Graft position and fusion rate following arthroscopic Latarjet

Current Trends and Outcomes for Open vs. Arthroscopic Latarjet

PURPOSE OF REVIEW

This paper aims to analyze and compare the existing research on open and arthroscopic Latarjet procedures for treating anterior shoulder instability. The review will assess different factors such as graft positioning, functional outcomes, complications, and return-to-play rates for both approaches. The study's primary goal is to establish which technique yields superior outcomes.

RECENT FINDINGS

Recent studies have suggested that arthroscopic Latarjet surgery can produce outcomes similar to open surgery regarding functional scores and patient satisfaction. Some research indicates that arthroscopy may even provide slightly better results. Both techniques have similar complication rates, but arthroscopy requires a longer learning curve and operating time. It is crucial to ensure the proper placement of the graft, and some studies suggest that arthroscopy may be better at achieving accurate positioning. Both open and arthroscopic Latarjet procedures are equally effective in treating shoulder instability. While arthroscopy offers a faster recovery time and causes less soft tissue damage, it requires surgeons to undergo a steeper learning curve. The optimal graft position for both techniques is still debated. More long-term data is needed to establish superiority. Future research should compare approaches in larger cohorts and identify outcome-affecting factors to improve the treatment of shoulder instability. Both techniques are promising, but arthroscopy may be a better option as the procedure evolves into a less invasive reconstruction.

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data

BACKGROUND

The Latarjet procedure is commonly performed in the treatment of recurrent shoulder instability and is also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. Although this procedure has shown success, there has been an increased awareness of complications in recent studies, especially graft osteolysis. Most relevant research has focused on the pathophysiology, incidence, or location of graft osteolysis or the risk factors for graft osteolysis; however, the data are limited to primary Latarjet procedures. This study aimed to investigate the effect of previous arthroscopic Bankart repair surgery on coracoid bone graft osteolysis in the Latarjet procedure.

METHODS

This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedures or revision Latarjet procedures following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion, the Subjective Shoulder Value, and the Rowe score. Volumetric analysis of each transferred coracoid graft was performed using early postoperative and late postoperative computed tomography scan data, and the amount of graft osteolysis was then calculated as the percentage of volume reduction of each graft.

RESULTS

A total of 32 patients who met the inclusion criteria were included in this study, with 24 patients in the primary Latarjet group (group I) and 8 patients in the revision Latarjet group (group II). The mean age of the patients was 32.5 ± 7.7 years, and the mean follow-up duration was 52.1 ± 8.9 months. Both study groups showed significant improvement in the Subjective Shoulder Value compared with baseline (P < .05). Comparison of postoperative clinical outcome measures showed no significant difference in any outcome parameter between the 2 study groups (P > .05). No recurrence was observed during the follow-up period. A positive apprehension sign was present in 6 patients (25%) in group I and 4 patients (50%) in group II (P > .05). Analysis of radiologic data revealed that all patients underwent some degree of graft osteolysis, with varying osteolysis ratios between 12% and 98%. The mean osteolysis ratio of the coracoid graft was 67.3% ± 22.6% in group I and 69.4% ± 25.6% in group II, with no significant difference between the 2 groups (P > .05).

CONCLUSION

The findings of this study suggest that a considerable amount of coracoid graft osteolysis is observed after both primary Latarjet procedures and revision Latarjet procedures following failed arthroscopic Bankart repair. Previous arthroscopic Bankart repair did not seem to have a significant influence on the amount of graft osteolysis, and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

Learning curve in the arthroscopic Latarjet procedure: An analysis of the first 171 cases

Background

Arthroscopic Latarjet procedure is accepted as effective and safe. However, it is more likely to be challenging in execution. Therefore, the analysis of the learning curve remains to be worth examination.

Objective

To examine the learning curve in the arthroscopic Latarjet procedure through an analysis of the correlation between the average operative time, complications rate, and the total number of performed surgeries and execution frequency.

Materials and method

A total of 171 patients who underwent arthroscopic Latarjet surgery between 2013 and 2020 were included. Clinical findings were recorded postoperatively. We fixed the operative time with account taken of the execution frequency and the number of intra- and postoperative complications. All procedures were completed by one surgeon.

Results

By statistical analysis, a significant association between the operative time and the number of surgical interventions was found (p < 0.05). After 120 procedures, the average operative time demonstrated a constant reduction and reached 62.8 min (p < 0.05). We detected the relation between the average operative time and surgery frequency. The significant correlation between the number of intraoperative complications and the number of procedures performed manifests after the 20th surgery (p < 0.05). In total, 13 episodes of complications were recorded (7.6 %). 9 cases of intraoperative complications (5.3 %) conversed into the open Latarjet procedure. 4 episodes of postoperative complications (2.3 %) were documented, among them 2 hematomas which were treated conservatively, and 2 cases of recurrent shoulder instability. There were no neurological, neurovascular, and infection complications seen in our cohort.

Discussion

It took more than 120 arthroscopic procedures to reach the stable and reproducible indices in operative time, and more than 20 surgeries to achieve a significant reduction in the intraoperative complications rate. There was no correlation between the postoperative complication rate and the number of performed procedures. The overall level of complications did not exceed the level mentioned in the literature. The high surgical activity could be considered as a favorable factor to increase the efficiency of the learning process.

Conclusion

Gaining clinical experience with the passing of the learning stages impacts significantly the rate of intraoperative complications and operative time. The arthroscopic Latarjet procedure is safe and characterized with good clinical results even within the initial stages of the learning curve.

The arthroscopic Latarjet procedure with a posterior guided system and suture-button fixation enables more precise bone block positioning in the axial plane versus anterior screws fixation

PURPOSE

Adequate position of the bone block during arthroscopic Latarjet procedure is critical for an optimal functional outcome. However, this procedure is complex with a long learning curve. Our aim was to compare the bone block position between a dedicated glenoid posterior instrumentation and suture button fixation versus an anterior screw fixation, on a postoperative computed tomography (CT) scan.

METHOD

Seventy-nine consecutive patients operated on for an anterior shoulder instability were included in this retrospective study. The same surgeon performed arthroscopically the Latarjet procedure either with an anterior drilling and screw fixation (Group A), or with a specific posterior glenoid guide pin, a posterior drilling, and a suture cortical button fixation (Group B). Evaluations were made by two independent observers. The position was evaluated by CT scan in the axial and sagittal planes. Learning curves with operative time, complications and clinical outcomes were assessed at a minimum of 2 years of follow-up.

RESULTS

Thirty-five patients were included in Group A and 44 in Group B. In Group A, 27 bone blocks were flush (87.1%) and 38 in Group B (92.7%) (p < 0.01). In Group A, 72% of the bone block height was below the equator and 76%, in Group B (ns). The mean operating time was 123 ± 32.5 min in Group A and 95 ± 34.1 min in Group B (p < 0.0001). At the final follow-up, the mean aggregate Rowe score was respectively 94.6 ± 10.4 and 93.1 ± 9.8 points in Groups A and B. The mean aggregate Walch-Duplay score was respectively 94.2 ± 11.6 and 93.4 ± 10.6 points in Groups A and B. There were 11 complications (31.4%) in Group A and five complications (11.3%) in Group B (ns).

CONCLUSION

The arthroscopic Latarjet procedure with a posterior drilling guided system and suture-button fixation allows more precise positioning in the axial plane than with anterior drilling and screw fixation. This posterior-guided procedure could reduce intraoperative and short-term complications.

LEVEL OF EVIDENCE

Level IV.

Recurrent Anterior Shoulder Instability Treated Using the Arthroscopic Bankart-Latarjet Technique: Experience of a Peripheral Hospital

The arthroscopic Bankart-Latarjet procedure is used in the surgical management of anterior shoulder instability. This technique is mainly performed in referral centers due to its high technicity. This study aimed to evaluate surgical outcomes in a peripheral hospital center. This is a retrospective study of patients treated for recurrent anterior shoulder instability. The clinical scores (Walch-Duplay, Rowe, and Western Ontario Shoulder Instability Index (WOSI)) were assessed preoperatively and at 12 months after surgery. The consolidation and the position of the bone block were evaluated at 6 months using a CT scan. Between 2016 and 2020, 40 patients had been operated on (mean age: 28.5 ± 7.9 years). During a mean follow-up of 29.5 ± 11.6 months, we noted only one complication, a case of fracture of the callus of a consolidated bone block. No recurrence of instability was recorded. The Walch-Duplay score increased from 17.8 to 94.6, the Rowe score from 24.9 to 96.8, and the WOSI score decreased from 52.1% to 6.9%. The bone block was consolidated in 35 patients (87.5%), and a flush position with the anterior edge of the glenoid was noted for all patients. At one year, 67.0% of the patients practicing sport had returned to sports. The arthroscopic Bankart-Latarjet technique was a reliable procedure in the hands of an experienced shoulder surgeon, even in a peripheral hospital center.

Screw-Related Complications May Occur at a Greater Rate After Arthroscopic Versus Open Latarjet Procedure: A Systematic Review

Purpose

To determine the rate of complications attributable to the use of screw fixation during the Latarjet procedure and to delineate screw-related complications for open and arthroscopic Latarjet surgery.

Methods

A systematic review of the literature was performed by querying MEDLINE and EMBASE computerized databases for relevant articles that reported clinical outcomes associated with the Latarjet procedure. Clinical studies of open and/or arthroscopic Latarjet surgery that employed screw fixation of the coracoid were included in our analysis.

Results

From 692 articles identified initially, 32 studies met eligibility criteria. The study cohort comprised 2,758 shoulders, with a mean age of patients ranged from 17 to 62 years, and the mean duration of follow-up ranged from 0.3 to 25.6 years. Twenty-two studies reported outcomes of an open Latarjet technique whereas 10 studies reported on an arthroscopic Latarjet technique. Across all studies, the overall complication rate ranged from 1.4% to 36%. The rate of screw-related complications ranged from 0% to16%, and the rate of screw removal ranged from 0% to 18%. Among the subset of studies that reported specific indications for screw removal, the most common indications were pain and screw loosening. Reported rates of screw-removal among arthroscopic Latarjet procedures range from 0% to 18% and among open procedures range from 0% to 7.3%.

Conclusions

(1) Up to one-third of the overall surgical complications associated with the Latarjet procedure may be related to the use of screw fixation, (2) arthroscopic Latarjet procedure did not decrease the rate of screw related complications. The reported rate of screw-removal may be higher after the arthroscopic Latarjet procedures (up to 18%) than after open procedures (up to 7,3%), and is mainly indicated for persistent shoulder pain and/or screw loosening.

Level of Evidence

Level IV, systematic review of Level III-IV studies.

FIXATION METHODS IN LATARJET: BIOMECHANICAL COMPARISON OF SCREW TYPES AND PLATE FIXATION

Objective

Latarjet procedure is often preferred in recurrent shoulder dislocations accompanied by glenoid bone loss. It is observed that the superiority of bone graft fixation methods is still controversial. The aim of this study is to biomechanically compare the bone graft fixation methods in the Latarjet procedure.

Methods

15 third-generation scapula bone models were divided into 3 groups. Graft was fixated in the first group with fully-threaded cortical screws of 3.5mm diameter, in the second group two 16 mm partially-threaded cannulated screws of 4.5mm diameter, and in the third group via a mini plate and screw. The hemispherical humeral head was placed on the tip of the cyclic charge device, and thus, the charge applied to the coracoid graft was homogeneous.

