Bone Graft Surgery
What Is Bone Graft Surgery in the Treatment of Shoulder Instability?
The shoulder is the most mobile joint in the body, and this wide range of movement also makes it prone to dislocation. The foundation of shoulder stability is the bone structure of the joint: the humeral head (the ball) and the glenoid (the socket). With repeated dislocations, bone loss can develop on these surfaces; when the bony foundation is compromised, soft-tissue repair alone may not be enough.
Bone graft surgery aims to restore the bony support of the joint in shoulder instability with significant bone loss, by rebuilding the missing bone with a graft (autograft from the patient's own bone or allograft from a tissue bank). For general information about shoulder dislocation and instability you can review the shoulder dislocation page, and for detail on the related conditions the failed shoulder stabilization and bone loss page.
Why Does Bone Loss in the Shoulder Matter?
Bone loss at the rim of the glenoid or on the humeral head makes the socket shallower and makes recurrent dislocation more likely. In patients with significant bone loss, soft-tissue repair alone (such as arthroscopic stabilization) is not always enough; the risk of recurrence is higher in these cases.
For this reason the treatment plan is shaped by the location and amount of bone loss: with limited bone loss a soft-tissue repair may be enough, while with significant loss methods that add bone come onto the agenda. The aim is to rebuild the bony foundation of the joint and make the stability durable.
Who Is a Candidate, and Who Is Not?
Bone graft surgery is considered for selected patients in whom bone loss is the decisive factor. The decision is made according to the bone loss established by examination and imaging.
- Patients with recurrent shoulder dislocation and significant glenoid or humeral head bone loss.
- Patients whose instability persists despite a previous soft-tissue stabilization and in whom bone loss is found.
- In patients with limited bone loss a capsulolabral repair may be enough; the place of a bone graft is significant bone loss.
Preoperative Assessment
Before surgery the history of the dislocation and the direction of instability are assessed by examination; the most critical step is measuring the bone loss. An X-ray gives basic information; a three-dimensional CT shows the bone loss at the glenoid and the humeral head in detail and guides the graft planning.
MRI helps to assess any accompanying labral and soft-tissue damage. With this imaging the location and amount of bone loss are established, and the most appropriate method and graft choice for the patient are planned.
Measuring the bone loss accurately is decisive for the success of treatment. Unrecognised significant bone loss is one of the leading causes of recurrence of instability when only a soft-tissue repair is done; for this reason three-dimensional imaging is important in selected cases.
Graft Options and How the Surgery Is Performed
The aim of bone graft surgery is to place the missing bone at the rim of the glenoid to deepen the socket again and provide stability. The graft can come from the patient's own bone (autograft) or from a tissue bank (allograft).
- The Latarjet procedure: the patient's coracoid process is transferred to the rim of the glenoid together with its attached muscles; it both adds bone and provides an additional stabilising effect.
- Free bone graft: bone such as an iliac crest (pelvis) autograft or a distal tibia allograft is placed into the glenoid defect and fixed with screws.
- Additional procedures for bone loss on the humeral head side (e.g. filling the defect with soft tissue) can be added in selected cases.
Anaesthesia and the First Period
The operation is performed under general anaesthesia, usually with a regional nerve block. In the early period the arm is supported in a sling to protect the graft and the repair; the duration of the sling and the movements allowed are set according to the method used.
Forceful movements of the shoulder are avoided early on while movement of the elbow, hand and neck is preserved. Cold application and the pain medication advised by the doctor are used for pain and swelling. Most patients are discharged after a short hospital stay.
Rehabilitation and Return to Sport
The first aim of rehabilitation is to allow the graft to unite with the natural bone. The programme begins with gentle passive movement; as the graft heals it progresses gradually to active movement, then strengthening and finally sport-specific work.
Return to sport is guided by criteria rather than a fixed date: union of the graft, pain-free movement, muscle strength close to the other shoulder and good joint control. Return to contact and overhead sports takes longer; no fixed timeframe is promised.
Risks and When Should You See a Doctor?
The procedure is generally safe; nevertheless, as with any surgery, certain risks are kept in mind: infection, joint stiffness, failure of the graft to unite or its resorption, problems with the fixation hardware, nerve or blood-vessel injury and recurrence of the instability.
- Your shoulder has dislocated more than once and a sense of apprehension persists; for assessment of bone loss.
- Dislocations continue despite a previous shoulder stabilization.
- After surgery there is increasing pain, fever, wound drainage or numbness or weakness in the arm; do not delay.
For the assessment of shoulder instability and bone loss you can contact Assoc. Prof. Serkan Sürücü, and you can also review the other conditions covered within shoulder surgery.