Arthroscopic Latarjet procedure: is optimal positioning of the bone block and screws possible? A prospective computed tomography scan analysis

Graft Position, Healing, and Resorption in Anterior Glenohumeral Instability: A Comparison of 4 Glenoid Augmentation Techniques

Background

The success of glenoid augmentation procedures depends on accurate placement and healing of the graft to the glenoid. Different glenoid augmentation techniques have been described, but no comparative studies between them exist.

Purpose

To assess the bone graft position, healing, and resorption in a group of patients treated with 1 of 4 procedures: arthroscopic anterior bone-block procedure using either (1) fresh-frozen iliac crest allograft or (2) iliac crest autograft, (3) open Latarjet, or (4) arthroscopic Latarjet.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 40 patients (87.5% men; mean age, 29.5 ± 7.9 years) were included, with 10 patients in each of the procedure groups. The graft position in the axial and sagittal planes was assessed on postoperative computed tomography (CT). Graft healing and resorption were assessed in a second CT scan performed 1 year postoperatively. Qualitative variables were compared between the 4 procedures using the chi-square test, and quantitative variables were compared with the Student t test or Mann-Whitney U test.

Results

No differences were found between the procedures in the axial or sagittal position. The healing rate was significantly lower in the allograft bone-block group (20%) compared with the autograft bone-block (80%), open Latarjet (90%), and arthroscopic Latarjet (90%) groups (P < .001). Graft resorption developed in 17 of 40 (42.5%) cases overall. Osteolysis occurred in 100% of cases in the allograft bone-block group compared with 50% in the autograft group, 20% in the open Latarjet group, and 0% in the arthroscopic Latarjet group (P < .001). The glenoid surface area on 1-year CT scan was significantly lower in the allograft bone-block group compared with the autograft bone-block, open Latarjet, and arthroscopic Latarjet groups (P < .001).

Conclusion

Arthroscopic bone-block, open Latarjet, and arthroscopic Latarjet procedures provided accurate bone graft positioning. However, very high rates of osteolysis and nonunion were observed in the iliac crest fresh-frozen allograft bone-block procedure when compared with the other procedures.

Shoulder Instability-Return to Sports After Injury (SIRSI) Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization

PURPOSE

This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery.

METHODS

A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the SIRSI scale (≥ 55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the Visual Analogue Scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System (ASOSS). The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of ½ standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI a regression model analysis and a receiver operating characteristic (ROC) curve were used.

RESULTS

A total of 108 who achieved psychological readiness (PSR) and 41 who did not (NPSR) met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than NPSR (MCID: 68.5% vs 48.7%, p=0.026; PASS: 92.5% vs 58.5%, p<0.001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, p=0.999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve 0.745, 95% CI 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (p= 0.002). A power analysis was not conducted for this study.

CONCLUSION

The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain, and a higher risk of recurrence.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

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.

Clinical Significance Thresholds in Primary and Revision Latarjet Procedures With Comparable Outcome Achievements

BACKGROUND

Given the variability across populations and settings, defining the MCID and the PASS for the Rowe and ASOSS scores and patients undergoing primary and revision Latarjet it is essential to have accurate benchmarks relevant to these groups when interpreting clinical results.

PURPOSE

To determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for the visual analog scale (VAS) for pain during sports, Athletic Shoulder Outcome Scoring System (ASOSS), and Rowe scores after primary and revision Latarjet procedures for treatment of shoulder instability.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Between January 2018 and January 2020, a retrospective review of 149 patients undergoing primary Latarjet (n = 82) and revision Latarjet (n = 67) to treat shoulder instability was performed in a single institution. Patient-reported outcome measures were collected preoperatively and 1 year postoperatively. The delta was defined as the change between the pre- and postoperative scores. Distribution-based and anchored-based approaches were used to estimate the MCID and the PASS, respectively. The optimal cutoff point and the percentage of patients achieving those thresholds were also calculated.

RESULTS

The distribution-based MCIDs after primary Latarjet were 1.1, 7.5, and 9.6 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the MCID thresholds were 93.9%, 98.7%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds after primary Latarjet were ≤1, ≥90, and ≥85 for the VAS, Rowe, and ASOSS scores, respectively. The percentages of patients who achieved PASS thresholds were 82.9%, 89%, and 86.5% for the VAS, Rowe, and ASOSS scores, respectively. The distribution-based MCIDs after revision Latarjet were 0.6, 6.2, and 3.4 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved MCID thresholds were 89.3%, 100%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds were ≤3, ≥87, and ≥86 after revision Latarjet for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the PASS thresholds were 88%, 88%, and 91% for the VAS, Rowe, and ASOSS, respectively.

