Early Clinical outcomes of reconstruction of glenoid bone loss with distal clavicle autograft (DCA) bone block in patients with Recurrent Anterior Shoulder Dislocation.

Early Clinical outcomes of reconstruction of glenoid bone loss with distal clavicle autograft (DCA) bone block in patients with Recurrent Anterior Shoulder Dislocation. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early Clinical outcomes of reconstruction of glenoid bone loss with distal clavicle autograft (DCA) bone block in patients with Recurrent Anterior Shoulder Dislocation. HOSSAM ELSYED, MAYSARA BAYOUMY, MOHAMED MOSA MOHAMED, MOSTAFA KHALAF MAHMOUD, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6381634/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Glenoid bone loss has emerged as one of the most significant risk factors for recurrence after arthroscopic treatment of glenohumeral instability There are Many Bony augmentation procedures to reconstruct glenoid bone loss , Technical Notes and anatomic studies describing the reconstruction of glenoid bone lossusing a distal clavicle autograft (DCA) were recently published. The aim of this study is to assess the early clinical outcomes and re-dislocation rate after glenoid reconstrction by distal clavicle autograft Methods: this a case series study, included 20 patients with recurrent shoulder dislocstion with glenoid bone loss operated by distal clavicle autograft bone block betweenApril, 2023, to may, 2024. All patients were preoperatively subjected to detailed History talking; Complete Clinical examination, Full Imaging investigations with 3D- CT with glenoid enface view and MRI. and preoperative and final postoperative follow up Scoring and Full Imaging investigations with 3D- CT with glenoid enface view and MRI. ROWE, Constant, The visual analog scale for pain ( VAS) and modified patient satisfactory scores. Results: At the final follow-up, the mean and individual functional scores had significantly improved in all patients. The mean Rowe, constant, and VAS scores were 90, 94.5,87.1, and 1.2 respectively. 40% patients were very satisfied, 30% were satisfied, 20% neutral, while 10% patients were dissatisfied at the end of the study. Conclusion: In general, our results showed that distal clavicle auto graft is an effective surgical option for patients with recurrent anterior shoulder dislocation with improvement of post operative patient outcomes DCA glenoid autograft shoulder Figures Figure 1 Figure 2 Figure 3 What is known about the subject up to date, there is only few articles and Technical Notes with limited clinical studies describing the reconstruction of glenoid bone loss using a distal clavicle autograft (DCA) with Promising anatomic and biomechanical results have been reported with the use of osteochondral DCA. What this study adds to existing knowledge: this study is considered one of early studies about the clinical short-term results of reconstruction of glenoid bone loss with distal clavicle autograft. Introduction The shoulder is the most common joint to dislocate in the body with anterior dislocation is most frequent type of instability. Glenoid bone loss has emerged as one of the most significant risk factors for recurrence after arthroscopic treatment of glenohumeral instability [ 1 ] The complex anatomy of the shoulder joint and the various types of lesions and associated injuries, that can occur made more than 150 procedures have been introduced for the treatment of recurrent anterior shoulder dislocation ,many of them become only historical [ 2 ]. Many of arthroscopic and open procedure have been introduced as a solution for recurrent shoulder instability either Soft tissue procedure or bony augmentation procedure. There are Many Bony augmentation procedures to reconstruct glenoid bone loss which include : Coracoid bone transfer with or without conjoint tendon (Latarjet procedure) is the most commonly performed procedure in the treatment of recurrent anterior shoulder instability,This procedure was first described in 1954 [ 3 ]. Eden-Hybbinette procedure using Iliac crest bone grafting, but lack any articular cartilage, and concerns for longer-term osteoarthritis persist [ 4 ] Osteochondral allograft transfer provide a source of articular cartilage, but the, availability, cost, and failure of allograft incorporation remain issues of concern [ 2 ] Technical Note describing the reconstruction of glenoid bone loss using a distal clavicular autograft (DCA) was recently published in the last decade by Tokish et al [ 5 ].The main advantages of the distal clavicular autograft include lack of antigenicity, decreased infection risk, lower cost, and greater availability, moreover Promising anatomic and biomechanical results have been reported with the use of osteochondral DCA [ 5 , 6 ]. Recent studies has shown that the DCA can reproduce up to 44% of the glenoid radius, which compares favorably to the 31% restoration achieved with the coracoid transfer in Latarjet procedure [ 7 ]. Moreover, articular cartilage coverage of the distal clavicle autograft which is within 1 mm of glenoid cartilage thickness reduce the risk of subsequent osteoarthritic changes [ 8 ]. Patient and methods Study design The study was a case series study, performed at our orthopedic department. The sampling frame was from April, 2023, to may, 2024. The study was approved by the Institute's Ethical review board. A written informed consent had signed by all Participants included in this study after they have been made aware of the purpose of the study, interventions, outcome, and possible complications. Patients with a history of ≥ 3 recurrent Anterior Shoulder Dislocation. caused by a traumatic event with one of the following criteria:bony Bankart lesion,significant glenoid bone loss(>20), failed previous arthroscopic labral repair,and failed previous Latarjet procedure were included in the study. Those patients with recurrent shoulder dislocation patients who get benefit from arthroscopic labral repair, multidirectional instability; habitual dislocation; uncontrolled convulsive fits; generalized joint laxity or had any other associated pathology in shoulder or the upper extremity that might affect the results of functional evaluations of shoulder; Non-compliant patient with rehabilitation and follow up, were excluded from the study. All patients were preoperatively subjected to detailed History talking; Complete Clinical examination and preoperative Scoring with ROWE, Constant, the visual analog scale for pain (VAS) and modified patient satisfactory scores; and Full Imaging investigations with 3D- CT with glenoid enface view and MRI. Surgical technique: Patient position and preparation: After general anesthesia, the patient is placed in a beach chair position with a chair inclination of 45degrees. The arm and the lateral half of the chest