Thursday, December 20, 2012

Glenoid dysplasia

One of my most respected colleagues presented the case of a 40 year old with a painful left shoulder that had responded to an arthroscopic posterior labral repair, but had recurrence of symptoms.

While we do not have plain radiographs of this case, the axillary view would probably look something like this case from a previous post, a Walch C

The MRI's for the patient look like this, showing the dysplastic glenoid bone with soft tissue - presumed  cartilagenous anlage occupying the area that would normally be the posterior glenoid bone.

In the MRI below, we've labeled the bone with the white arrow and the cartilagenous anlage with the red arrow. The blue arrows point to osteophytes on the anterior and posterior humerus, indicating that degenerative arthritis has begun.

Such cases represent big challenges for the shoulder surgeon - a triad of congenital deformity, arthritis and posterior instability. The issue is that the posterior soft tissues are not able to manage the posteriorly directed forces applied to them by the humerus. The risk with a soft tissue repair is that it is likely to fail under the major loads applied to it. The risks with bony reconstructions are that (1) there is no 'perfect' position for a posterior bone graft and (2) they may accelerate the progression of the arthritis.

In our vernacular, this is a “B” (we know the problem, but do not have a great solution).
When we have cases like this, we start with vocational rehabilitation to a non physical occupation and with physical therapy to maintain external rotation range and strength to prevent internal rotation contracture and optimize dynamic stability. 


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