CONCLUSION

This study identified useful values for the MCID and PASS thresholds in VAS, Rowe, and ASOSS scores after primary and revision Latarjet procedures for treating shoulder instability. Most patients achieved MCID and PASS benchmarks, indicating successful primary and revision Latarjet procedure outcomes. These metrics can serve as valuable parameters when analyzing parameters in future studies and have the potential to enhance patient care by optimizing treatment strategies and surgical decision making.

Inlay structure can improve bone graft stability in the Bristow procedure

BACKGROUND

Compared with the Latarjet procedure, the Bristow procedure has a lower screw-related complication rate but poor bone healing. A modified Inlay Bristow procedure has been reported to significantly improve the bone healing rate, but the biomechanical mechanism is unclear. The aim of this study was to evaluate the biomechanical stability of the bone graft between a modified Inlay Bristow procedure and the classic Bristow procedure.

METHODS

Sixteen left scapula models (Sawbones, Composite Scapula, and fourth generation) were randomly divided into 2 groups (8:8). The bone graft in the first group was fixed with a 3.5 mm screw using the Inlay structure. The bone graft in the second group was fixed with a 3.5 mm screw via the traditional method. The maximum cyclic displacement, ultimate failure load and stiffness were evaluated biomechanically. The failure type was recorded for each model.

RESULTS

Cyclic loading tests demonstrated that the maximum cyclic displacement of the Inlay procedure was significantly smaller (P = .001) than that of the classic procedure. The Inlay Bristow technique resulted in a significantly higher (P = .024) ultimate failure load than the classic Bristow technique. The stiffness of the classic group was 19.17 ± 4.01 N/mm and that of the inlay group was 22.34 ± 5.35 N/mm (P = .232). Failure was mainly due to bone graft fractures through the drill hole or glenoid bone fractures.

CONCLUSION

Inlay Bristow fixation of the bone graft in a Sawbones model provides significantly stronger fixation and better time point zero stability than classic Bristow fixation, suggesting a higher likelihood of graft union.

Arthroscopic Coracoid Transfer in the Lateral Decubitus Position is Safe and Effective at Short-Term Follow-Up

Purpose

To report on operative and clinical outcomes in a series of shoulders treated with arthroscopic Latarjet performed in the lateral decubitus position.

Methods

Patients with shoulders that underwent arthroscopic Latarjet in the lateral decubitus position were identified. Data were retrospectively collected, including patient demographics, operative times, intra- and postoperative complications, and clinical and functional outcomes. Descriptive statistics were performed.

Results

Eighteen shoulders in 17 patients were included in the study with a mean follow-up of 14 ± 12.1 months (range, 4-39 months). The mean operative time for all procedures was 132.2 ± 18.0 minutes, and the mean operative time for the first half of the cohort was significantly longer than that of the second half (141.6 ± 14.2 minutes vs 122.8 ± 17.0 minutes, P = .02). There were no intraoperative complications, and no patients required a conversion to open surgery. One patient experienced a recurrent dislocation after a traumatic event but was able to be treated nonoperatively. Preoperative and postoperative patient-reported outcome measures (PROMs) were able to be collected on 8 of 18 patients (44.4%). Although all PROMs demonstrated improvements postoperatively, only the Single Assessment Numeric Evaluation score and American Shoulder and Elbow Surgeons Shoulder Index displayed a statistically significant increase (P < .05). Five of 8 (62.5%) shoulders demonstrated bony fusion on postoperative computed tomography scan. Of those eligible, 100% of patients returned to sport or felt that they could return if they wanted to.

Conclusions

The arthroscopic Latarjet is an effective procedure for managing glenohumeral instability and can safely be performed in the lateral decubitus position.

Level of Evidence

Level IV, therapeutic case series.

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.

Suspensory fixation for bone transfer procedures in shoulder instability is superior to screws in an angled construct: a biomechanical analysis

Background

The Latarjet procedure is a common bony augmentation procedure for anterior shoulder instability. Historically, screw fixation is used to secure the coracoid graft to the anterior glenoid surface; however, malpositioning of the graft leads to oblique screw insertion that contributes to complications. Suture buttons (SBs) are a more recent fixation technique that have not been studied alongside standard screw fixation in the context of biomechanical models of angulated fixation. This study aims to compare the biomechanical strength of single and double, screw and SB fixation at various levels of angulation.

Methods

Testing was performed using polyurethane models from Sawbones. The graft piece was secured with screw fixation (Arthrex, Naples, FL, USA) or suspensory button (ABS Tightrope, Arthrex, Naples, FL, USA). Single or double constructs of screws and SBs were affixed at 0°, 15°, and 30° angles to the face of the glenoid component. An aluminum testing jig held the samples securely while a materials testing system applied loads. Five constructs were used for each condition and assessed load to failure testing.