Results

No statistically significant difference was found between paired comparisons (p>0.05). The forces in 5 mm displacement in total vary between 502-857N. Total stiffness measurements ranged between 105 and 625; the mean value was 258.13±53.54 with no statistically significant difference by groups (p = 0.958).

Conclusion

This biomechanical study showed that there is no difference between three coracoid fixation options in terms of fixation strength. Unlike previous assumptions, plate fixation is not biomechanically superior to screw fixation. Surgeons should consider their personal preferences and experience in choosing fixation methods.

Arthroscopic Latarjet procedure and suture-button fixation: can we predict nonunion early?

BACKGROUND

The arthroscopic Latarjet procedure is a technically challenging technique that provides well-known results. The first series reported fixation with screws. An alternative fixation technique has been proposed, using a button, to improve the reproducibility and to decrease the complications due to screws. The first reports using this fixation technique have yielded comparable rates of fusion. The objective of this study was to assess the fusion rate and bone modifications with this type of fixation.

METHODS

Two hundred sixteen patients were included in this prospective study. An arthroscopic Latarjet procedure, fixed with 1 button according to the Smith & Nephew technique, was performed by a single surgeon for the treatment of anterior instability. The radiographic protocol consisted of computed tomography scans at 3, 12, and 24 weeks postoperatively. We measured the coronal and sagittal positions of the bone block, distance between the bone block and the glenoid, diameter of the glenoid tunnel, fusion rate, and time to fusion.

RESULTS

The position was deemed flush in 92.6% of cases in the coronal plane and under the equator in 87.5% of cases in the sagittal plane. At last follow-up, we observed 9 cases of nonunion (4%), as well as 18 cases of delayed fusion. The fusion rate was 92% at 3 months and 96% at 6 months. For bone blocks that ultimately healed, the diameter of the glenoid tunnel was <2 mm in 62% of cases at 3 weeks and <1 mm in 90% of cases at 3 months. Conversely, the diameter of this tunnel significantly increased and was >3 mm in all cases of delayed union or nonunion.

CONCLUSION

The described technique achieved a reliable position of the bone block and a very good fusion rate with a new type of fixation. The time to obtain fusion can be lengthy, occurring between the third and sixth months. The diameter of the glenoid tunnel was the best predictive factor for fusion. Widening of the glenoid tunnel diameter >3 mm during the first 3 weeks was the most predictive factor for delayed union or nonunion of the bone block. This finding is probably explained by a sliding effect of the sutures through this tunnel, comparable to the bungee effect in anterior cruciate ligament repair in the knee.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

Clinical and Radiological Outcomes in Patients With Anterior Shoulder Instability and Glenoid Bone Loss after Arthroscopic Free Bone Block Combined With Dynamic Anterior Stabilization

BACKGROUND

As an alternative to the Latarjet procedure, the arthroscopic free bone block (FBB) procedure combined with dynamic anterior stabilization (DAS) has been recently proposed to provide both glenoid augmentation and a tendon sling effect for treating anterior shoulder instability (ASI) with glenoid bone loss.

PURPOSE

To evaluate the clinical and radiological outcomes of FBB-DAS for ASI with glenoid bone loss.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent arthroscopic FBB-DAS for ASI with >15% glenoid bone loss between February 2017 and March 2020 were screened and enrolled in this study. Clinical outcome measures were assessed preoperatively and at a minimum 2-year follow-up, including recurrence, complications, shoulder functional scores, range of motion, and return to sports. Postoperative computed tomography and magnetic resonance imaging were also performed.

RESULTS

Of a total of 65 patients with a mean follow-up of 46.1 ± 13.1 months, no patients experienced a recurrent dislocation or subluxation postoperatively, while 2 had a positive anterior apprehension test (3.1%). Additionally, 2 patients (3.1%) experienced complications of hematoma and shoulder stiffness, respectively. The mean visual analog scale score, American Shoulder and Elbow Surgeons score, Rowe score, and Oxford Shoulder Instability Score all improved significantly from 3.2 ± 2.4, 75.0 ± 18.9, 43.6 ± 27.3, and 33.8 ± 9.0 preoperatively to 1.3 ± 0.8, 95.1 ± 8.0, 95.5 ± 7.8, and 14.8 ± 3.5 at final follow-up, respectively (all P < .001). No difference was detected in range of motion except for 8.1° and 7.5° external rotation limitations in adduction and abduction, respectively. There were 62 patients (95.4%) who returned to sports, and 54 patients (83.1%) returned to the preinjury level. The transferred biceps tendon was intact in all 59 patients who completed radiological examination at the latest follow-up. Good bone healing was achieved in 98.3% of patients, and the glenoid bone defect decreased from 18.1% to 4.9%. Osseous and labral glenoids were significantly enlarged in width and depth on the latest magnetic resonance imaging (all P < .001).

CONCLUSION

Arthroscopic FBB-DAS provided satisfactory clinical and radiological outcomes for ASI with glenoid bone loss. Despite slight external rotation restrictions, it achieved low recurrence and complication rates, excellent shoulder functional scores, a high return-to-sports rate, and favorable graft healing and remodeling.

How to Fashion the Bone Block for Reconstruction of the Glenoid in Anterior and Posterior Instability

BACKGROUND

Glenoid restoration techniques to address glenohumeral instability-induced anterior and posterior glenoid bone loss (AGBL and PGBL) often require reconstruction, but best-fit bone block (BFBB) modeling has not been developed.

PURPOSE

To provide glenoid bony reconstruction models for anterior and posterior instability of the shoulder using a bone loss instability cohort with high-fidelity 3-dimensional (3D) imaging.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We reviewed consecutive patients indicated for operative stabilization who had posterior glenohumeral instability and suspected GBL who underwent 2-dimensional (2D) computed tomography (CT). Patients were matched by sex, laterality, and age to patients who underwent operative stabilization of anterior glenohumeral instability. Mimics software was used to convert all 2D CT scans into 3D models of the scapula. A BFBB model was designed to digitally reconstruct GBL and was used to predict the amount, anatomic configuration, and fixation configuration of bony reconstruction required in AGBL and PGBL.

RESULTS

The study included 30 patients with posterior instability and 30 patients with anterior instability; the participants' mean ± SD age was 28.8 ± 8.15 years (range, 16.0-51.0 years). Mean surface area of AGBL was 24.9% ± 7.7% (range, 14.7%-39.1%). Mean BFBB dimensions to reconstruct the anterior glenoid were determined to be a superior-inferior length of 23.9 ± 4.2 mm, anterior-posterior width of 6.4 ± 2.4 mm, and height of 1 cm. Mean angle of AGBL bone block interface relative to glenoid to reconstruct the native concavity was 79.4°± 5.9°. For PGBL, the mean surface area was 9.2% ± 5.6% (range, 3.0%-26.3%). Mean BFBB dimensions to reconstruct the posterior glenoid were a superior-inferior length of 21.9 ± 3.4 mm, width of 4.5 ± 2.3 mm, and height of 1 cm. The mean angle of PGBL bone block interface relative to the glenoid to reconstruct the native concavity was 38.6°± 14.3°. Orientation relative to the vertical glenoid axis was 77.2°± 13.8° in anterior reconstructions versus 105.9°± 10.9° in posterior reconstructions.

CONCLUSION

Patients with anterior instability required a more rectangular BFBB with a bone block-glenoid interface angle of 79°, whereas patients with posterior instability required a more trapezoidal, obtusely oriented BFBB with a bone block-glenoid interface angle of 39°. BFBBs for either AGBL or PGBL can be effectively designed, and their size and/or shape can be predicted based on approximate percentage of GBL.

Arthroscopic Latarjet for Primary Shoulder Instability With Off-Track Lesions or Revision Surgery Yields Satisfactory Clinical Results and Reliable Return to Sport and Work at Minimum 3-Year Follow-Up

PURPOSE

To retrospectively evaluate clinical and radiologic outcomes and return to sport and to work of patients after arthroscopic Latarjet stabilization for primary instability or revision surgery; factors influencing and determining results and potential predictors for clinical outcomes also were evaluated.

METHODS

This is a retrospective study including patients older than 18 years old who underwent arthroscopic Latarjet stabilization for recurrent anterior glenohumeral instability with off-track lesions, or for cases of recurrence after previous surgery, from 2011 to 2017. Patients were assessed preoperatively and at a minimum 3 years of follow-up using the Rowe score, the University of California at Los Angeles Shoulder Score and Simple Shoulder Test score; the range of motion, satisfaction rate, return to work and sport, perception of discomfort during sporting and daily activities, and complications and recurrence after surgery were also evaluated. The integration of the coracoid graft and the position of the screws were examined by computed tomography scan.

RESULTS

At a mean follow-up time of 6 ± 2 years, 93 patients (95 shoulders) showed significant improvement of all scale scores (P < .001), 97.8% of the patients had returned to the same working condition as before surgery, and all the patients who practiced sports preoperatively (85; 91.4%) returned to sport after surgery; 97.9% of patients were satisfied with surgery. The complication rate was 5.4%, and 2 cases (2.1%) of recurrence occurred, both after high-energy trauma. At an average of 17 ± 13 months postoperatively, computed tomography scans showed 4 (6.6%) stable nonunions, 9 (14.8%) superior, and 1 (1.6%) inferior lyses of the graft; a correct positioning of the graft was observed in 86.9% of the cases. Greater satisfaction, fewer complications, less pain during daily activities, and a lower number of reoperations were associated with a shorter time between the first dislocation episode and surgery (P = .019, P < .001, P = .014, and P = .005, respectively). Complications were directly associated with older patient age at operation (P = .001). A greater number of nonunions was found in patients with increased angle between the line linking the posterior and anterior glenoid rim and the screw axis (P = .040) and a medial axial position or a lower coronal position of the graft (both P = .010). A lower age at the time of surgery predicted better Rowe scores at follow-up (P < .001), and a lower age at the time of the first episode of dislocation predicted better postoperative Simple Shoulder Test scores (P = .026).

CONCLUSIONS

At a mean 6-year follow-up time, excellent clinical outcomes, and radiological results, with few complications, high rates of satisfaction and return to work and sport and low sports anxiety can be expected after arthroscopic Latarjet procedure. A shorter time between the first dislocation episode and surgery was associated with higher satisfaction, fewer complications, less pain during daily activities and lower reoperations; a lower age at the operation was associated with lower complications.

Biomechanical comparison between various screw fixation angles for Latarjet procedure: a cadaveric biomechanical study

BACKGROUND

The Latarjet procedure is a reliable treatment for the management of anterior glenohumeral instability with glenoid bone loss. However, the biomechanical properties of different fixation angles between screw and glenoid surface (α angle) have rarely been studied. The aim of the study was to investigate and compare the fixation stability, failure load, and failure mechanism between different α angles for Latarjet procedures, which were performed on cadaver specimens.

