (AS) portal.

Fig 3

Left shoulder. Viewing from anterosuperior portal. Calibrated probe is placed through the posterior portal. The defect size is then measured to confirm graft size.

Fig 4

The harvested iliac crest bone graft has 2 k-wires placed using the alpha-beta guide to prepare screw tracks. This technique is used to prepare both the anterior and posterior glenoid augment grafts.

Fig 5

The double-barrel cannula is secured to the prepared graft in readiness for insertion into the shoulder. This cannula allows for ease of stable graft passage into the shoulder.

Fig 6

Left shoulder viewed from the anterosuperior portal; the graft (black arrow) is placed flush to the anterior glenoid surfaced. Note the 1-mm rim of denuded cartilage (blue arrow) that will serve for later capsular repair.

Fig 7

Left shoulder, anterosuperior viewing portal. Fixation of the anterior glenoid augment graft. Two 3.5-mm titanium screws are passed over the top of the guide wires within the double-barrel cannula (black arrow). Anterior graft (blue arrow).

Fig 8

Left shoulder, viewed from the anterosuperior portal. Anterior graft (blue arrow) is to the right of the picture. The capsule (black arrow) is secured along the edge of the patient's native glenoid, keeping the graft extra-articular.