are prepped and draped in a manner that allows free movement of the entire limb. Distal clavicle autograft harvesting and preparation: A 3-cm skin incision was made over the subcutaneous border of the acromioclavicular joint (ACJ), along the midline of the longitudinal axis of the clavicle. The skin and subcutaneous tissues with full-thickness periosteal flaps were divided and raised to expose the ACJ. sharp dissection by scalpel was preferred over electrocautery dissection to protect the cartilage of the joint. A1-cm wide saw blade or sharp osteotome was used to remove the distal 10 mm of clavicle and soft tissue is cleaned from around the bone. Care should be taken to avoid any damage to the bulk of the trapezoid ligament [Fig. 1 ]. The graft is separated, and the harvest site periosteum is closed with nonabsorbable No. 2 interrupted stitches [Fig. 2 a&b] The overlying soft tissue is closed in 2 layers, and the wound is dressed at the completion of the procedure. Glenoid exposure with subscapularis split approach: the approach of Walch-Boileau technique [ 9 ] was used in all cases, The skin incision 6 to 8 cm in length and begins from below the tip of the coracoid process to the superior border of axillary fold, the clavipectoral fascia is opened in line with the skin incision, the deltoid and the cephalic vein retracted laterally. The subscapularis stretched by positioning the arm is in adduction and external rotation, to identify the upper and lower borders of the subscapularis tendons. The tendon and its muscle are sectioned in line with the muscle fibers, using the Mayo scissors at the junction of the upper two-thirds and the lower one-third. The split is started at the level of the lesser tuberosity and extended medially up to 20 mm medial to the musculotendinous junction, to avoid injury to the nerve supply of the muscle. A self-retaining blunt Gelpi retractor and an inferior Hohmann are used to expose and clearly visualizing the white capsule. the capsule was vertically incised just lateral to the anterior glenoid rim. A small Fukuda retractor is then placed in the capsule split and pulled laterally to allow clear visualization of the glenohumeral joint. The labrum is excised in the lower half of anterior glenoid using a scalpel or a cautery. The excision of the labrum is extended medially to include the periosteum over the anterior glenoid reaching at least 2 cm medial to the glenoid rim. Decortication of the anterior surface of the glenoid neck to bleeding cancellous bone was done by using a curved osteotome to prepare the surface to which the DCA fixed. Delivery and Fixation of ADC Graft The cleaned harvested graft was passed into the joint along a K-wire guide predrilled in the location of inferior hole of the glenoid with the distal surface of the graft parallel to the glenoid articular surface, A K-wire was passed through the superior hole of the graft and to glenoid to avoid graft mobilization during inferior screw fixation. Screw length was confirmed by depth gauge measurement, typically in all cases the screw length was 34 to 36 mm, and definitive graft fixation is achieved with the placement of two 3.5-mm cortical or 4.0-mm partially threaded cancellous screws and washers, A first inferior screw was derived first to achieve a contact between the glenoid anterior surface and the graft interface. After assessment and controlling the graft position the superior hole was drilled, and the second screw is inserted. The 2 screws are then tightened sequentially until satisfactory compression is achieved (Fig. 3 a-d). After graft fixation, the glenoid articular surface reassessed to ensure proper graft flushing with the glenoid. Capsule and Subscapularis Repair: With the arm adducted to the side and placed in approximately 45º of external rotation, the capsular repair was performed with high-strength No. 2 suture, The subscapularis split was closed with high-strength No. 2 suture, and the wound was closed. A postoperative dressing was applied in a sterile fashion, a drain was not used in all cases, 1 dose of intravenous post operative antibiotics was given in the recovery room. Follow up: All patients were followed for average 2 years duration postoperatively with first visit at 2weaks postoperative for evaluation of surgical wound and stitches removal. The second visits at 45 days postoperative, then every 3 months till complete follow up. After surgery, a sling is maintained for 4 weeks. Active motion of the fingers, hand and elbow were encouraged but shoulder range of motion was restricted to pendulum exercises. No resisted elbow flexion was allowed for at least 4–5 weeks to reduce the risk for nonunion. Formal physiotherapist-supervised rehabilitation started at 4 weeks following surgery and the return to work/sport was allowed according to the improvement of each patient in the rehabilitation pathway. Post operative Clinical evaluation: At the final follow up the active range of motion (ROM) is evaluated in all patients (forward flexion, external and internal rotation) comparing the post operative versus preoperative ROM, also ROWE, Constant, vas, and patient satisfaction scores were recorded and compared with the preoperative data. Any clinical or radiological postoperative complications (intra and postoperative) and how it had been managed, any sort of instability (frank dislocation, subluxation, subjective sense of apprehension was evaluated. Statistics: The SPSS 24.0 statistical software (IBM Corp., Armonk, NY) was used for data analysis. The Mean (standard deviation [SD] was used to present the continuous variables with a normal distribution; and median (range) was used to present the non-normally distributed variables. Paired t-test was performed for pre- and post-operative data comparisons. P < 0.05 indicated a statistically significant difference Results Demographic data: All patients in this series were male individuals with active daily living 20 (100%), 10 patients (50%) were heavy manual workers, four patients (20%) were employee, four patients (20%) were driver and two case (10%) were student. The average age at the time of surgery was 28.3 years (18–45 years). Ten patients (50%) were right affected side, and 10 cases (50%) were left affected side (50%), while 16 patients (80%) were right dominance side, and 4 cases (20%) were left dominance side. Four patients (20%) patients had history of controlled epileptic fits. The mean duration between 1st dislocation and operation (19.05 ± 9.63 months). Median number of dislocations was 7 times with range between 4 and 9 times. The average follow-up period was 17.3months. two patients had reached a follow-up of 24 months, and nine patients had a follow-up period of 12 months. preoperatively the mean normal glenoid diameter was 30.9 mm, mean glenoid defect was 4.9 mm (15.9% of mean glenoid