METHODS

Twenty-four shoulder specimens (8 in each of 3 groups) were dissected free of all soft tissue, and a 25% glenoid defect was created. The coracoid process was osteomized and fixed with 2 screws at 3 different α angles: 0° (group A), 15° (group B), and 30° (group C). Specimens were mounted to a testing apparatus, and cyclic loading (100 cycles at 1 Hz) was applied with a staircase protocol (50, 100, 150, and 200 N). Gross graft displacement and interface displacement were measured. The ultimate failure loads and failure mechanisms were recorded.

RESULTS

There was no significant difference in gross displacement under any cyclic load between 3 groups. However, a significant larger interface displacement was noted in group C than in group A in 150-N cyclic loading (P = .017). Under failure strength testing, all 24 specimens failed because of screw cutout from the glenoid, and the ultimate failure load was similar among the three groups.

CONCLUSION

Compared with the 0° α angle, the displacement after cyclic loading did not significantly increase when the α angle was increased to 15° but significantly increased at 30° for Latarjet procedures, which were performed on cadaver specimens. The results suggest that surgeons should apply the screws as parallel as possible to the glenoid surface when performing the Latarjet procedure. Although mild deviation may not reduce fixation stability, α angles greater than 30° should be avoided.

Clinical and Radiologic Outcomes of All-Arthroscopic Latarjet Procedure With Modified Suture Button Fixation: Excellent Bone Healing With a Low Complication Rate

PURPOSE

To investigate the clinical outcomes and radiologic evaluation of an all-arthroscopic Latarjet procedure with modified button fixation.

METHODS

Patients who received all-arthroscopic Latarjet procedure with modified suture button fixation between September 2015 to September 2016 were retrospectively reviewed. Indications for surgery were recurrent anterior shoulder dislocation with any 1 of these 3 conditions: glenoid defect >15%, contact-sport athlete, or failure after Bankart repair. Inclusion criteria included cases who received this surgery. Clinical outcomes were evaluated by University of California Los Angeles, ASES and Rowe score with a minimal follow-up of 3 years. Radiologic assessment on 3D computed tomography scan was performed preoperatively and postoperatively at different time points. Complications were also recorded.

RESULTS

A total of 30 patients were eventually included in this study. The mean follow-up time was 38.0 ± 2.5 months. There were 25 patients who performed contact sports. Of them, 10 patients were without glenoid defect >15% or failed Bankart repair. The remaining 20 patients had glenoid defect >15%, including 2 failed Bankart cases. Ten patients had glenoid defect < 13.5%, and the rest 20 patients had > 13.5%. UCLA, American Shoulder and Elbow Surgeons, and Rowe score significantly improved during follow-up, and the improvement exceeded MCID for all patients. No severe complications were noted. In total, 86.7% of the graft positioning was measured as flush and 13.3% as medial. The bone union rate was 96.7% at 3 months postoperatively and at final follow-up. The remodeling process for the restoration of the normal anatomy of the lower part of glenoid was noted.

CONCLUSIONS

All-arthroscopic Latarjet with modified suture button fixation can achieve stable fixation of the coracoid, good clinical outcomes (all patients with improvement exceeding MCID), low complications rate. Furthermore, the bone remodeling process contributes to the recovery of the normal anatomy of anteroinferior glenoid.

STUDY DESIGN

Case series; Level of evidence, 4.

The Cuistow: A Modified Arthroscopic Bristow Procedure for the Treatment of Recurrent Anterior Shoulder Instability

The rate of nonunion observed among the variety of Bristow-Latarjet procedures reportedly ranges from 9.4% to 28%¹. In Chinese timber buildings, the mortise-tenon joint is commonly utilized to connect beams to columns. Drawing inspirations from this concept, we created a bone trough in the glenoid neck to serve as a mortise and trimmed the coracoid graft to serve as a tenon, then fixed this mortise-tenon joint with a metal screw. Compared with a standard Bristow-Latarjet procedure, the key feature of this technique was that the coracoid process was placed into a trough (5 to 10 mm deep) in the glenoid neck, which substantially increased the bone contact area between the graft and glenoid neck. We called this surgical technique the Chinese unique inlay Bristow (Cuistow).

Description

Specific instruments have been designed to improve the safety and accuracy of the arthroscopic inlay Bristow procedure (Weigao, Shangdong, China). The posterior portal (A), superolateral portal (B), and 3 anterior portals (i.e., proximal [C], inferolateral [D], and inferomedial [E]) were utilized. General anesthesia and an interscalene block were administered with the patient in the beach-chair position. The surgical technique can be divided into 6 steps: (1) evaluation of the shoulder joint; (2) coracoid preparation, drilling, and osteotomy; (3) subscapularis splitting and labrum detachment; (4) glenoid preparation and drilling; (5) coracoid retrieval, trimming, transfer, and fixation; and (6) Bankart repair.

Alternatives

Soft-tissue capsulolabral repairs or bone reconstruction procedures are commonly performed for the treatment of anterior glenohumeral instability². The arthroscopic Bristow-Latarjet procedure is increasingly popular for the treatment of anterior shoulder instability with a substantial osseous defect of the glenoid³. Defects that are too large to be restored with the coracoid process can be treated with use of the Eden-Hybbinette procedure or a distal tibial allograft^4,5.

Rationale

This procedure was inspired by the structure of mortise-tenon joints, resulting in a modified version of the Bristow-Latarjet technique in which the coracoid process is trimmed and placed into a trough (5 to 10 mm deep) in the glenoid neck. This procedure substantially increases the contact area between the fresh bone surface and the coracoid and glenoid neck. Another important advantage of this technique is that it can facilitate accurate positioning of the coracoid on the glenoid. This procedure resulted in a high rate of graft healing, excellent functional outcomes (Rowe and American Shoulder and Elbow Surgeons Shoulder scores), and a high rate of return to sport⁶. Currently, indications of this procedure are (1) participation in high-demand sports (i.e., collision and overhead) combined with the presence of a glenoid defect involving <25% of the glenoid, or (2) any glenoid defect involving 10% to 25% of the glenoid.

Expected Outcomes

Increased bone-contact area and accurate positioning of the graft helped to facilitate osseous union, with a union rate of 96.1% at 12 months postoperatively. The clinical outcomes were excellent, with a high rate of return to sport (87%) at a minimum of 3 years of follow-up⁶.

Important Tips

When the coracoid is retrieved through portal D (the inferolateral portal), there is a risk of stretching the musculocutaneous nerve.Trimming the coracoid graft could lead to stretching of the graft and the surrounding soft tissue, resulting in overstretching of the musculocutaneous nerve.To minimize the risk of musculocutaneous nerve injury, (1) the graft should be gently retrieved through portal D, (2) the graft should be trimmed with caution without overstretching it and surrounding soft tissue, and (3) a cannula should be utilized when driving the screw to fix the graft in order to avoid the surrounding soft tissue.

Acronyms & Abbreviations

RHD = right-hand dominantMRA = magnetic resonance angiography3D-CT = 3-dimensional computed tomographyPDS = polydioxanone sutureMCN = musculocutaneous nerve.

Clinical and Radiographic Outcomes After Arthroscopic Inlay Bristow Surgery With Screw Versus Suture Button Fixation: A Comparative Study of 117 Patients With 3.3-Year Follow-up

Background:

Some studies have advocated the use of suture button fixation during Bristow-Latarjet surgery to reduce complications associated with screw fixation. However, data comparing these fixation methods are relatively incomplete.

Purpose:

To investigate the efficacy of modified arthroscopic Bristow-Latarjet surgery and compare the clinical and radiographic outcomes using screw versus suture button fixation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We evaluated 136 patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow-Latarjet surgery between June 2015 and February 2018. Of these patients, 117 who met the inclusion criteria were enrolled at a mean follow-up of 3.3 ± 0.7 years. Shoulders were separated into 2 groups based on fixation technique: screw fixation (group A; n = 63) or suture button fixation (group B; n = 54). Computed tomography imaging findings and clinical results were assessed preoperatively; immediately after operation; and postoperatively at 3 months, 6 months, 1 year, and final follow-up.

Results:

There were no significant differences between the groups in terms of postoperative clinical scores, the level of return to sports, range of motion, graft position, or reoperation rates. Bone healing was observed in 97.4% of the cases overall (114/117), with 98.4% bone union in group A and 96.3% in group B at final follow-up. Bone absorption was more common in group A (n = 30; 47.6%) compared with group B (n = 10; 18.5%) (P = .003). There were no hardware-related complications in group B, compared with 7.9% of patients in group A (P = .034). One patient in group B had a recurrent dislocation due to an unexpected event, and there were no recurrent dislocations in group A.

Conclusion:

After the modified arthroscopic Bristow-Latarjet procedure, both suture button and screw fixation methods demonstrated high bony healing rates and low risk of recurrence. Less coracoid graft resorption and no hardware-related complications were seen with suture button fixation.

Arthroscopic Latarjet: 2 or 4 Cortical Buttons for Coracoid Fixation? A Case-Control Comparative Study

BACKGROUND

While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons.

PURPOSE

To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months).

RESULTS

The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B (P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B (P≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B (P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009).

CONCLUSION

A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).

[An arthroscopic "inlay" Bristow procedure with suture button fixation: Surgical technique and radiology evaluation]

OBJECTIVE

To introduce an arthroscopic "inlay" Bristow procedure based on the Mortise-Tenon joint structure concept using suture button fixation, and to evaluate its clinical and radiology results postoperatively with a minimal 3-year follow-up.

METHODS

A total of 56 patients who received arthroscopic "inlay" Bristow procedure with suture button fixation between June 2015 to June 2016 were eventually enrolled in this study. Radiological assessment on the 3D CT scan was performed preoperatively, immediately after operation, and postoperatively at the end of 3 months, 6 months and the final follow-up. Complications postoperatively were also recorded.

RESULTS

A total of 56 patients were finally included in this study. The mean follow-up time was (36.1±3.7) months. Coracoid grafts (middle point) were positioned at about 4 o'clock (123.8°±12.3°) in the En-face view. In the axial view, 95% (53/56) of the grafts positioning were measured as flush, 5% (3/56) as medial. Bone union rate was 96.4% at the final follow-up. At the end of 3 months, 6 months, and the final follow-up, the length of the coracoid graft was 96.9%±4.9%, 91.9%±6.2%, and 91.6%±6.6% of the immediate postoperative length, respectively. Compared with the immediate postoperative length, the length measured at the end of 3 months shortened not significantly (t=2.12, P > 0.05). The coracoid graft shortened more pronouncedly 6 months postoperatively (t=4.98, P < 0.05) and then remained almost constant over time (t=-0.75, P > 0.05), with all grafted coracoid graft retaining more than 90% of their initial length by the 3-year follow-up. And new bone formation at the junction between the coracoid graft and glenoid neck in the axial view were obviously noted in 25 cases. The quantitative evaluation showed that the glenoid area in En-face view was significantly increased at the final follow-up than that immediately after surgery [(9.72±1.22) cm² vs. (9.42±1.11) cm²]. No degenerative changes were noted on CT images in all the patients at the final follow-up.

CONCLUSION

This study reported a series of "inlay" Bristow procedure with suture button fixation for recurrent shoulder dislocation, providing satisfactory union rate and excellent graft positioning. And using suture button fixation instead of screw can reduce osteolysis and complications related to hardware implantation. Moreover, the bone remodeling between the coracoid process and glenoid could be beneficial to restoring the anterior stability of shoulder joint in a long term follow-up.