Results

For single fixation constructs, suspensory buttons were 60% stronger than screws at 0° (P < .001), and 52% stronger at 15° (P = .004); however, at 30°, both were comparable (P = .180). Interestingly, single suspensory button at 15° was equivalent to a single screw at 0° (P = .310). For double fixation, suspensory buttons (DT) were 32% stronger than screws at 0° (P < .001) and 35% stronger than screws at 15° (P < .001). Both double fixation methods were comparable at 30° (P = .061). Suspensory buttons at 15° and 30° were equivalent to double screws at 0 (P = .280) and 15° (P = .772), respectively.

Conclusion

These measurements indicate that the suspensory button has a significantly higher load to failure capacity over the screw fixation technique, perpendicularly and with up to 15° of angulation. These analyses also indicate that the suspensory button fixation offers superior strength even when positioned more obliquely than the screw fixation. Therefore, suspensory button fixation may confer more strength while offering greater margin for error when positioning the graft.

All-Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Procedure for Recurrent Anterior Shoulder Instability: Button Fixation Is a Feasible and Satisfactory Alternative to Screw Fixation

PURPOSE

To investigate the efficacy of all-arthroscopic glenoid bone augmentation surgery using the iliac crest autograft procedure. Furthermore, we sought to compare the clinical and radiographic outcomes of using screw versus button fixation, in patients with recurrent anterior shoulder instability.

METHODS

Between 2015 and 2019, 134 shoulders with persistent instability were surgically treated with an arthroscopically placed autologous iliac crest bone graft transfer procedure. Preoperative and postoperative clinical follow-up data were evaluated using the range of motion, and the Walch-Duplay, American Shoulder and Elbow Society, and Rowe scores. Radiologic assessment on 3-dimensional computed tomography scans was performed preoperatively, immediately after surgery, as well as postoperatively, at 3 months, 6 months, 1 year, and at the final follow-up stage. Graft positions, healing, and resorption were evaluated from postoperative images.

RESULTS

This study included 102 patients who underwent arthroscopic iliac crest bone grafting procedure with 2 screws fixation (n = 37; group 1) and 2 button fixation (n = 65; group 2). The mean follow-up period was 37 months. There were no significant differences between groups in terms of clinical scores, shoulder motion range, graft healing, or graft positions on computed tomography scans (P>.05). In group 1, 1 patient showed mechanical irritation and persistent pain around the screw insertion site, being treated through the arthroscopic removal of the screws. The average postoperative bony resorption percentages were 20.3% and 11.2% at 6 months, and 32.4% and 19.3% at 12 months, in group 1 and group 2, respectively. A statistically significant difference was detected between the two groups (P<.05).

CONCLUSIONS

In the arthroscopic iliac crest bone grafting procedure for the treatment of chronic osseous anterior shoulder instability, excellent functional results were obtained after both button fixation and screw fixation techniques. In addition, less graft resorption and no hardware-related complications were detected with suture button fixation technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Biomechanical Evaluation of the 2 Different Levels of Coracoid Graft Positions in the Latarjet Procedure for Anterior Shoulder Instability

Background

In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial.

Purpose

To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure.

Study Design

Controlled laboratory study.

Methods

A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis.

Results

Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P = .51) or 4 to 6 o'clock (1.55 ± 0.68, P = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock (P = .71).

Conclusion

The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance.

Clinical Relevance

An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure.

A Systematic Review of Screw and Suture Button Glenoid Augmentation Constructs

Background

Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed.

Purpose

To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation.

Study Design

Systematic review.

Methods

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss.

Results

Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid.

Conclusion

Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.

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.

The Influence of Glenoid Bone Loss and Graft Positioning on Graft and Cartilage Contact Pressures After the Latarjet Procedure

BACKGROUND

Glenohumeral joint contact loading before and after glenoid bone grafting for recurrent anterior instability remains poorly understood.

PURPOSE

To develop a computational model to evaluate the influence of glenoid bone loss and graft positioning on graft and cartilage contact pressures after the Latarjet procedure.

STUDY DESIGN

Controlled laboratory study.

METHODS

A finite element model of the shoulder was developed using kinematics, muscle and glenohumeral joint loading of 6 male participants. Muscle and joint forces at 90° of abduction and external rotation were calculated and employed in simulations of the native shoulder, as well as the shoulder with a Bankart lesion, 10% and 25% glenoid bone loss, and after the Latarjet procedure.