diameter). Mean hill Sachs lesion was 35.2 mm. Intraoperative the mean distal clavicle graft (DCA) height was 10.3 mm, width was 20.8 mm, and the length was 20.3 mm (Table 1). Table.1: Intraoperative measurements of glenoid whole diameter, its dfect, hillschas lesion, and DCA among all patients Intraoperative measurements among all patients No. (n = 20) Glenoid diameter (mm) Range 25.7–34.8 Mean ± SD 30.93 ± 2.47 Glenoid defect (mm) Range 2.6–8.1 Mean ± SD 4.94 ± 1.68 Glenoid defect (%) Range 8% -27% Mean ± SD 16.69%±7% Hill sachs lesion (mm) Range 13.5–56.3 Mean ± SD 35.25 ± 14.12 Measurements of graft Hight (mm) Range 8 − 13 Mean ± SD 10.3 ± 1.53 Width (mm) Range 9 − 13 the mean length of screws was 36.4 mm for superior screws and 36.8 mm for inferior one. regarding the type of screws used, for superior screws, cortical 3.5 mm were used in 16 (80%) shoulders and cancellous 4 mm in 4 (20%) patients. the inferior screw was cancellous 4mm to produce lag mechanism and increase bone contact in 18 (90%) shoulders and was cortical screw 3.5 in 2 (10%) patients. Clinical and ROM assessment: Results of range of motion evaluation at one year follow-up are displayed in (Table 2). None of our patients had clinical evidence of neurological affection. There were no complaints related to hardware. Functional outcomes: At the final follow-up, the mean and individual functional scores had significantly improved in all patients. The mean Rowe, constant, scores were 90 (range 70–95), 94.5 (range 70–95), 87.1 (range 67–95), and 2.3 (range 1–3), respectively. The pain scores during ROM were recorded with VAS score. VAS scores were reduced from preoperatively mean 4.2 (range 0–8 to postoperatively mean 1.2 (range 0–3) at the final follow-up. 8 (40%) patients were very satisfied and 6 (30%) were satisfied. 4 were neutral (20%) while 2 (10%) patients were dissatisfied at the end of the study. Statistical analysis A statistically significant improvement, defined by P value less than 0.05, was seen in all functional outcome scores (ROWE, constant, and VAS, patient satisfaction scores). Discussion When treating shoulder instability, the significant glenoid bone loss is a difficult and commonly encountered condition to manage. Multiple glenoid augmentation grafts have been proposed to reduce the risk of re-dislocation after surgery and improve shoulder functions. [ 10 – 12 ] Recent published anatomic and pilot cohort studies supporting the use of distal clavicle autograft to provide a locally available source of osteochondral autograft for glenoid bone loss reconstitution due to its easy and safe harvesting. [ 5 , 6 , 13 ] This study provides early clinical outcomes of 20 cases underwent DCA bone block augmentation for anterior instability with anterior glenoid bone loss using the open technique to reconstruct the glenoid bone defect. Both Tokish et al. and Boileau et al. had previously described the arthroscopic technique for distal clavicle bone block augmentation of the glenoid bone loss. [ 5 , 6 ] In the current article we use the open technique and graft is placed so that the articular surface of the distal clavicle augments the glenoid curvature like that described by Tokish et al. [ 5 ] the glenoid articular cartilage defect was reconstructed via the lateral distal clavicle articular cartilage with results similar to previously published systematic and meta-analysis study comparing the open versus arthroscopic Latarjet that found no statistically significant differences in clinical outcome measurement (ROWE score, external rotation ROM), and recurrence of dislocation after surgery[ 14 ]. moreover the DCA is capped with articular cartilage that is. like, though slightly thinner than, the glenoid, [ 15 ] allowing it to restore a more native glenoid articular surface than coracoid transfers or other bony autografts, [ 16 ] with no cost, antigenicity, or disease transmission risks associated with osteochondral allografts.[ 17 ] In current study, the senior author stayed 1cm medial to the ACJ in preforming resection of the distal clavicle graft. Many studies reported that harvesting the DCA by this technique is a relatively safe with no reported donor site morbidity and a well-known procedure that commonly performed for chronic AC joint painful arthritis, while coracoid transfer procedures have been associated with reported nerve complications in 821% of patients. [ 18 , 19 ] Harris et al. recommended the resection should be done less than1.5 cm (15 mm) medially from the AC joint to avoid injury to the coracoclavicular ligament and resultant instability [ 20 ]. In their study, Petersen et al. [ 21 ] performed distal clavicle resection 1 cm medial to the AC joint, while Tokish et al. stayed closer (68 mm) to the AC joint during graft harvesting procedure. [ 5 ] The intra-operative finding in this study showed distal clavicle dimensions that is comparable to that reported by Larouche et al. [ 22 ] in their anatomic and cadaveric study investigating the morphology and dimensions of the distal clavicle autograft, they found that the distal clavicle graft can reconstruct up to 22% of the glenoid articular surface. Moreover, in another cadaveric study by Kwapisz et al. comparing the distal clavicle to coracoid graft, they reported that the distal clavicle graft has the ability to reconstitute larger glenoid bone defects (44% vs 33%), and the distal clavicle has a variable dimensions, with a versatile amount of version and an articular surface that is generally 19-mm long and 13-mm wide [ 15 ]. and Hudson PW et al., in their comparative anatomic study reported That the average measurements of the height, length, articular area, and graft volume of the DCA were larger than the respective coracoid measurements, while The coracoid grafts showed greater density than DCA [ 17 ]. Although this article supports the previous reported studies in considering the distal clavicle a reasonable option for graft choice, it does have some disadvantages. The lack of slinge effect provided by the Latarjet procedure. [ 7 , 23 ] In addition, the distal clavicle is believed to have poorer bone quality, which was supported by different studies that show the low bone density comparable to the coracoid.