Computed Tomography-Based Preoperative Planning Provides a Pathology and Morphology-Specific Approach to Glenohumeral Instability With Bone Loss

PURPOSE

To use computed tomography (CT) to determine a reproducible method of coracoid measurement to compare the ability of the classic Latarjet technique and the congruent arc modification (CAM) to restore native glenoid diameter and to develop a preoperative planning algorithm for glenoid restoration with a goal of achieving an on-track shoulder.

METHODS

Coracoid dimensions were measured on multiplanar reconstructed shoulder CT scans of patients aged 18 to 45 years obtained between December 1, 2019, and March 13, 2020. Patients were excluded if CT demonstrated osteophyte formation, glenoid dysplasia, coracoid fracture, or tumor. The proportion of glenoid diameter able to be restored using classic Latarjet technique and CAM were calculated. A treatment algorithm was proposed considering the amount of bone loss present and coracoid dimensions.

RESULTS

Coracoid dimensions of 117 consecutive patients were measured and varied considerably (length: 17.5-31.8 mm, width: 9.1-20.5 mm, thickness: 6.1-15.7 mm). While most patients had harvestable coracoid length ≥20 mm (male: 96.3% vs female: 94.4%, P = .65), only 27.8% of female patients had coracoid thickness ≥10 mm. When comparing Latarjet techniques, there was no difference in the proportion of patients in whom 30% glenoid diameter could be fully restored, but CAM was able to restore at least 35% in more male and female patients (98.8% vs 79.0% and 100% vs 61.1%, respectively, P = .00001). Intra- and inter-rater reliability was excellent ( intraclass correlation coefficient ≥0.950 for all dimensions).

CONCLUSIONS

We describe a reliable method of measuring coracoid dimensions for preoperative planning of glenoid restoration. The classic Latarjet technique reliably restores the glenoid anteroposterior diameter with bone loss of up to 30%. The majority of female patients have coracoid thickness <10 mm, which may increase the risk of graft fracture when using CAM. The decision to use the classic Latarjet technique or CAM considers each individual's glenoid and coracoid dimensions with a goal of achieving an on-track shoulder.

CLINICAL RELEVANCE

Our reliable method of coracoid measurement demonstrated the differing abilities of the classic Latarjet and CAM to restore the native glenoid diameter. An evidence-based algorithm using these measurements was developed to assist in preoperative planning for glenohumeral instability in the setting of bone loss, with a goal of achieving an on-track shoulder. Alternative techniques may be considered if an on-track shoulder cannot be achieved with Latarjet.

Arthroscopic Latarjet Procedure: Indications, Techniques, and Outcomes

»

The proposed advantages of the arthroscopic approach in the Latarjet procedure for shoulder dislocation include improved visualization for accurate positioning of the coracoid graft, the ability to address any associated intra-articular pathologies, and the diminished potential for the formation of postoperative scar tissue and stiffness associated with an open procedure.

»

Young age, the presence of glenoid and/or humeral bone loss, a history of dislocation, a history of failed arthroscopic stabilization surgery, and an active lifestyle are all associated with recurrent dislocation and are relative indications for an osseous augmentation procedure.

»

Both the open and arthroscopic Latarjet procedures result in substantial improvements in patient function, with comparable rates of recurrent instability and complication profiles.

Cuistow: Chinese Unique Inlay Bristow: A Novel Arthroscopic Surgical Procedure for Treatment of Recurrent Anterior Shoulder Instability with a Minimum 3-Year Follow-Up

BACKGROUND

The prevalence of nonunion after the Latarjet procedure remains high. The purpose of the present study was to investigate healing and clinical outcomes after a novel arthroscopic coracoid process transfer procedure.

METHODS

Sixty-three patients who underwent the arthroscopic inlay Bristow procedure combined with Bankart repair were identified, and 51 patients who met the inclusion criteria were enrolled in this study. The key feature of this technique was that the coracoid process was trimmed and fixed into a trough (5 to 10 mm deep) in the glenoid neck with a metal screw. Bone graft union and positioning accuracy were assessed with use of postoperative computed tomography (CT) imaging. Clinical examinations, return to sport, and functional scores (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) were recorded.

RESULTS

The mean duration of follow-up (and standard deviation) was 41.5 ± 7.7 months (range, 36 to 48 months). Postoperative CT scans showed that the position of coracoid graft was at 4:10 (from 3:50 to 5:00) (referencing the right shoulder) in the sagittal view. The α angle was 16.4° ± 9.5°, with 4 (7.8%) of 51 screws being over-angulated (α > 25°). On the axial view, the graft position was considered to be flush in 33 patients (64.7%), medial in 11 (21.6%), congruent in 7 (13.7%), and lateral or too medial in none. At 1 year, the coracoid graft had healed in 49 patients (96.1%) and had failed to unite in 2 patients. CT scanning, performed for 47 patients, showed grade-0 osteolysis in 9 patients, grade-1 osteolysis in 21 patients, and grade-2 osteolysis in 17 patients. At the time of the latest follow-up, there was a significant increase in the Rowe score (from 35.5 ± 8.3 to 95.7 ± 7.2) and the ASES score (from 71.2 ± 9.7 to 91.5 ± 4.4), and 87.0% of patients were able to return to sport. No arthropathy was observed in any patient.

CONCLUSIONS

After a minimum 3-year follow-up, the arthroscopic inlay Bristow procedure resulted in a high rate of graft healing, excellent clinical outcomes, and a high rate of return to sports.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Follow-Up of Arthroscopic Latarjet Procedure with Screw or Suture-Button Fixation for Recurrent Anterior Shoulder Instability

Objective

To evaluate the early clinical and radiographic results of arthroscopic Latarjet procedure using screw or suture‐button fixation in patients with recurrent anterior shoulder dislocation.

Methods

Twelve patients who underwent arthroscopic Latarjet procedure between January 2015 and December 2018 at our institution were retrospectively studied. Data of the patients' history, including age, gender, side of affected arm, body mass index (BMI), and the number of dislocations since fist dislocation were collected. Preoperative and postoperative clinical follow‐up data were evaluated using Walch–Duplay score, American Shoulder and Elbow Society (ASES) score, and modified Rowe score. Active external rotation and active internal rotation at 90° of abduction as well as active elevation were evaluated preoperatively and postoperatively. The position and healing condition of the transferred coracoid bony graft were also assessed using computed tomography (CT) and Mimics 19.0 software.

Results

Mean follow‐up was 24.9 months (range, 13 to 53 months) of all patients. At final follow‐up, the average ASES score (preoperative vs postoperative values) had improved from 68.9 ± 7.9 to 91.1 ± 6.1 in screw fixation group and 68.9 ± 8.9 to 87.5 ± 6.7 in suture‐button fixation group; the average Rowe score (preoperative vs postoperative values) had improved from 25.0 ± 8.4 to 92.5 ± 4.2 in screw fixation group and 21.7 ± 13.7 to 93.3 ± 4.1 in suture‐button fixation group; the average of Walch–Duplay score (preoperative vs postoperative values) had improved from 12.5 ± 15.1 to 91.7 ± 4.1 in screw fixation group and 18.3 ± 20.7 to 88.3 ± 7.5 in button fixation group. The forward flexion was 175.0° ± 8.4° preoperatively and 178.3° ± 4.1° postoperatively in screw fixation group while 174.8° ± 10.2° preoperatively and 175.0° ± 5.5° postoperatively in suture‐button fixation group. The active external rotation was 77.5° ± 5.2° preoperatively and 71.7° ± 4.1° postoperatively in screw fixation group while 72.5° ± 6.9° preoperatively and 68.3° ± 7.5° postoperatively in suture‐button fixation group. The average of active internal rotation was 66.7° ± 6.1° preoperatively and 67.5° ± 6.1° postoperatively in screw fixation group while 68.3° ± 11.3° preoperatively and 66.7° ± 7.5° postoperatively in suture‐button fixation group. In postoperative CT scan, 91.7% grafts midline center were located at or under the equator in the en face view; 75% of the bone blocks were flush to the glenoid face in the axial view, with only two grafts exhibiting slight medial placement in screw fixation group (33.3%) and one graft exhibiting slight lateral placement in suture‐button fixation group (16.7%). All grafts achieved bone union. Graft absorption mostly occurred outside of the “best‐fit” circle. The average bony absorption rates of the coracoid grafts were 25.2% and 10.18% in screw fixation group and suture‐button fixation group, respectively, at 6 months postoperative follow‐up.

Conclusion

Both suture‐button fixation and screw fixation techniques in arthroscopic Latarjet procedure revealed excellent clinical outcomes with low complication rates in the early follow‐up. The suture‐button fixation exhibited a flexible fixation pattern that allowed for self‐correction to some extent, even slight lateralization could finally remodel over time.

Osseous Healing With Nonrigid Suture Fixation in the Arthroscopic Latarjet Procedure

Background:

The Latarjet procedure is a popular means to surgically address anterior glenohumeral joint instability. Although the Latarjet procedure is becoming increasingly common, challenges persist and include postoperative complications secondary to use of the conventional 2 bicortical fixation screws. Recently, a novel surgical technique using a guided surgical approach for graft positioning with nonrigid fixation via a suture suspensory system has been described.

Purpose:

To evaluate healing rates and stability of the grafts in patients who underwent this new Latarjet technique.

Study Design:

Case series; Level of evidence, 4.

Methods:

We retrospectively gathered anonymized computed tomography (CT) data sets from a total of 107 patients who underwent nonrigid suture fixation using a cortical button fixation for anterior glenohumeral instability. Of the 107 patients, 45 had CT scans performed at 2 different time periods. The CT scans of each patient were compared by 2 fellowship-trained musculoskeletal radiologists. Data recorded included age, sex, date of scan, initial graft position on the glenoid, presence and degree of graft migration relative to the equator on follow-up scan, and percentage of osseous healing (as assessed by osseous bridging) on the follow-up scan. Descriptive statistics were calculated to evaluate the average migration and average percentage of healing at both time points.

Results:

Our population (n = 45) consisted of 38 men (84.4%) and 7 women (15.6%). The mean age was 27.1 ± 1.1 years. The mean time between initial CT scan (2 weeks postoperatively) and follow-up CT scan was 26 ± 2 weeks. On follow-up scan, reviewer 1 found 75.6% of patients had greater than 75% healing, and reviewer 2 found 70.2% of patients had greater than 75% healing. The center of the graft was measured at or below the equator on follow-up examination in 43 of 45 (95.6%) patients by reviewer 1 and 44 of 45 (97.8%) patients by reviewer 2.

Conclusion:

Based on these findings, nonrigid suture fixation using a cortical button device offers an effective alternative to traditional screw fixation for the Latarjet procedure with a high level of osseous healing and minimal graft migration.

Risk Factors for Coracoid Graft Osteolysis after the Open Latarjet Procedure

Objective  Coracoid osteolysis has been described as a possible complication after the Latarjet procedure. The aim of the present study was to investigate the incidence and risk factors associated to coracoid graft osteolysis and to correlate them with clinical results.

