Arthroscopic Transfer of the Conjoined Tendon-Coracoid Tip Complex for Anterior Shoulder Instability

Reconstruction of recurrent shoulder dislocation with glenoid bone defect with 3D-printed titanium alloy pad: outcomes at 2-year minimum follow-up

BACKGROUND

To evaluate the outcome of shoulder arthroscopy-assisted implantation of three-dimensional (3D)-printed titanium pads for recurrent shoulder dislocation with glenoid bone defects.

METHODS

From June 2019 to May 2020, the clinical efficacy of 3D printed titanium pad implantation assisted by shoulder arthroscopy, for the treatment of recurrent shoulder dislocations with shoulder glenoid defects was retrospectively analyzed. The American Shoulder and Elbow Surgeons (ASES) shoulder, Rowe, and Constant scores were recorded before surgery and at 3 months, 6 months, 1 year, and 2 years after surgery. 3D computed tomography (CT) and magnetic resonance imaging were used to evaluate the location of the glenoid pad, bone ingrowth, joint degeneration, and osteochondral damage.

RESULTS

The mean age of the 12 patients was 21.4 (19-24) years and the mean follow-up time was 27.6 (24-35) months. The Visual Analog Scale score significantly improved from 5.67 ± 1.98 preoperatively to 0.83 ± 0.58 postoperatively (p = 0.012). The postoperative ASES score was significantly increased to 87.91 ± 3.47 compared with preoperative ASES score (46.79 ± 6.45) (p < 0.01). Rowe and Constant scores also improved from 22.5 ± 12.34 and 56.58 ± 7.59 preoperatively to 90.83 ± 4.69 and 90.17 ± 1.89 at 2 years postoperatively, respectively. CT performed 2 years after surgery showed that the pad perfectly replenished the bone-defective part of the shoulder glenoid and restored the articular surface curvature of the shoulder glenoid in the anterior-posterior direction, and the bone around the central riser of the pad was tightly united. Magnetic resonance imaging 2 years after surgery showed that the humeral head osteochondral bone was intact, and there was no obvious osteochondral damage.

CONCLUSIONS

3D printed titanium pads are a reliable, safe, and effective surgical procedure for treating recurrent shoulder dislocations with glenoid bone defects.

Transglenoid Fixation Technique for Arthroscopic Subscapularis Augmentation Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

The optimal surgical management of anterior shoulder instability remains controversial. Although it has low recurrence rates and good clinical results, the Latarjet procedure has some disadvantages and is considered "overtreatment" in inactive patients with moderate glenoid bone loss. Several studies have described an arthroscopic technique called arthroscopic subscapularis augmentation. We developed a technical variation of the arthroscopic subscapularis augmentation technique involving tenodesis of the upper third of the subscapularis tendon using a graft. This technique uses a transglenoid fixation-immobilization with 2 knotless TightRope devices instead of anchors.

Editorial Commentary: Shoulder Arthroscopic Dynamic Anterior Stabilization Is Effective for Anteroinferior Shoulder Instability With Limited Anterior Bone Loss

Shoulder dynamic anterior stabilization (DAS) is an efficient and well-established glenohumeral stabilization technique, offering an arthroscopic alternative to Latarjet and glenoid reconstruction with distal tibial allograft or the iliac crest autograft. DAS is essentially an augmented Bankart procedure and can be performed using transfer of either the long head of the biceps tendon or the conjoined tendon. Both result in similar and acceptable rates of recurrences, complications, return to sport, and subjective shoulder function. However, the effectiveness of Bankart repair on shoulder stability decreases significantly over time, so long-term follow-up evaluations of DAS are required. The best indication for DAS may be anteroinferior shoulder instability with limited anterior bone loss.

Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate

PURPOSE

To compare the clinical outcomes of arthroscopic dynamic anterior stabilization (DAS) between transferring the long head of the biceps (DAS-LHB) and the conjoined tendon (DAS-CT) for anterior shoulder instability with <15% glenoid bone loss.

METHODS

From January 2016 to May 2019, a total of 63 patients who underwent DAS for recurrent anterior shoulder dislocation with <15% glenoid bone loss were included, comprising 33 patients in DAS-LHB group and 30 patients in DAS-CT group. Clinical outcomes were assessed preoperatively and at a minimum 3-year follow-up, including patient-reported outcomes, range of motion, and return to sports (RTS). Postoperative recurrent instability (including dislocation, subluxation, and subjective instability with a positive apprehension test), revisions and complications also were recorded.