[ 24 ] Limitations of our study included the short follow-up period. Small group of patients and Postoperative 3D- CT assessment of the graft union during follow up was not done. Also telephone visits were used to obtain some of the deficient subjective outcome score Conclusion the distal clavicle auto graft is an effective surgical option for patients with recurrent anterior shoulder dislocation as there was marked increase in shoulder functional outcomes, including range of motion and scores on the Rowe and Constant shoulder function assessments. The procedure was associated with a high rate of patient satisfaction, with the majority of patients returning to pre-injury daily activities, and work . Declarations Ethics approval and consent to participate: the study was approved by the research ethics committee of faculty of medicine, Al-Azhar university, Assiut, Egypt Committee reference number: AZAST/MS/1/09 OCT 2023 A written informed consent had signed by all Participants included in this study after they have been made aware of the purpose of the study, interventions, outcome, and possible complications This study adhered to the Declaration of Helsinki Concent for publication: NOT Applicable Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing of interest : The authors declare that they have no competing interests Funding: No funding was received to assist with the preparation of this manuscript Authors contribution : HE was the senior surgeon whoall operated all the cases. MB analysed and interpreted the patient data regarding the demographic data and preoperative and post operative scores, and was a major contributor in writing the manuscript,MMM collecting the data,MKM was responsible for patient preparation and post operative follow up, TF revised the data . All authors read and approved the final manuscript. Acknowledgements: not applicable References Mizuno N, Denard PJ, Raiss P, Melis B, Walch G. Long-term results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elb Surg. 2014;23(11):1691–9. 10.1016/j.jse.2014.02.015 . Provencher MT, Ghodadra N, LeClere L, Solomon DJ, Romeo AA. 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Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med. 2006;34:205–12. 10.1177/0363546505281798 . Hudson PW, Pinto MC, Brabston EW, Hess MC, Cone BM, Williams JF, Brooks WS, Momaya AM, Ponce BA. Distal clavicle autograft for anterior-inferior glenoid augmentation: A comparative cadaveric anatomic study. Shoulder Elb. 2020;12(6):404–13. 10.1177/1758573219869335 . Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elb Surg. 2010;19:769–80. 10.1016/j.jse.2010.01.011 . Shah AA, Butler RB, Romanowski J, et al. Short-term complications of the Latarjet procedure. J Bone Joint Surg Am. 2012;94:495–501. 10.2106/JBJS.J.01830 . Harris RI, Vu DH, Sonnabend DH, et al. Anatomic variance of the coracoclavicular ligaments. J Shoulder Elb Surg. 2001;10:585–8. 10.1067/mse.2001.118480 . Petersen SA, Bernard JA, Langdale ER, et al. Autologous distal clavicle versus autologous coracoid bone grafts for restoration of anterior-inferior glenoid bone loss: a biomechanical comparison. J Shoulder Elb Surg. 2016;25:960–6. 10.1016/j.jse.2015.10.023 . Larouche M, Knowles N, Ferreira L, Tokish JM, Athwal GS. Osteoarticular distal clavicle autograft for the management of instability-related glenoid bone loss: An anatomic and cadaveric study. J Shoulder Elb Surg. 2020;29:1615–20. 10.1016/j.jse.2019.12.027 . Giles JW, Boons HW, Elkinson I, et al. Does the dynamic sling effect of the Latarjet procedure improve shoulder stability? A biomechanical evaluation. J Shoulder Elb Surg. 2013;22:821–7. 10.1016/j.jse.2012.08.002 . Yamamoto N, Muraki T, An KN, Sperling JW, Cofield RH, Itoi E, et al. The stabilizing mechanism of the Latarjet procedure: a cadaveric study. J Bone Joint Surg Am. 2013;95:1390–7. 10.2106/JBJS.L.00777 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6381634","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456693386,"identity":"4047ebbc-424e-4562-8806-43afdd6c7a2a","order_by":0,"name":"HOSSAM ELSYED","email":"","orcid":"","institution":"Al-Azhar university,faculty of medicine ,Assiut branch","correspondingAuthor":false,"prefix":"","firstName":"HOSSAM","middleName":"","lastName":"ELSYED","suffix":""},{"id":456693387,"identity":"df95ac09-6dcd-4ddd-884a-7be94f6f1bcb","order_by":1,"name":"MAYSARA BAYOUMY","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYPACGx42+QMMDB8YGBKI1ZImxy/BwMA4gwQth40lgcqZeYjRojsj/eHnihrmxA23G9g+27bZ5fGzNzB++JiDW4vZjRxjyTPH2BI33DnAPDu3LblYsucAs+TMbXi1MEg2sPEkbjiQwMyc2wa07kYCGzMvXi3pj382/JOAaLFsqydGS4KZZGObAdD7QC2MbYeJ0HLmjZllY1+CHD/PAWbGnnPHE2f2HGzG75fj6Y9vNnz7z8PG3sDM8KOsOrGfvfngh494tDAIJMBY/B8YGNlADMYGPOpBCg8g8/7gVzwKRsEoGAUjEwAALp1VaGIyglgAAAAASUVORK5CYII=","orcid":"","institution":"Al-Azhar university,faculty of medicine ,Assiut branch","correspondingAuthor":true,"prefix":"","firstName":"MAYSARA","middleName":"","lastName":"BAYOUMY","suffix":""},{"id":456693389,"identity":"bba72052-9746-4540-a971-9a9328fd5ca9","order_by":2,"name":"MOHAMED MOSA MOHAMED","email":"","orcid":"","institution":"Al-Azhar university,faculty of medicine ,Assiut branch","correspondingAuthor":false,"prefix":"","firstName":"MOHAMED","middleName":"MOSA","lastName":"MOHAMED","suffix":""},{"id":456693391,"identity":"55611be4-3e54-4c37-9913-ab6c77f811be","order_by":3,"name":"MOSTAFA KHALAF MAHMOUD","email":"","orcid":"","institution":"Al-Azhar university,faculty of medicine ,Assiut branch","correspondingAuthor":false,"prefix":"","firstName":"MOSTAFA","middleName":"KHALAF","lastName":"MAHMOUD","suffix":""},{"id":456693392,"identity":"ef4d0882-15e9-4291-aacd-dfafbe2a0c4b","order_by":4,"name":"TAREK NABIL Fetih","email":"","orcid":"","institution":"Assiut University Hospitals","correspondingAuthor":false,"prefix":"","firstName":"TAREK","middleName":"NABIL","lastName":"Fetih","suffix":""}],"badges":[],"createdAt":"2025-04-05 11:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6381634/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6381634/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83029686,"identity":"b77d8e30-4315-4d37-b9e7-8929ffcf9111","added_by":"auto","created_at":"2025-05-19 08:53:40","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":359081,"visible":true,"origin":"","legend":"\u003cp\u003eintra-operative photo of RT shoulder showing the distal end clavicle with yellow lone showing the mark of graft osteotomy medial to ACJ.\u003c/p\u003e","description":"","filename":"figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6381634/v1/44de4a7798c0798a0115ed15.jpeg"},{"id":83029685,"identity":"9d4e2045-2097-418c-94c8-05954857d444","added_by":"auto","created_at":"2025-05-19 08:53:40","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":693502,"visible":true,"origin":"","legend":"\u003cp\u003eHarvested distal end clavicle with the measurement of its width \u0026amp; height\u003c/p\u003e","description":"","filename":"figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6381634/v1/0e779911d3dd4f0ff3f9c4d9.jpeg"},{"id":83028386,"identity":"d85793cc-7135-4c57-a256-d2894c33815a","added_by":"auto","created_at":"2025-05-19 08:45:40","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":411423,"visible":true,"origin":"","legend":"\u003cp\u003eintra operative photos of Rt shoulder shows the steps of graft drilling and fixation to the glenoid with (a) graft drilling, (b) inferior screw fixation, (c) superior screw fixation, and (d) showing the DCA graft fixed and compressed to the glenoid by two screws\u003c/p\u003e","description":"","filename":"figure3abcd.