Methods  A retrospective review of 38 Latarjet procedures was conducted. Computed tomography (CT) scans were obtained from all of the patients before and at least 1 year after the surgery. Coracoid osteolysis was evaluated and correlated to preoperative factors, namely: age, smoking status, and preoperative glenoid bone loss. The patients were divided into 2 groups: A (no or minor bone resorption) and B (major or total bone resorption). The functional outcome was determined by the Rowe score.

Results  Coracoid graft osteolysis occurred in 22 cases (57.8%). The mean preoperative glenoid defect was 22.8% in group A, and 13.4% in group B ( p  = 0.0075). The mean ages of the subjects in both groups were not significantly different. Smoking did not seem to affect the main outcome either, and no correlation was found between graft osteolysis and postoperative range of motion, pain, or Rowe score. There were no cases of recurrent dislocations in our sample, although four patients presented with a positive anterior apprehension sign.

Conclusion  Bone resorption of the coracoid graft is present in at least 50% of the patients submitted to the Latarjet procedure, and the absence of significant preoperative glenoid bone loss showed to be the only risk factor associated with severe graft osteolysis, even though this did not influence significantly the clinical outcome.

Basic morphological characteristics of coracoid grafts obtained by open and arthroscopic Latarjet techniques: A comparative study

BACKGROUND

A knowledge of the anthropometric characteristics of the coracoid graft (CG) that can be obtained by the open and arthroscopic Latarjet techniques may be beneficial in the preoperative planning and intraoperative decision making for coracoid osteotomy and transfer. We have not found any study that compared the morphology of the CG that can be obtained from open and arthroscopic Latarjet techniques. The purpose of this study was to verify if the basic anthropometric characteristics of CGs are equivalent.

HYPOTHESIS

We hypothesize that the basic anthropometric characteristics of the CGs are similar.

METHODS

Twenty fresh-frozen human paired cadaveric shoulder specimens that had been randomly distributed in two groups of 10 specimens each were used. Two surgeons, each with experience in performing the open and arthroscopic Latarjet technique, performed these procedures in each of the respective groups (OG, open group; AG, arthroscopic group). A CT scan was performed. Using the volume rendering technique, a metric analysis of the volume, area and length of the CG were performed, evaluated and statistically analysed.

RESULTS

There were no significant differences in length (p=0.162) (mean length, 22.6mm for OG and 23.6mm for AG). There were significant differences in the volume (p=0.031) and area (p=0.007) of the CG, being lower in the OG (mean volume, 2.8 cm³ for OG and 3.6 cm³ for AG; mean area, 9.9 cm² for OG and 12.8 cm² for AG). No significant differences were observed by sex or laterality.

CONCLUSION

The mean lengths of the CGs that were obtained by each technique are equivalent. However, the areas and volumes of the grafts are different, being lower in the open surgery. These differences have not been an impediment to perform the technique. Our results corroborates that consolidation is more related to the preparation and placement than to the anthropometric characteristics of the CG. No significant differences were observed by sex or laterality.

LEVEL OF EVIDENCE

Basic Science.

An Arthroscopic "Inlay" Bristow Procedure With Suture Button Fixation for the Treatment of Recurrent Anterior Glenohumeral Instability: 3-Year Follow-up

BACKGROUND

Coracoid graft positioning, fixation, and bone union are key factors affecting the clinical outcomes of Bristow and Latarjet procedures. We developed an arthroscopic "inlay" Bristow procedure based on the "mortise-tenon" joint structure concept using suture button fixation to achieve more stable fixation and better bone union of the graft.

PURPOSE

To evaluate the positioning of the coracoid graft, bone union rate, and clinical outcomes of this arthroscopic inlay Bristow procedure with suture button fixation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 62 patients who received the arthroscopic inlay Bristow procedure with suture button fixation between June 2015 to June 2016 were eligible for inclusion, and 56 patients who met the inclusion criteria were enrolled in this study. Radiological assessment on 3-dimensional computed tomography scan was performed preoperatively, immediately after the operation, and postoperatively at 3 months, 6 months, 1 year, and the final follow-up. Pre- and postoperative clinical results were also assessed.

RESULTS

A total of 56 patients were included in this study. The mean ± SD follow-up time was 36.1 ± 3.7 months. Coracoid grafts (middle point) were positioned at 4 o'clock (range, 123.8°± 12.3°) in the sagittal view. In the axial view, 94.6% (53/56) of the graft positioning was measured as flush and 5.4% (3/56) as medial. Neither lateral nor too medial positioning was noted. The bone union rate was 96.4% at final follow-up. The mean visual analog scale score for pain during motion, American Shoulder and Elbow Surgeons score, and Rowe score all improved significantly after surgery-from 4.8 ± 2.6 to 1.1 ± 1.0, 69.2 ± 12.5 to 92.5 ± 7.0, and 33.5 ± 12.1 to 96.0 ± 4.9 at last follow-up, respectively. Almost all patients (98%; 55/56) returned to sports within 1 year after surgery at the same or higher level as compared with their preinjury performance. The mean subjective value for sports participation was 90.3% ± 7.1% (range, 70%-100%) as compared with the normal shoulder. The overall complication rate was 3.6%. No degenerative changes were noted in any patients.

CONCLUSION

This study reported the first series of an inlay Bristow procedure with suture button fixation for recurrent shoulder dislocation, providing a satisfactory union rate and excellent graft positioning with a low complication rate. The mortise-tenon joint structure can provide excellent graft fixation and healing, while using suture button fixation instead of screw fixation could reduce osteolysis and complications related to hardware implantation.

Comparison of Coracoid Graft Position and Fixation in the Open Versus Arthroscopic Latarjet Techniques: A Cadaveric Study

BACKGROUND

Since the description of the arthroscopic Latarjet technique, discussion about the superiority of the open or arthroscopic procedure has arisen. The appropriate placement of the coracoid graft (CG) on the anterior glenoid neck is reported to be the most important step of the Latarjet procedure.

PURPOSE

To verify if there are differences in the parameters that may affect the final position and fixation of CG obtained from the open and arthroscopic Latarjet techniques.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty fresh-frozen human paired cadaveric shoulder specimens were randomly distributed in 2 surgery groups (open group [OG] and arthroscopic group [AG]) with 10 specimens in each. Two surgeons, each with experience performing open and arthroscopic Latarjet techniques, executed these procedures: one surgeon performed all open techniques, and the other performed all arthroscopic techniques, respectively. After surgery, a computerized tomography scan was performed. The surgical time, the position of each CG, a series of variables that might affect the CG fixation, and the level of the subscapularis muscle split were evaluated.

RESULTS

The mean surgical time was significantly longer in the AG (mean, 26 minutes for OG and 57 minutes for AG). Three intraoperative complications (30%) were identified in the AG, consisting of graft fractures. The CG was determined to be in an optimal cranial-caudal position in 90% of specimens of the OG and 44% of the AG (Fisher, P = .057). In both groups, the CG was placed in an optimal medial-lateral position in all specimens. In the OG, the degree of parallelism between the major axes of the glenoid surface and CG was significantly greater than in the AG (mean, 3.8º for OG and 15.1º for AG). No significant differences were observed in superior and inferior screw orientation between the groups. In the longitudinal and transverse directions, significant differences were found in the centering of the superior screw, being closer to the ideal point in the OG than in the AG. The location where the longitudinal subscapularis muscle split was performed was significantly higher in the AG.

CONCLUSION

The open Latarjet technique required less surgical time; presented a lower number of intraoperative complications; and allowed more adequate placement of the CG, better centering of the screws, and a subscapularis muscle split closer to the ideal position.

CLINICAL RELEVANCE

The reported benefits of the arthroscopic Latarjet technique seem less clear if we take into account the added surgery time and complications.

Arthroscopic Latarjet for Shoulder Instability

Arthroscopic Latarjet is a relatively new, but viable option for the treatment of anterior shoulder instability. Arthroscopic Latarjet has the advantage of faster recovery, reduced stiffness, identification of additional shoulder pathology, and improved cosmesis when compared with open Latarjet. By the majority of clinical and radiographic parameters, arthroscopic Latarjet produces equivalent outcomes compared with open Latarjet. A relatively substantial learning curve for arthroscopic Latarjet exists at about 25 cases; however, multiple studies have demonstrated comparable outcomes and surgical time after the learning curve.

Arthroscopic Latarjet: Technique Description and Preliminary Results. Study of the First 30 Cases

Objective  Arthroscopic Latarjet has been performed with the aim to be an accurate technique with a low incidence of complications. The aim of the present study was to briefly describe the technique and to evaluate the shot-term complications following arthroscopic Latarjet procedure to correct anterior shoulder dislocation with glenoid bone loss.

Methods  Retrospective study with 30 subjects with anterior shoulder instability, submitted to arthroscopic Latarjet. Intraoperative and short-term postoperative complications were recorded, as well as the rate of revision surgery.

Results  Five cases had complication (16.7%), and in the last 10 cases no complication occurred. In 1 case (3.3%), it was required to reverse for open surgery due to a fracture of the coracoid process during fixation in the glenoid. No other intraoperative complication occurred. No infection was observed. Two cases (6.7%) evolved with temporary neuropraxia of the musculocutaneous nerve, totally reversed with physiotherapy. With a follow-up from 6 to 26 months, 2 patients (6.7%) required a new intervention for graft/screws removal and release of the joint due to excessive limitation in external rotation. There was no case of recurrence.

Conclusion  Even in an initial learning curve, arthroscopic Latarjet demonstrated a low rate of short-tem complications and was a safe procedure for treating anterior dislocation of the shoulder with glenoid bone loss.

Open Versus Arthroscopic Latarjet Procedure for the Treatment of Chronic Anterior Glenohumeral Instability With Glenoid Bone Loss

PURPOSE

The purpose of this study was to compare the clinical, functional, and radiographic outcomes of open versus arthroscopic Latarjet procedures.

METHODS

Between December 2009 to January 2015, all patients older than 18 years of age who were treated with a Latarjet procedure for chronic osseous anterior instability by a single surgeon were included in this retrospective cohort study. Range of motion, strength, Rowe, Western Ontario Shoulder Instability Index (WOSI) scores, and pain level according to the Visual Analog Scale (VAS) were evaluated. In addition, postoperative computed tomography scans were used to evaluate the position of the transferred coracoid, screw orientation, and degree of graft resorption.

RESULTS

Forty-eight patients with a mean age of 29.5 years (range 19-59 years) who underwent open (n = 15; group OL) and arthroscopic (n = 33; group AL) Latarjet procedures were included in the study. The mean follow-up was 30.5 months (range 24-50 months). At final follow-up there were significant differences in the mean internal rotation loss (mean of 9° vs 14°, P = .044) favoring open surgery and WOSI (P = .017) scores favoring arthroscopic. No significant differences were detected in mean forward flexion loss (P = .918), external rotation loss (P = .883), Rowe (P = .429), and Visual Analog Scale (P = .208) scores. Mean superoinferior position of the coracoid bone graft was found between the 1:55 and 4:49 o'clock positions (2:05-4:55 for group OL; 1:51-4:47 for group AL) in en-face views. The grafts were placed laterally in 13% (group OL) and 9% (group AL) of patients. The mean α angles of the screws were 11° and 19.2°, respectively (P = .004). The mean graft resorption rates were 21% and 34% (P = .087), respectively.