RESULTS

No significant demographic characteristics difference was detected between the DAS-LHB (26.3 ± 7.9 years) and DAS-CT groups (26.0 ± 6.7 years). At the latest follow-up, there were no significant differences between the 2 groups in functional scores: Oxford Shoulder Instability Score (14.8 ± 2.8 vs 15.2 ± 3.6), Rowe score (95.9 ± 6.5 vs 93.2 ± 10.2), visual analog scale for pain (0.8 ± 1.2 vs 0.7 ± 1.7), and American Shoulder and Elbow Surgeons (95 ± 8.8 vs 95.2 ± 9.1) (all P > .218). No significant difference was detected between groups in the rates of RTS (90.1% vs 86.7%, P = .700) and RTS at previous level (78.7% vs 73.3%, P = .258), respectively. No recurrent dislocation occurred in either group. One patient felt occasional subluxation in the DAS-LHB group, and one was positive for the apprehension test in each group. One patient presented with postoperative shoulder stiffness and underwent a secondary arthroscopic debridement in the DAS-CT group.

CONCLUSIONS

Comparable rates of recurrence, complication, return to sports, and subjective shoulder function were observed between DAS-LHB and DAS-CT groups.

LEVEL OF EVIDENCE

Ⅲ; retrospective comparative therapeutic trial.

Bankart Repair With Transferred Long Head of the Biceps Provides Better Biomechanical Effect Than Conjoined Tendon Transfer in Anterior Shoulder Instability With 20% Glenoid Defect

PURPOSE

To examine the biomechanical differences between labral repair with transferred conjoined tendon and transferred long head of the biceps tendon (LHBT) for anterior shoulder instability with 20% bone loss.

METHODS

Twelve cadaveric shoulders were tested in sequent 5 conditions: intact, 20% glenoid defect, Bankart repair, Bankart repair with transferred conjoined tendon (dynamic conjoined tendon sling, DCS), and with transferred LHBT (dynamic LHBT sling, DLS) at 60° of glenohumeral abduction and 60° of external rotation. The physiological glenohumeral joint load was created by forces applied to the rotator cuff, conjoined tendon, and LHBT. The glenohumeral compression force and range of motion were recorded before anteroinferior force application. The anterior, inferior, and total translations were measured with 20, 30, 40, and 50 N of anteroinferior force, respectively.

RESULTS

Anteroinferior glenoid defect led to significant increase of humerus translation and decrease of glenohumeral compression force. DLS provided better resistance effect in both anterior-posterior and superior-inferior directions than DCS under high loading condition (40 N, P =.03; 50 N, P <.01). Both DCS and DLS procedures could further restore glenohumeral compression force with Bankart repair (Bankart repair: 32.1 ± 4.0 N; DCS: 36.7 ± 3.2 N, P < .01; DLS: 35.8 ± 3.6 N, P =.03). No range of motion restrictions were observed relative to the normal shoulder.

CONCLUSIONS

Both the DLS and DCS techniques could reduce the anterior-inferior translation and partially restore the glenohumeral stability in anterior shoulder instability with 20% anteroinferior glenoid defect compared with Bankart repair. Under greater loading conditions, DLS provides better stability than DCS.

CLINICAL RELEVANCE

Shoulder stability can be restored by DLS and DCS with low load. With greater shoulder stability requirements, DLS might be a better option than DCS for anterior shoulder instability with 20% bone loss.

Dynamic Double-Sling Augmentation Prevents Anteroinferior Translation for Recurrent Anteroinferior Shoulder Dislocation With 20% Glenoid Bone Loss: A Cadaveric Biomechanical Study

PURPOSE

To biomechanically compare the dynamic double-sling with single-sling augmentation using the conjoined tendon (CT) with 20% of an anteroinferior glenoid bone defect under the high loads in shoulders.

METHODS

With the shoulder in 60° of glenohumeral abduction and 60° of external rotation, the 12 shoulders stability was tested sequentially in 5 conditions: intact, 20% glenoid bone loss, Bankart repair, single-sling augmentation with the CT, and double-sling augmentation with both the CT and long head of the biceps tendon (LHBT). The anteroinferior humeral head (HH) translation force of 20N, 30N, 40N, 50N, or 60N was applied to determine the shoulder stability in each condition.

RESULTS

The total HH translation over 8.77 mm represented the anteroinferior shoulder instability (95% confidence interval of bone defect: 7.76-8.77 mm). A significant increase in anteroinferior HH translation was demonstrated after the creation of 20% glenoid bone defect under the 20N translational force (10.52 ± 0.71 mm). Structural failure after the Bankart repair and the single-sling augmentation under the 30N (9.84 ± 1.25 mm) and 40N (9.59 ± 0.66 mm) translational forces, respectively, were observed. The double-sling augmentation effectively prevented the anteroinferior HH translation under the translational force of less than 40N, and only half of the augmentation structure (8.25 ± 1.66 mm) had failed under the 50N translational forces.