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6381634/v1/44e2966b62bc83c3e5b4166a.jpeg"},{"id":92092821,"identity":"e98f627f-f9d1-4f27-a352-8b08470e86f9","added_by":"auto","created_at":"2025-09-24 13:54:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2163052,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6381634/v1/1c34bd84-0f95-4e14-aa2f-cb924c9630e0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early Clinical outcomes of reconstruction of glenoid bone loss with distal clavicle autograft (DCA) bone block in patients with Recurrent Anterior Shoulder Dislocation.","fulltext":[{"header":"What is known about the subject","content":"\u003cp\u003eup to date, there is only few articles and Technical Notes with limited clinical studies describing the\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003ereconstruction of glenoid bone loss using a distal clavicle autograft\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(DCA) with Promising anatomic and biomechanical results have been reported with the use of osteochondral DCA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds to existing knowledge:\u0026nbsp;\u003c/strong\u003ethis study is considered one of early studies about the clinical short-term results of reconstruction of glenoid bone loss with distal clavicle autograft.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe shoulder is the most common joint to dislocate in the body with anterior dislocation is most frequent type of instability. Glenoid bone loss has emerged as one of the most significant risk factors for recurrence after arthroscopic treatment of glenohumeral instability [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe complex anatomy of the shoulder joint and the various types of lesions and associated injuries, that can occur made more than 150 procedures have been introduced for the treatment of recurrent anterior shoulder dislocation ,many of them become only historical [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany of arthroscopic and open procedure have been introduced as a solution for recurrent shoulder instability either Soft tissue procedure or bony augmentation procedure.\u003c/p\u003e \u003cp\u003eThere are Many Bony augmentation procedures to reconstruct glenoid bone loss which include : Coracoid bone transfer with or without conjoint tendon (Latarjet procedure) is the most commonly performed procedure in the treatment of recurrent anterior shoulder instability,This procedure was first described in 1954 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Eden-Hybbinette procedure using Iliac crest bone grafting, but lack any articular cartilage, and concerns for longer-term osteoarthritis persist [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Osteochondral allograft transfer provide a source of articular cartilage, but the, availability, cost, and failure of allograft incorporation remain issues of concern [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTechnical Note describing the reconstruction of glenoid bone loss using a distal clavicular autograft (DCA) was recently published in the last decade by Tokish et al [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].The main advantages of the distal clavicular autograft include lack of antigenicity, decreased infection risk, lower cost, and greater availability, moreover Promising anatomic and biomechanical results have been reported with the use of osteochondral DCA [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent studies has shown that the DCA can reproduce up to 44% of the glenoid radius, which compares favorably to the 31% restoration achieved with the coracoid transfer in Latarjet procedure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Moreover, articular cartilage coverage of the distal clavicle autograft which is within 1 mm of glenoid cartilage thickness reduce the risk of subsequent osteoarthritic changes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e"},{"header":"Patient and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study was a case series study, performed at our orthopedic department. The sampling frame was from April, 2023, to may, 2024. The study was approved by the Institute's Ethical review board. A written informed consent had signed by all Participants included in this study after they have been made aware of the purpose of the study, interventions, outcome, and possible complications. Patients with a history of \u0026ge;\u0026thinsp;3 recurrent Anterior Shoulder Dislocation. caused by a traumatic event with one of the following criteria:bony Bankart lesion,significant glenoid bone loss(\u0026gt;20), failed previous arthroscopic labral repair,and failed previous Latarjet procedure were included in the study. Those patients with recurrent shoulder dislocation patients who get benefit from arthroscopic labral repair, multidirectional instability; habitual dislocation; uncontrolled convulsive fits; generalized joint laxity or had any other associated pathology in shoulder or the upper extremity that might affect the results of functional evaluations of shoulder; Non-compliant patient with rehabilitation and follow up, were excluded from the study.\u003c/p\u003e \u003cp\u003eAll patients were preoperatively subjected to detailed History talking; Complete Clinical examination and preoperative Scoring with ROWE, Constant, the visual analog scale for pain (VAS) and modified patient satisfactory scores; and Full Imaging investigations with 3D- CT with glenoid enface view and MRI.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique:\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePatient position and preparation:\u003c/h2\u003e \u003cp\u003eAfter general anesthesia, the patient is placed in a beach chair position with a chair inclination of 45degrees. The arm and the lateral half of the chest are prepped and draped in a manner that allows free movement of the entire limb.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDistal clavicle autograft harvesting and preparation:\u003c/h3\u003e\n\u003cp\u003eA 3-cm skin incision was made over the subcutaneous border of the acromioclavicular joint (ACJ), along the midline of the longitudinal axis of the clavicle. The skin and subcutaneous tissues with full-thickness periosteal flaps were divided and raised to expose the ACJ. sharp dissection by scalpel was preferred over electrocautery dissection to protect the cartilage of the joint.