CONCLUSION

Good functional results were obtained after both open and arthroscopic Latarjet procedures for the treatment of chronic osseous anterior shoulder instability. Comparative analysis showed small but statistically significant differences in internal rotation loss favoring open and in WOSI favoring arthroscopic techniques. All measured radiographic parameters were similar with the exception of a significant difference in alpha angle with improved screw position in open surgery. OL and AL techniques provide similar clinical and radiographic outcomes.

LEVEL OF EVIDENCE

III; Retrospective cohort study with comparison group.

Understanding the causes behind coracoid graft osteolysıs in latarjet procedure (finite element analysis and comparison of three fixation methods)

BACKGROUND

Latarjet is one of the most common surgical procedure performed on patients with shoulder instability with osseous defects, some complications include coracoid bone graft osteolysis, osteoarthritis, graft detachment, and malpositioning were previously reported. Several studies investigated potential causes of graft osteolysis but still, it remains a crucial area of investigation. We aim to use finite element analysis to examine the potential correlations between three modes of fixation methods used in the Latarjet procedure (screw, wedge plate, and endobutton), and the coracoid graft osteolysis.

HYPOTHESIS

Finite element analysis tested the hypothesis that there is a linear relationship between the compression stress on graft which was generated by fixation methods used in the latarjet and the coracoid graft osteolysis.

MATERIAL AND METHODS

Boundary conditions and inhomogeneous material properties were carefully assigned within the material of the scapula and coracoid interface. For the screw and wedge plate fixations, an applied torque in the range of 1-1.5Nm was used to characterize the surgeon's insertion torque during the surgical operation, while a 100N compressive force was selected for the endobutton fixation.

RESULTS

Relatively lesser stress magnitudes were observed with endobutton fixation method rather than screw and the wedge plate fixation. Statistical analyses revealed significant differences between the groups (p<0.05).

DISCUSSION

Excessive compressive stresses within the coracoid graft regions may be responsible for osteolysis due to negative effects over biological factors such as blood flow. Our study emphasizes the importance of taking into account the fixation method while performing the Latarjet procedure. We concluded that the mode of fixation used within the Latarjet procedure has a correlation on the coracoid graft osteolysis.

LEVEL OF EVIDENCE

I.

Latarjet with cortical button fixation is associated with an increase of the risk of recurrent dislocation compared to screw fixation

PURPOSE

The purpose of this study was to compare the clinical results of the Latarjet procedure using two cortical buttons vs two screws. It was hypothesized that cortical button would result in similar rates of recurrent dislocations, but a lower rate of reoperation compared to screw fixation.

METHODS

A retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior glenohumeral instability. Patient demographics, number of dislocations prior surgery, arm dominance, shoulder hyperlaxity, level of sport, type of sport and ISIS score were collected. Shoulders were separated into two groups based on surgical fixation (screws vs cortical button). Postoperatively, shoulders were evaluated for recurrent dislocation, revision surgery, post-operative Walch-Duplay score, and the Simple shoulder test (SST). Two hundred and thirty-six patients were included in the screw fixation group (group A) and 72 in button fixation group (group B) and were evaluated at a mean follow-up of 3.4 ± 0.8 years. Demographics of the two groups were similar with the exception of operative side hand dominance, which was more common in group B [50 (69.4%) vs 128 (54.2%), p = 0.02].

RESULTS

Recurrent dislocation was significantly lower in Group A: 6 (2.5%) vs 6(8.3%) (p = 0.02). Reoperation was more common in group A [14 (5.9%) vs 0 (0%)]. At follow-up, Walch-Duplay scores and simple shoulder tests were similar in both groups.

CONCLUSION

Button fixation for Latarjet showed higher rates of recurrent dislocation compared to screw fixation. However, the increased stability afforded by screw fixation needs to be weighed against the increased risk of reoperation for hardware prominence.

LEVEL OF EVIDENCE

III.

Subscapularis structural integrity and function after arthroscopic Latarjet procedure at a minimum 2-year follow-up

BACKGROUND

Subscapularis function after arthroscopic Bankart repair has been widely studied. However, data regarding subscapularis performance after arthroscopic Latarjet procedures are lacking. This study aimed to evaluate subscapularis clinical and radiologic performance after arthroscopic Latarjet procedures.

METHODS

We included 40 patients who underwent arthroscopic Latarjet procedure with a minimum 2-year follow-up. Clinical evaluation included Western Ontario Shoulder Instability Index and Rowe scores, specific subscapularis isokinetic study, and lift-off tests. Contralateral measurements were used for comparison. Computed tomographic evaluation included graft consolidation, muscle dimensions, and degree of fatty atrophy, calculated as the mean muscle attenuation (MMA).

RESULTS

There was a decrease of 8.3% of maximum internal rotation peak torque in the operated arm (P = .02). However, there was no significant difference in the agonist-antagonist ratio: 76.9% in the operated arm and 76% in the contralateral (P = .82). Lift-off strength test demonstrated a decrease in the first year but not at final follow-up (P = .38). There was a significant decrease in lift-off distance of 23% compared to the contralateral side (P < .001). Subscapularis MMA was diminished when compared to the infraspinatus/teres minor (P < .001) at the expense of its upper part (P = .03). Hyperlaxity and number of dislocation episodes were correlated to a lower MMA (P = .046 and P = .005).

CONCLUSION

Arthroscopic Latarjet procedures provide satisfactory clinical results. There seems to be a diminished subscapularis MMA depending on its superior half. Hyperlaxity and number of previous dislocations were correlated to a lower MMA. Although there was a decrease in the maximum internal rotation peak torque, we did not find any difference in the agonist-antagonist ratio or in the final lift-off strength between sides.

Early Outcomes and Perioperative Complications of the Arthroscopic Latarjet Procedure: Systematic Review and Meta-analysis

BACKGROUND

The arthroscopic Latarjet-Bristow procedure is emerging as a reliable alternative to the open procedure. The reduced soft tissue damage with potential advantages of early pain control and functional recovery is attractive. However, the operation is technically more demanding, and there are concerns regarding the potential for increased recurrence and complication rates.

PURPOSE

To evaluate the available literature focusing on the reported functional outcomes and complications of the arthroscopic Latarjet procedure and compare them with the open procedure.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive systematic review was performed with the keywords "arthroscopy," "arthroscopic," "Latarjet," and "Bristow," with no limit regarding the year of publication. The review was limited to the English-language articles, and each article was evaluated with a modified MINORS (methodological index for nonrandomized studies) scoring system.

RESULTS

Fourteen studies met the inclusion criteria and were included in the review. Overall, 813 patients met inclusion criteria, with a mean follow-up of 24.5 months. The mean Walch-Duplay and Rowe scores were 89.6 and 90.2, respectively. The overall complication rate was 16.5%; intraoperative conversion to open surgery, 2%; recurrence, 2.5%; and revision surgery, 5.6%. When only comparative studies were considered, the overall complication rates were 23.7% (arthroscopically) and 15.3% (open). The recurrence and revision surgery rates were 6.5% and 5.7% in the study group, while the corresponding values in the control group were 4% and 2.9%. The mean MINORS score was 14.5 (11.6 for noncomparative studies and 19 for comparative studies).

CONCLUSION

The arthroscopic Latarjet-Bristow procedure is reliable. Outcomes are satisfactory, with less pain and faster recovery in the first postoperative week. However, the procedure is technically demanding, and higher rates of complications and reoperations should be expected. Finally, the arthroscopic operation is much more expensive in terms of implanted materials than the open procedure.

Clinical outcomes and radiologic assessment of a modified suture button arthroscopic Latarjet procedure

Background

As several neurologic and hardware complications have been reported with screw fixation. Suture buttons are used to serve as an alternative to screw fixation to obtain better outcome and to reduce the complication. The purpose of this study was to observe the clinical outcomes and make the radiologic assessment of a modified suture button (MSB) arthroscopic Latarjet procedure.

Methods

A total of ninty-one patients with recurrent shoulder joint dislocation who underwent MSB arthroscopic Latarjet procedure was retrospectively reviewed. Fifty cases identified from the chart review met the inclusion criteria. The clinical outcomes and position of the grafts, glenohumeral degeneration, and graft healing condition were assessed postoperatively in a follow-up with at least one and half of a year.

Results

All the fifty patients were satisfied with their clinical outcome. The overall complication rate was 4% in this study. The mean visual analog scale score, the affected shoulder active mobility in Ers(external rotation at the side), Era(external rotation in abduction) decreased significantly; the ASES score, Rowe score, Walch-Duplay score improved significantly. CT scans in the sagittal view showed that grafts in 88% of cases were in good position, grafts in 12% of cases were fixed too superiorly and inferiorly. In the axial view grafts in forty cases were flush with the glenoid rim, ten were considered as too lateral. The ten grafts became remodeled and were more flush with the glenoid rim in the follow-up.

Conclusions

The MSB arthroscopic Latarjet procedure provides excellent outcome with few complications, and no degenerative changes were observed in the follow-up. Moreover, the graft fixed too laterally presented a phenomenon of remodeling and became flush with the glenoid rim over time.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2544-x) contains supplementary material, which is available to authorized users.

Tissue on the Transferred Coracoid Graft After Latarjet Procedure: Histological and Morphological Findings

BACKGROUND

Anterior shoulder instability is a debilitating condition that can require stabilization via a Latarjet procedure.

PURPOSE

The aim of this study was to characterize the histological composition of the articular-sided surface of the coracoid bone graft after Latarjet procedure. Specific features of cells isolated from the coracoid and graft tissues were assessed.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Tissue samples were harvested from 9 consecutive patients undergoing arthroscopic debridement and screw removal after arthroscopic or open Latarjet procedure. Tissues were processed histologically. In 2 patients, the samples were analyzed to assess specific cellular properties.

RESULTS

Safranin O staining indicated that glenoid tissues contained variable amounts of glycosaminoglycan (GAG) and round chondrocytic cells mainly organized in clusters. Graft tissues contained less GAG and were more cellular but were not organized in clusters and had variable morphological features. An association appeared to exist between the cartilage quality of glenoid tissues and that of the graft tissues. Cells isolated from glenoid and graft tissues exhibited similar proliferation capacity.

CONCLUSION

The results of our analysis show that cells located at the articular-sided surface of transferred coracoid grafts demonstrate fibrocartilaginous properties and may have the capacity for chondral proliferation. Further studies are needed to confirm this observation and future application.

Intraoperative graft-related complications are a risk factor for recurrence in arthroscopic Latarjet stabilisation

PURPOSE

The goal of this study was to evaluate clinical and radiological outcomes after arthroscopic Latarjet stabilisation in anterior shoulder instability.

METHODS

Ninety-three patients after primary arthroscopic Latarjet stabilisation were reviewed. Satisfaction, subjective shoulder value (SSV), Walch-Duplay and Rowe scores, and range of motion and stability were evaluated on clinical examination. Computed tomography (CT) was used to analyse graft position and fusion.