CONCLUSION

In the absence of any Hill-Sachs lesion and when tested at 60° abduction and external rotation in shoulders with 20% glenoid bone defects, at time-zero, the double-sling augmentation strategy could effectively prevent anteroinferior translation when compared with the Bankart repair or the single-sling augmentation technique under all magnitudes of the translational force in biomechanical simulation. Nevertheless, none of the constructs restored the HH translation to the normal intact state.

CLINICAL RELEVANCE

Double-sling augmentation technique may represent a reliable option for preventing anteroinferior translation.

Arthroscopic Subscapularis Augmentation Using the Long Head of the Biceps Tendon for Anterior Shoulder Instability

The limitations of transferring the coracoid process along with the conjoined tendon are coracoacromial arch damage, technical difficulty, and nerve injury. The long head of the biceps tendon (LHBT) proximal transposition technique has a weaker sling effect and a risk of nerve injury. The arthroscopic subscapularis augmentation technique may have risks of shoulder external rotation restriction and subscapularis transection. Herein, we introduce an arthroscopic technique for the transfer of the LHBT for subscapularis augmentation to address these risks. Indications of this technique were patients younger than 45 years of age who engage in competitive sports, require forceful external rotation and abduction, have a related capsule-ligament insufficiency, and have a glenoid bone loss <25%. The steps include detaching the LHBT at the upper edge of the pectoralis major, transecting and braiding the LHBT, establishing a scapular tunnel, placing a guide suture through the upper third of the subscapular and scapular tunnel, passing the LHBT through the established tunnels, and fixating the LHBT. This technique achieves stability of the anterior shoulder by transecting and transferring the distal end of the LHBT to press on the upper third of the subscapularis muscle.

Double-Sling Augmentation for Anterior Shoulder Dislocation

Anterior capsule ligament deficiency occurs in complicated anterior shoulder dislocation and poses a challenge to surgeons because of the irreparability of the capsule labrum structure or the nonoptimal healing potential after repair. Single-sling augmentation with either conjoined tendon or the long head of the biceps brachii has been reported to enhance the anterior stability of the shoulder. However, single-sling augmentation may still not be enough in cases of complicated anterior shoulder dislocation. Thus we introduce a double-sling anterior shoulder augmentation technique in which both the conjoined tendon and the long head of the biceps brachii are transferred to the anterior inferior side of the glenoid. Our clinical experience indicates that this procedure is effective to address complicated anterior shoulder dislocation. We believe that the introduction of this technique will provide a special choice in the treatment of anterior shoulder dislocation.

Arthroscopic subscapularis augmentation combined with capsulolabral reconstruction is safe and reliable

PURPOSE

The study aimed to compare modified arthroscopic subscapularis augmentation (MASA) with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction (Group A) or Bankart repair (Group B) for recurrent anterior shoulder instability (RASI).

METHODS

A retrospective series of 49 patients underwent primary surgery for RASI with glenoid bone loss (GBL) < 25%. Outcomes included the Oxford Shoulder Instability Score (OSIS), Visual Analogue Scale (VAS) score, Rowe score, and American Shoulder and Elbow Surgeons (ASES) functional outcome scale score. Recurrent instability, sports activity level, and range of motion (ROM) were also analysed.

RESULTS

No significant differences were observed at baseline. Forty-six patients were available for more than 2 years of follow-up. At the last follow-up after surgery, the patients in both groups had experienced significant improvements in all outcome scores (P < 0.05 for all), and obvious decreases in forward flexion and external rotation were noted in both groups (P < 0.05 for all). Group A had superior ASES scores, VAS scores, and OSISs (P < 0.05) but did not experience significant differences in either the Rowe score or ROM compared to Group B. Group A had lower rates of recurrent instability and superior outcomes for the return to sports activities. One patient in Group A had subluxation, and 4 patients in Group B had dislocation or subluxation. No patients in either group experienced neurovascular injury, joint stiffness, or surgical wound infection.

CONCLUSION

For RASI with GBL < 25%, MASA with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction was a safe technique that produced better outcomes in terms of ASES scores, VAS scores, OSISs, the return to sports, and postoperative recurrent instability and did not decrease the ROM compared to that achieved by arthroscopic Bankart repair.

LEVEL OF EVIDENCE

III.

All-Arthroscopic, 270° Reconstruction of the Inferior Glenohumeral Ligament With Palmaris Longus Autograft

Numerous factors play a role in anterior shoulder stability. The inferior glenohumeral ligament, especially the anterior band, is the main passive anterior stabilizer in the end range of motion. Surgical treatment of this pathology continues to be a challenge in patients with capsular deficiency, in whom the recurrence rate of soft-tissue arthroscopic repair increases significantly. There is not yet a fair solution for these patients without glenoid bone loss, in whom the poor tissue quality determines recurrent instability. We present an all-arthroscopic technique for reconstruction of the inferior glenohumeral ligament by means of palmaris longus autograft as an alternative to nonanatomic bone block procedures.