\u003c/p\u003e \u003cp\u003eA1-cm wide saw blade or sharp osteotome was used to remove the distal 10 mm of clavicle and soft tissue is cleaned from around the bone. Care should be taken to avoid any damage to the bulk of the trapezoid ligament [Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe graft is separated, and the harvest site periosteum is closed with nonabsorbable No. 2 interrupted stitches [Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea\u0026amp;b] The overlying soft tissue is closed in 2 layers, and the wound is dressed at the completion of the procedure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eGlenoid exposure with subscapularis split approach:\u003c/h3\u003e\n\u003cp\u003ethe approach of Walch-Boileau technique [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] was used in all cases, The skin incision 6 to 8 cm in length and begins from below the tip of the coracoid process to the superior border of axillary fold, the clavipectoral fascia is opened in line with the skin incision, the deltoid and the cephalic vein retracted laterally. The subscapularis stretched by positioning the arm is in adduction and external rotation, to identify the upper and lower borders of the subscapularis tendons. The tendon and its muscle are sectioned in line with the muscle fibers, using the Mayo scissors at the junction of the upper two-thirds and the lower one-third. The split is started at the level of the lesser tuberosity and extended medially up to 20 mm medial to the musculotendinous junction, to avoid injury to the nerve supply of the muscle. A self-retaining blunt Gelpi retractor and an inferior Hohmann are used to expose and clearly visualizing the white capsule. the capsule was vertically incised just lateral to the anterior glenoid rim. A small Fukuda retractor is then placed in the capsule split and pulled laterally to allow clear visualization of the glenohumeral joint. The labrum is excised in the lower half of anterior glenoid using a scalpel or a cautery. The excision of the labrum is extended medially to include the periosteum over the anterior glenoid reaching at least 2 cm medial to the glenoid rim. Decortication of the anterior surface of the glenoid neck to bleeding cancellous bone was done by using a curved osteotome to prepare the surface to which the DCA fixed.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDelivery and Fixation of ADC Graft\u003c/h2\u003e \u003cp\u003eThe cleaned harvested graft was passed into the joint along a K-wire guide predrilled in the location of inferior hole of the glenoid with the distal surface of the graft parallel to the glenoid articular surface, A K-wire was passed through the superior hole of the graft and to glenoid to avoid graft mobilization during inferior screw fixation. Screw length was confirmed by depth gauge measurement, typically in all cases the screw length was 34 to 36 mm, and definitive graft fixation is achieved with the placement of two 3.5-mm cortical or 4.0-mm partially threaded cancellous screws and washers, A first inferior screw was derived first to achieve a contact between the glenoid anterior surface and the graft interface. After assessment and controlling the graft position the superior hole was drilled, and the second screw is inserted. The 2 screws are then tightened sequentially until satisfactory compression is achieved (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea-d).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter graft fixation, the glenoid articular surface reassessed to ensure proper graft flushing with the glenoid.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCapsule and Subscapularis Repair:\u003c/h3\u003e\n\u003cp\u003eWith the arm adducted to the side and placed in approximately 45\u0026ordm; of external rotation, the capsular repair was performed with high-strength No. 2 suture, The subscapularis split was closed with high-strength No. 2 suture, and the wound was closed. A postoperative dressing was applied in a sterile fashion, a drain was not used in all cases, 1 dose of intravenous post operative antibiotics was given in the recovery room.\u003c/p\u003e\n\u003ch3\u003eFollow up:\u003c/h3\u003e\n\u003cp\u003eAll patients were followed for average 2 years duration postoperatively with first visit at 2weaks postoperative for evaluation of surgical wound and stitches removal. The second visits at 45 days postoperative, then every 3 months till complete follow up.\u003c/p\u003e \u003cp\u003eAfter surgery, a sling is maintained for 4 weeks. Active motion of the fingers, hand and elbow were encouraged but shoulder range of motion was restricted to pendulum exercises. No resisted elbow flexion was allowed for at least 4\u0026ndash;5 weeks to reduce the risk for nonunion. Formal physiotherapist-supervised rehabilitation started at 4 weeks following surgery and the return to work/sport was allowed according to the improvement of each patient in the rehabilitation pathway.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePost operative Clinical evaluation:\u003c/h2\u003e \u003cp\u003eAt the final follow up the active range of motion (ROM) is evaluated in all patients (forward flexion, external and internal rotation) comparing the post operative versus preoperative ROM, also ROWE, Constant, vas, and patient satisfaction scores were recorded and compared with the preoperative data.\u003c/p\u003e \u003cp\u003eAny clinical or radiological postoperative complications (intra and postoperative) and how it had been managed, any sort of instability (frank dislocation, subluxation, subjective sense of apprehension was evaluated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistics:\u003c/h2\u003e \u003cp\u003eThe SPSS 24.0 statistical software (IBM Corp., Armonk, NY) was used for data analysis. The Mean (standard deviation [SD] was used to present the continuous variables with a normal distribution; and median (range) was used to present the non-normally distributed variables. Paired t-test was performed for pre- and post-operative data comparisons. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated a statistically significant difference\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDemographic data:\u003c/h2\u003e \u003cp\u003eAll patients in this series were male individuals with active daily living 20 (100%), 10 patients (50%) were heavy manual workers, four patients (20%) were employee, four patients (20%) were driver and two case (10%) were student. The average age at the time of surgery was 28.3 years (18\u0026ndash;45 years). Ten patients (50%) were right affected side, and 10 cases (50%) were left affected side (50%), while 16 patients (80%) were right dominance side, and 4 cases (20%) were left dominance side. Four patients (20%) patients had history of controlled epileptic fits.\u003c/p\u003e \u003cp\u003eThe mean duration between 1st dislocation and operation (19.05\u0026thinsp;\u0026plusmn;\u0026thinsp;9.63 months). Median number of dislocations was 7 times with range between 4 and 9 times.