RESULTS

Ninety patients (96.8%) were available for clinical and 85 for CT evaluation. The mean follow-up was 23.7 months (13-50, SD 7.1) and age at surgery was 26.2 years (16-44, SD 5.6). Intraoperative complications were reported in eight patients (8.9%) and recurrence in three (3.3%). Significantly, two out of three patients with recurrence had intraoperative graft complications (p = 0.0107). Forty-one patients (45.6%) reported the feeling of "subjective return to sport anxiety". External rotation with arm at the side was 59° (10-90°, SD 20) with 15° (0-70°, SD 17) of loss of rotation. These two factors correlated with results the most. Patient satisfaction was evaluated as 92% (40-100, SD 14) and SSV 90% (30-100, SD12). Revision rate after primary surgery was 10%. CT showed graft healing in 81 (95.3%) patients. A graft position between 2 and 5 o'clock was found in 70 (83.4%) patients and flush to the anterior glenoid rim in 34 (40.5%). Osteolysis of the superior part of the graft was found in 55 (64.7%) patients. CT evaluation showed no correlation with clinical results.

CONCLUSION

Arthroscopic Latarjet stabilisation demonstrates satisfactory results in short-term follow-up; however, intraoperative graft-related complications are a risk factor for recurrence. "Subjective return to sport anxiety" and loss of external rotation with the arm at the side are factors worsening the results. Graft position imperfections and osteolysis of the superior part of the graft reported in CT evaluation do not influence the clinical results.

Monocortical fixation of the coracoid in the Latarjet procedure is significantly weaker than bicortical fixation

PURPOSE

A crucial step of the Latarjet procedure is the fixation of the coracoid process onto the glenoid. Multiple problems associated with the fixation have been described, including lesions of the suprascapular nerve due to prominence of the screw or bicortical drilling. The purpose of the present study was to evaluate whether monocortical fixation, without perforating the posterior glenoid cortex, would provide sufficient graft stability.

METHODS

Coracoid transfer was performed in 14 scapula models (Sawbones^®, Composite Scapula, 4th generation). Two groups were assigned: in one group, fixation was achieved with two screws that did not perforate the posterior cortex of the glenoid neck (monocortical fixation), in the other group, fixation was achieved with perforation of the posterior cortex (bicortical fixation). The ultimate failure load and mode of failure were evaluated biomechanically.

RESULTS

Monocortical fixation was a significantly weaker construct than bicortical fixation (median failure load 221 N, interquartile range 211-297 vs. median failure load 423 N, interquartile range 273-497; p = 0.017). Failure was either due to a pullout of the screws from the socket or a fracture of the glenoid. There was no significant difference in the mode of failure between the two groups (n.s.).

CONCLUSION

Monocortical fixation was significantly weaker than bicortical fixation. However, bicortical drilling and overly long screws may jeopardize the suprascapular nerve. Thus, anatomic knowledge about the safe zone at the posterior rim of the glenoid is crucial. Until further research has evaluated, if the inferior stability is clinically relevant, clinicians should be cautious to use a monocortical fixation technique for the coracoid graft.

Anterior Shoulder Instability: A Systematic Review of the Quality and Quantity of the Current Literature for Surgical Treatment

Background

Anterior shoulder instability is the most common sequela of shoulder dislocation and can result in repeated dislocations or subluxation of the glenohumeral joint. Anterior shoulder instability can be treated conservatively or surgically with several procedures.

Purpose

To date, arthroscopic Bankart is the most common surgical procedure for the treatment of anterior shoulder instability. No previous studies have compared all anterior shoulder surgical procedures. In this study, the authors performed a systematic review of journal articles describing all surgical procedures for anterior shoulder instability to determine the scientific evidence and level of recommendation.

Study Design

Systematic review; Level of evidence, 4.

Method

A comprehensive literature search was conducted (July 19, 2016) with 4 reputed databases: PubMed, EMBASE, the Cochrane databases, and Web of Science. The articles found in the literature search were screened by 2 reviewers on the basis of their titles, abstracts, and full text. Data were extracted from relevant studies, and potentially relevant records were selected for full-text review. Included articles were classified according to their scientific quality (level of evidence, 1-5). The studies were then combined for each surgical procedure, and a grade of recommendation was assigned for each procedure: grade A, treatment recommendation based on level 1 evidence studies; B, based on level 2 or 3 evidence studies; C, based on level 4 or 5 evidence and could represent conflicting results; or I, insufficient evidence to recommend a treatment. As such, the grade of recommendation provides a summary score for the quality and quantity of available literature to support the surgical procedures reviewed here.

Results

The systematic literature review generated 11,281 articles. After screening, 655 articles were included. Results revealed 31 surgical procedures for shoulder instability following dislocation: 10 surgical procedures were given an A or B recommendation; 11, a C recommendation; and 10, an I recommendation.

Conclusion

This review identified many surgical procedures to treat anterior shoulder instability. Ten of these surgical procedures had an abundant amount of published articles to describe their safety and efficacy. Arthroscopic Bankart and open Bankart were the most commonly reported procedures that cite satisfactory postoperative outcomes and limited complications. Publications on the other surgical procedures were less common. Surgeons should be careful when recommending surgery, and they should choose the appropriate surgical procedure based on evidence-based literature.

Arthroscopic Latarjet procedure with double-button fixation: short-term complications and learning curve analysis

BACKGROUND

The arthroscopic Latarjet with double-button fixation is a guided procedure recently proposed to treat anterior shoulder instability with glenoid bone loss. The goal of this study was to report intraoperative and early postoperative complications and to analyze the learning curve.

METHODS

This was a prospective, nonrandomized study that included 88 patients. Intraoperative or postoperative complications as well as adverse events and operative time were recorded. Clinical outcomes were evaluated at 2 weeks, 1.5 months, and at the last follow-up. Radiologic analysis was based on an immediate postoperative computed tomography scan.

RESULTS

The intraoperative complications or adverse events rate was 3.3%: 1 conversion to open surgery, 1 bone block fracture, and 1 instrumentation problem. The postoperative complication rate was 6.8%: 4 coracoid migrations, and 2 subluxations. None of these complications occurred beyond the 10th case performed. The average operative time significantly decreased with surgical experience (r = -0.8426; 95% confidence interval, -0.9074 to -0.7384; P < .0001) to reach 76 ± 12 minutes (range, 62-95 minutes) at 30 cases. Radiologically, 90% of the bone blocks were flush and subequatorial beyond the 30th case. At a mean follow-up of 12.6 months (range, 6-24 months), Walch-Duplay and Rowe scores were 80 and 81 points, respectively.

CONCLUSIONS

At short-term follow-up, the arthroscopic Latarjet procedure with double-button fixation exhibited a low complication rate. Operative time significantly improved with surgical experience and was optimized after 30 cases. Early clinical results confirmed that this procedure can be safe and reliable.

Bony Reconstruction of the Anterior Glenoid Rim

Recurrent anterior shoulder instability is associated with glenohumeral bone loss. Glenoid deficiency compromises the concavity-compression mechanism. Medial Hill-Sachs lesions can result in an off-track humeral position. Anterior glenoid reconstruction or augmentation prevents recurrence by addressing the pathomechanics. In Bristow and Latarjet procedures, the coracoid process is harvested for conjoint tendon transfer, capsular reinforcement, and glenoid rim restoration. Complications and the nonanatomic nature of the procedure have spurred research on graft sources. The iliac crest is preferred for autogenous structural grafts. Tricortical, bicortical, and J-bone grafts have shown promising results despite the historical association of Eden-Hybinette procedures with early degenerative joint disease. Allogeneic osteochondral grafts may minimize the risk of arthropathy and donor site morbidity. Tibial plafond and glenoid allografts more closely match the native glenoid geometry and restore the articular chondral environment, compared with conventional grafts. Graft availability, cost, risk of disease transmission, and low chondrocyte viability have slowed the acceptance of osteochondral allografts.

Results of the Latarjet coracoid bone block procedure performed by mini invasive approach

INTRODUCTION

The coracoid block technique described by Latarjet was modified by Patte and Walch in order to increase the glenoid surface. Saragaglia further modified this technique and described a minimally invasive approach which allows faster post-operative recovery. The aim of this study was to evaluate the medium-term functional and radiological results of this technique.

METHODS

This is a single surgeon cohort of 40 shoulders in 38 patients (32 men, 6 women) with an average age of 34.5 years operated on between January and December 2014. The skin incision was 3 to 6 cm long allowing the bony block to be passed under the subscapularis tendon without sectioning it and to be placed in lying position. The bone block was fixed with a 6.5 cancellous screw or a 7.0 cannulated screw.

RESULTS

At an average follow-up of 48 months, there were no recurrent dislocations. The average WOSI score was 42, the average Constant score was 95 corrected to 97% and the average SSV was 97. Visual analogue scores were 0 at rest and 0.6 with activity. The bone block healed in 92.5% of cases. It was flush with the edge of the glenoid in 84% of cases, lateralised in 10% and medialised in 6% of cases. Mean internal rotation power was 12 kg in the operated shoulder compared with 9 kg in the non-operated shoulder.

CONCLUSION

The treatment of recurrent anterior shoulder instability by mini invasive Latarjet gives excellent medium-term functional results. The rate of recurrent dislocation in this series was zero and internal rotation power was well preserved. This is an excellent alternative to arthroscopic procedures which are yet to demonstrate their superiority over open surgery.

Arthroscopic Latarjet Procedure Combined With Bankart Repair: A Technique Using 2 Cortical Buttons and Specific Glenoid and Coracoid Guides

The arthroscopic Latarjet procedure is challenging because it can be difficult to place 2 screws parallel to the glenoid surface and a medial portal (dangerous for the brachial plexus) is mandatory. In addition, precise positioning of the coracoid bone block flush with the joint line and in a subequatorial position as recommended is troublesome without the use of a guiding system because of the arthroscopic lens distortion. To improve the reproducibility of the arthroscopic Latarjet procedure and to minimize the risk of nerve complications, we developed a guiding system to optimize the positioning of the coracoid bone block and 2 cortical buttons to facilitate its fixation. Four portals are used: a posterior standard portal and 3 anterior portals, all lateral to the conjoint tendon. The anterior rim of the glenoid and the coracoid process are prepared. Two holes are drilled in the glenoid and in the coracoid process with 2 specific guides. The subscapularis is then split, and 2 cortical buttons are passed from posterior to anterior through the tunnels with a shuttle relay. The coracoid process undergoes osteotomy and is guided through the split in the subscapularis to the anteroinferior rim of the glenoid by pulling on the cortical buttons.

Arthroscopic Versus Open Iliac Crest Bone Grafting in Recurrent Anterior Shoulder Instability With Glenoid Bone Loss: A Computed Tomography-Based Quantitative Assessment

PURPOSE

To assess the iliac crest bone graft (ICBG) position in the en-face view and axial plane comparing arthroscopic with open procedures.

METHODS

A total of 40 consecutive patients with recurrent anterior shoulder instability and glenoid bone loss over 10% treated by 2 independent orthopaedic departments were included. Two independent observers analyzed preoperative and immediate postoperative computed tomography scans of 20 open (group O) and 20 arthroscopic (group A) procedures. Defect and ICBG characteristics of the J-shaped graft in the en-face view and axial plane were manually assessed by multiplanar reconstructed computed tomography scans. Variances in terms of graft positioning were analyzed.