\u003c/p\u003e \u003cp\u003eThe average follow-up period was 17.3months. two patients had reached a follow-up of 24 months, and nine patients had a follow-up period of 12 months.\u003c/p\u003e \u003cp\u003epreoperatively the mean normal glenoid diameter was 30.9 mm, mean glenoid defect was 4.9 mm (15.9% of mean glenoid diameter). Mean hill Sachs lesion was 35.2 mm. Intraoperative the mean distal clavicle graft (DCA) height was 10.3 mm, width was 20.8 mm, and the length was 20.3 mm (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eTable.1: Intraoperative measurements of glenoid whole diameter, its dfect, hillschas lesion, and DCA among all patients\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIntraoperative measurements among all patients No. (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlenoid diameter (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.7\u0026ndash;34.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlenoid defect (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u0026ndash;8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlenoid defect (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8% -27%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.69%\u0026plusmn;7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHill sachs lesion (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.5\u0026ndash;56.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.25\u0026thinsp;\u0026plusmn;\u0026thinsp;14.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeasurements of graft\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHight (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 \u0026minus;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWidth (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 \u0026minus;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ethe mean length of screws was 36.4 mm for superior screws and 36.8 mm for inferior one. regarding the type of screws used, for superior screws, cortical 3.5 mm were used in 16 (80%) shoulders and cancellous 4 mm in 4 (20%) patients. the inferior screw was cancellous 4mm to produce lag mechanism and increase bone contact in 18 (90%) shoulders and was cortical screw 3.5 in 2 (10%) patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eClinical and ROM assessment:\u003c/h2\u003e \u003cp\u003eResults of range of motion evaluation at one year follow-up are displayed in (Table\u0026nbsp;2). None of our patients had clinical evidence of neurological affection. There were no complaints related to hardware.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFunctional outcomes:\u003c/h2\u003e \u003cp\u003eAt the final follow-up, the mean and individual functional scores had significantly improved in all patients. The mean Rowe, constant, scores were 90 (range 70\u0026ndash;95), 94.5 (range 70\u0026ndash;95), 87.1 (range 67\u0026ndash;95), and 2.3 (range 1\u0026ndash;3), respectively.\u003c/p\u003e \u003cp\u003eThe pain scores during ROM were recorded with VAS score. VAS scores were reduced from preoperatively mean 4.2 (range 0\u0026ndash;8 to postoperatively mean 1.2 (range 0\u0026ndash;3) at the final follow-up. 8 (40%) patients were very satisfied and 6 (30%) were satisfied. 4 were neutral (20%) while 2 (10%) patients were dissatisfied at the end of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eA statistically significant improvement, defined by P value less than 0.05, was seen in all functional outcome scores (ROWE, constant, and VAS, patient satisfaction scores).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhen treating shoulder instability, the significant glenoid bone loss is a difficult and commonly encountered condition to manage. Multiple glenoid augmentation grafts have been proposed to reduce the risk of re-dislocation after surgery and improve shoulder functions. [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eRecent published anatomic and pilot cohort studies supporting the use of distal clavicle autograft to provide a locally available source of osteochondral autograft for glenoid bone loss reconstitution due to its easy and safe harvesting. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study provides early clinical outcomes of 20 cases underwent DCA bone block augmentation for anterior instability with anterior glenoid bone loss using the open technique to reconstruct the glenoid bone defect.\u003c/p\u003e \u003cp\u003eBoth Tokish et al. and Boileau et al. had previously described the arthroscopic technique for distal clavicle bone block augmentation of the glenoid bone loss. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] In the current article we use the open technique and graft is placed so that the articular surface of the distal clavicle augments the glenoid curvature like that described by Tokish et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] the glenoid articular cartilage defect was reconstructed via the lateral distal clavicle articular cartilage with results similar to previously published systematic and meta-analysis study comparing the open versus arthroscopic Latarjet that found no statistically significant differences in clinical outcome measurement (ROWE score, external rotation ROM), and recurrence of dislocation after surgery[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. moreover the DCA is capped with articular cartilage that is. like, though slightly thinner than, the glenoid, [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] allowing it to restore a more native glenoid articular surface than coracoid transfers or other bony autografts, [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] with no cost, antigenicity, or disease transmission risks associated with osteochondral allografts.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn current study, the senior author stayed 1cm medial to the ACJ in preforming resection of the distal clavicle graft. Many studies reported that harvesting the DCA by this technique is a relatively safe with no reported donor site morbidity and a well-known procedure that commonly performed for chronic AC joint painful arthritis, while coracoid transfer procedures have been associated with reported nerve complications in 821% of patients. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Harris et al. recommended the resection should be done less than1.5 cm (15 mm) medially from the AC joint to avoid injury to the coracoclavicular ligament and resultant instability [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn their study, Petersen et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] performed distal clavicle resection 1 cm medial to the AC joint, while Tokish et al. stayed closer (68 mm) to the AC joint during graft harvesting procedure. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe intra-operative finding in this study showed distal clavicle dimensions that is comparable to that reported by Larouche et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] in their anatomic and cadaveric study investigating the morphology and dimensions of the distal clavicle autograft, they found that the distal clavicle graft can reconstruct up to 22% of the glenoid articular surface. Moreover, in another cadaveric study by Kwapisz et al. comparing the distal clavicle to coracoid graft, they reported that the distal clavicle graft has the ability to reconstitute larger glenoid bone defects (44% vs 33%), and the distal clavicle has a variable dimensions, with a versatile amount of version and an articular surface that is generally 19-mm long and 13-mm wide [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. and Hudson PW et al., in their comparative anatomic study reported That the average measurements of the height, length, articular area, and graft volume of the DCA were larger than the respective coracoid measurements, while The coracoid grafts showed greater density than DCA [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough this article supports the previous reported studies in considering the distal clavicle a reasonable option for graft choice, it does have some disadvantages. The lack of slinge effect provided by the Latarjet procedure. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] In addition, the distal clavicle is believed to have poorer bone quality, which was supported by different studies that show the low bone density comparable to the coracoid.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLimitations of our study included the short follow-up period. Small group of patients and Postoperative 3D- CT assessment of the graft union during follow up was not done. Also telephone visits were used to obtain some of the deficient subjective outcome score\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ethe distal clavicle auto graft is an effective surgical option for patients with recurrent anterior shoulder dislocation as there was marked increase in shoulder functional outcomes, including range of motion and scores on the Rowe and Constant shoulder function assessments. The procedure was associated with a high rate of patient satisfaction, with the majority of patients returning to pre-injury daily activities, and work .\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ethe study was approved by the research ethics committee of faculty of medicine, Al-Azhar university, Assiut, Egypt\u003c/li\u003e\n \u003cli\u003eCommittee reference number: AZAST/MS/1/09 OCT 2023\u003c/li\u003e\n \u003cli\u003eA written informed consent had signed by all Participants included in this study after they have been made aware of the purpose of the study, interventions, outcome, and possible complications\u003c/li\u003e\n \u003cli\u003eThis study adhered to the Declaration of Helsinki\u003c/li\u003e\n\u003c/ul\u003e\u003c/br\u003e\n\u003cp\u003eConcent for publication: NOT Applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eanalysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting of interest\u003cspan dir=\"RTL\"\u003e:\u003c/span\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: No funding was received to assist with the preparation of this manuscript\u003c/p\u003e\n\u003cp\u003eAuthors contribution :\u0026nbsp;HE was the senior surgeon whoall operated all the cases. MB analysed and interpreted the patient data regarding the demographic data and preoperative and post operative scores, and was a major contributor in writing the manuscript,MMM collecting the data,MKM was responsible for patient preparation and post operative follow up, TF revised the data . All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMizuno N, Denard PJ, Raiss P, Melis B, Walch G. Long-term results of the Latarjet procedure for anterior instability of the shoulder. 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J Bone Joint Surg Am. 2013;95:1390\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.L.00777\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.L.00777\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"DCA, glenoid, autograft, shoulder","lastPublishedDoi":"10.21203/rs.3.rs-6381634/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6381634/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Glenoid bone loss has emerged as one of the most significant risk factors for recurrence after arthroscopic treatment of glenohumeral instability There are Many Bony augmentation procedures to reconstruct glenoid bone loss , Technical Notes and anatomic studies describing the reconstruction of glenoid bone lossusing a distal clavicle autograft (DCA) were recently published.\u003c/p\u003e\n\u003cp\u003eThe aim of this study is to assess the early clinical outcomes and re-dislocation rate after glenoid reconstrction by distal clavicle autograft\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003ethis a case series study, included 20 patients with recurrent shoulder dislocstion with glenoid bone loss operated by distal clavicle autograft bone block betweenApril, 2023, to may, 2024. All patients were preoperatively subjected to detailed History talking; Complete Clinical examination, Full Imaging investigations with 3D- CT with glenoid enface view and MRI. and preoperative and final postoperative follow up Scoring and Full Imaging investigations with 3D- CT with glenoid enface view and MRI. ROWE, Constant, The visual analog scale for pain ( VAS) and modified patient satisfactory scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e At the final follow-up, the mean and individual functional scores had significantly improved in all patients. The mean Rowe, constant, and VAS scores were 90, 94.5,87.1, and 1.2 respectively. 40% patients were very satisfied, 30% were satisfied, 20% neutral, while 10% patients were dissatisfied at the end of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In general, our results showed that distal clavicle auto graft is an effective surgical option for patients with recurrent anterior shoulder dislocation with improvement of post operative patient outcomes\u003c/p\u003e","manuscriptTitle":"Early Clinical outcomes of reconstruction of glenoid bone loss with distal clavicle autograft (DCA) bone block in patients with Recurrent Anterior Shoulder Dislocation.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 08:45:35","doi":"10.21203/rs.3.rs-6381634/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4313430d-9dad-47b8-b2ed-e5d4babed50c","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-24T13:53:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 08:45:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6381634","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6381634","identity":"rs-6381634","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}