RESULTS

No significant variances in arthroscopic graft positioning were observed. The graft position in the en-face view was comparable in both groups, with the superior extent of the arthroscopic graft (40° ± 9° [inferior extent, 139° ± 16°]) lying significantly higher than the superior extent in group O (50° ± 13°, P = .005 [inferior extent, 147° ± 21°; P = .178]). The covered glenoid defect size was above 95% (98% ± 1% in group O vs 95% ± 2% in group A, P = .001). The arthroscopic graft in the axial plane showed a significantly steeper impaction angle (34.8° ± 7.8° vs 26.9° ± 9.9°, P = .010), with a significantly increased medial offset compared with group O (6.6 ± 1.7 mm vs 5.4 ± 1.3 mm, P = .024). The mediolateral step formation, however, was not significantly different (2.9 ± 1.1 mm in group A vs 3.2 ± 0.8 mm in group O, P = .289). The interobserver reliability was very good for all measurements (R = 0.969; 95% confidence interval, 0.965-0.972).

CONCLUSIONS

Positioning of the arthroscopic ICBG in the en-face view and axial plane is comparable to that of the open technique. Good glenoid defect coverage and glenoid concavity reconstruction can be achieved with the arthroscopic technique. The main difference compared with the open procedure is the significantly steeper impaction angle.

LEVEL OF EVIDENCE

Level III, case-control study.

Preoperative CT planning of screw length in arthroscopic Latarjet

PURPOSE

The Latarjet procedure has shown its efficiency for the treatment of anterior shoulder dislocation. The success of this technique depends on the correct positioning and fusion of the bone block. The length of the screws that fix the bone block can be a problem. They can increase the risk of non-union if too short or be the cause of nerve lesion or soft tissue discomfort if too long. Suprascapular nerve injuries have been reported during shoulder stabilisation surgery up to 6 % of the case. Bone block non-union depending on the series is found around 20 % of the cases. The purpose of this study was to evaluate the efficiency of this CT preoperative planning to predict optimal screws length. The clinical importance of this study lies in the observation that it is the first study to evaluate the efficiency of CT planning to predict screw length.

METHODS

Inclusion criteria were patients with chronic anterior instability of the shoulder with an ISIS superior to 4. Exclusion criteria were patients with multidirectional instability or any previous surgery on this shoulder. Thirty patients were included prospectively, 11 of them went threw a CT planning, before their arthroscopic Latarjet. Optimal length of both screws was calculated, adding the size of the coracoid at 5 and 15 mm from the tip to the glenoid. Thirty-two-mm screws were used for patients without planning. On a post-operative CT scan with 3D reconstruction, the distance between the screw tip and the posterior cortex was measured. A one-sample Wilcoxon test was used to compare the distance from the tip of the screw to an acceptable positioning of ±2 mm from the posterior cortex.

RESULTS

In the group without planning, screw 1 tended to differ from the acceptable positioning: mean 3.44 mm ± 3.13, med 2.9 mm, q1; q3 [0.6; 4.75] p = 0.1118, and screw 2 differed significantly from the acceptable position: mean 4.83 mm ± 4.11, med 3.7 mm, q1; q3 [1.7; 5.45] p = 0.0045. In the group with planning, position of screw 1 or 2 showed no significant difference from the acceptable position: mean 2.45 mm ± 2.07 med 1.8 mm, q1; q3 [1; 3.3] p = 1; mean 2.75 mm ± 2.32 med 2.3 mm, q1; q3 [1.25; 3.8] p = 0.5631.

CONCLUSION

Unplanned Latarjet can lead to inaccurate screw length especially in the lower screw and can increase the risk of non-union and nerve damage. The clinical relevance of this article is that CT planning of screw length before surgery showed good results on post-operative CT.

Reliability of a CT reconstruction for preoperative surgical planning in the arthroscopic Latarjet procedure

PURPOSE

The arthroscopic Latarjet procedure has provided reliable results in the treatment of anterior shoulder instability. However, this procedure remains technically challenging and is related to several complications. The morphology of the coracoid and the glenoid are inconsistent. Inadequate coracoid and glenoid preparing may lead to mismatching between their surfaces. Inadequate screws lengthening and orientation are a major concern. Too long screws can lead to suprascapular nerve injuries or hardware irritation, whereas too short screws can lead to nonunions, fibrous unions or migration of the bone block. The purpose of the study was to investigate the application of virtual surgical planning and digital technology in preoperative assessment and planning of the Latarjet procedure.

METHODS

Twelve patients planned for an arthroscopic Latarjet had a CT scan evaluation with multi-two-dimensional reconstruction performed before surgery. Interobserver and intraobserver reliability were evaluated. The shape of the anterior rim of the glenoid and the undersurface of the coracoid were classified. Coracoid height was measured, respectively, at 5 mm (C1) and 10 mm (C2) from the tip of the coracoid process, corresponding to the drilling zone. Measurements of the glenoid width were then taken in the axial view at 25 % (G1) and 50 % (G2) of the glenoid height with various α angles (5°, 10°, 15°, 20°, 25°, 30°) 7 mm from the anterior glenoid rim. Shapes of the undersurface of the coracoid and the anterior rim of the glenoid were noted during the surgical procedure. Post-operative measurements included the α angle.

RESULTS

Concerning coracoid height measurements, there was an almost perfect to substantial intra- and inter-reliability, with values ranging from ICC = 0.75-0.97. For the shape of the coracoid, concordances were, respectively, perfect (ICC = 1) and almost perfect (0.87 [0.33; 1]) for the intra- and interobserver reliabilities. Concerning the glenoid, concordance was always almost perfect for 50 % height. Concordance was almost perfect for 25 % height 15° and 30° for inter- and intraobserver, for intraobserver at 0° and 25°. All the other values were still showing moderate concordance. Shape of the coracoid analysis reproducibility was perfect for both intra- and interobserver ICC = 1. There was a total agreement (ICC = 1) between the preoperative evaluation of the shape of the glenoid and the coracoid and the intraoperative assessment.

CONCLUSION

The ideal and accurate preoperative planning of screwing of the coracoid graft in the arthroscopic Latarjet can be achieved in the real surgery assisted by the virtual planning. The clinical importance of this study lies in the observation that this new preoperative planning could offer a simple, effective and reproducible tool for surgeons helping them to prepare in the best possible way a technically challenging procedure usually associated with a high rate of complications.

Can a Drill Guide Improve the Coracoid Graft Placement During the Latarjet Procedure? A Prospective Comparative Study With the Freehand Technique

Background

One of the factors that can affect the success of the Latarjet procedure is accurate coracoid graft (CG) placement.

Hypothesis

The use of a guide can improve placement of the CG and screw positioning in the sagittal and axial planes as compared with the classic open ("freehand") technique.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 49 patients who underwent a Latarjet procedure for the treatment of recurrent anterior shoulder instability were prospectively included; the procedure was performed with the freehand technique in 22 patients (group 1) and with use of a parallel drill guide during screw placement in 27 patients (group 2). All patients underwent a postoperative computed tomography scan with the same established protocol. The scans were used to evaluate and compare the position of the CG in the sagittal and axial planes, the direction of the screws (α angle), and overall contact of the graft with the anterior surface of the glenoid after the 2 surgical techniques.

Results

The CG was placed >60% below the native glenoid equator in 23 patients (85.2%) in group 2, compared with 14 patients (63.6%) in group 1 (P = .004). In the axial plane, the position of the CG in group 2 patients was more accurate (85.2% and 88.9% flush) at the inferior and middle quartiles of the glenoid surface (P = .012 and .009), respectively. Moreover, with the freehand technique (group 1), the graft was in a more lateral position in the inferior and middle quartiles (P = .012 and .009, respectively). No differences were found between groups 1 and 2 regarding the mean α angle of the superior (9° ± 4.14° vs 11° ± 6.3°, P = .232) and inferior (9.5° ± 6° vs 10° ± 7.5°, P = .629) screws. However, the mean contact angle (angle between the posterior coracoid and the anterior glenoid surface) with the freehand technique (3.8° ± 6.8°) was better than that of the guide (8.55° ± 8°) (P = .05).

Conclusion

Compared with the classic freehand operative technique, the parallel drill guide can ensure more accurate placement of the CG in the axial and sagittal planes, although with inferior bone contact.

Is the two-dimensional computed tomography scan analysis reliable for coracoid graft positioning in Latarjet procedures?

BACKGROUND

The aim of the study was to develop a computed tomography (CT)-based measurement protocol for coracoid graft (CG) placement in both axial and sagittal planes after a Latarjet procedure and to test its intraobserver and interobserver reliability.

METHODS

Fifteen postoperative CT scans were included to assess the intraobserver and interobserver reproducibility of a standardized protocol among 3 senior and 3 junior shoulder surgeons. The evaluation sequence included CG positioning, its contact area with the glenoid, and the angle of its screws in the axial plane. The percentage of CG positioned under the glenoid equator was also analyzed in the sagittal plane. The intraobserver and interobserver agreement was measured by the intraclass correlation coefficient (ICC), and the values were interpreted according to the Landis and Koch classification.

RESULTS

The ICC was substantial to almost perfect for intraobserver agreement and fair to almost perfect for interobserver agreement in measuring the angle of screws in the axial plane. The intraobserver agreement was slight to almost perfect and the interobserver agreement slight to substantial regarding CG positioning in the same plane. The intraobserver agreement and interobserver agreement were both fair to almost perfect concerning the contact area. The ICC was moderate to almost perfect for intraobserver agreement and slight to almost perfect for interobserver agreement in analyzing the percentage of CG under the glenoid equator.

CONCLUSION

The variability of ICC values observed implies that caution should be taken in interpreting results regarding the CG position on 2-dimensional CT scans. This discrepancy is mainly explained by the difficulty in orienting the glenoid in the sagittal plane before any other parameter is measured.

Arthroscopic Versus Open Latarjet in the Treatment of Recurrent Anterior Shoulder Dislocation With Marked Glenoid Bone Loss: A Prospective Comparative Study

BACKGROUND

Very few studies have compared open Latarjet versus arthroscopic Latarjet procedures.

PURPOSE

To compare the clinical and computed tomographic outcomes between open and arthroscopic Latarjet procedures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A prospective, comparative study was performed. The open Latarjet group included 44 patients, and the arthroscopic Latarjet group included 46 patients. All patients had more than 2 years of clinical follow-up (range of motion, American Shoulder and Elbow Surgeons [ASES] score, Constant-Murley score, and Rowe score). The position of the transferred coracoid, the screw orientation, and graft resorption were evaluated on computed tomography (CT) scan.

RESULTS

The surgery time for the open group was significantly shorter than that for the arthroscopic group ( P = .003). No recurrent dislocation occurred in either group. The apprehension test was negative in all patients in both groups. At the final follow-up, no significant difference was detected between the open group and the arthroscopic group regarding any of the clinical outcome measurements. The transferred coracoid graft was level with the glenoid in all patients in both groups. The open group had better position in the superior-inferior direction compared with the arthroscopic group ( P < .001). No significant difference was found in screw orientation between the 2 groups ( P = .102). At 1 year after surgery, patients in the arthroscopic group had significantly less resorption compared with patients in the open group ( P = .044).

CONCLUSION

Both procedures are effective for the treatment of recurrent anterior shoulder dislocation with marked glenoid bone loss. The open group had better position in the superior-inferior direction compared with the arthroscopic group. At 1 year after surgery, patients in the arthroscopic Latarjet group showed notably less graft resorption compared with patients in the open Latarjet group.