RESULTS

A Bankart lesion as well as glenoid bone loss of 10% and 25% significantly increased glenoid and humeral cartilage contact pressures compared with the native shoulder (P < .05). The Latarjet procedure did not significantly increase glenoid cartilage contact pressure. With 25% glenoid bone loss, the Latarjet procedure with a graft flush with the glenoid and the humerus positioned at the glenoid half-width resulted in significantly increased humeral cartilage contact pressure compared with that preoperatively (P = .023). Under the same condition, medializing the graft by 1 mm resulted in humeral cartilage contact pressure comparable with that preoperatively (P = .097). Graft lateralization by 1 mm resulted in significantly increased humeral cartilage contact pressure in both glenoid bone loss conditions (P < .05).

CONCLUSION

This modeling study showed that labral damage and greater glenoid bone loss significantly increased glenoid and humeral cartilage contact pressures in the shoulder. The Latarjet procedure may mitigate this to an extent, although glenoid and humeral contact loading was sensitive to graft placement.

CLINICAL RELEVANCE

The Latarjet procedure with a correctly positioned graft should not lead to increased glenohumeral joint contact loading. The present study suggests that lateral graft overhang should be avoided, and in the situation of large glenoid bone defects, slight medialization (ie, 1 mm) of the graft may help to mitigate glenohumeral joint contact overloading.

Evaluation of the inter and intraobserver reproducibility of the "defect coverage index method", a new computed tomography assessment method of sagittal graft positioning in arthroscopic bone block procedures

PURPOSE

To assess the reproducibility of a new 2-dimensional computed tomography (CT) method of assessing graft positioning in arthroscopic bone block procedure.

METHODS

This is a prospective observational study. Twenty-seven patients, (all men, mean [Standard deviation] age at surgery 30.9 [8.49] years) were included. Vertical graft position was assessed on the sagittal view by measuring the amount of glenoid bone defect covered by the graft. The length of the bone defect and the amount of graft covering the defect were measured. Positioning of the graft on the sagittal plane was classified as accurate if the graft covered at least 90% of the defect. Intraobserver and interobserver reproducibility was analyzed using intraclass correlation coefficients (ICC) and Kappa coefficient with 95% confidence.

RESULTS

Excellent intraobserver reproducibility was found, with an ICC of 0.94 (CI 95%, 0.86-0.97). Interobserver reproducibility was good, with the ICC value of 0.71, ranging from 0.45 to 0.86 (CI 95%).

CONCLUSION

This new method of assessing graft positioning in arthroscopic bone block procedures on 2-dimensional computed tomography scans is reliable, with an excellent intraobserver and good interobserver reproducibility.

LEVEL OF EVIDENCE

III.

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.

Arthroscopic Latarjet Learning Curve: Operating Time Decreases After 25 Cases

Purpose

To demonstrate the learning curve associated with the arthroscopic Latarjet procedure and create a timetable to proficiency.

Methods

Using retrospective data of a single surgeon, consecutive patients who had an arthroscopic Latarjet procedure performed between December 2015 and May 2021 were initially reviewed for inclusion in the study. Patients were excluded if medical data were insufficient for accurate surgical time record, their surgery was transitioned to open or minimally invasive, or if their surgery was performed in conjunction with a second procedure for a separate issue. All surgeries were performed on an outpatient basis and sports participation was the most common reason for initial glenohumeral dislocation.

Results

Fifty-five patients were identified. Of these, 51 met the inclusion criteria. Analysis of operative times for all 51 procedures demonstrated that proficiency with the arthroscopic Latarjet procedure was obtained after 25 cases. This number was determined by 2 methods using statistical analysis (P < .05). The average operative time over the course of the first 25 cases was 105.68 minutes and beyond 25 cases was 82.41 minutes. Male gender was seen in 86.3 percent of the patients. The average age of the patients was 28.6 years old.

Conclusions

With continued transition towards bony augmentation procedures for addressing glenoid bone deficiency there is an increasing demand for the arthroscopic bony glenoid reconstruction procedures including the Latarjet procedure. It is a challenging procedure with a substantial initial learning curve. For a skilled arthroscopist there is a significant decrease in overall surgical time after the first 25 cases.

Clinical Relevance

The arthroscopic Latarjet procedure has advantages over the open Latarjet approach; however, it is controversial because it is technically challenging. It is important for surgeons to understand when they can expect to be proficient with the arthroscopic approach.

Recurrence of instability after Latarjet procedure: causes, results and treatment algorithm

Latarjet modifies the anatomy of the shoulder, and subsequent revision surgery is challenging. It is mandatory to determine the cause of recurrence in order to select the best treatment option. A CT scan is needed to measure glenoid track and evaluate coracoid graft status: position, degree of consolidation, and osteolysis. Conservative management can be advocated in selected patients in whom the instability level does not interfere with the activities they wish to perform. Surgical treatment is based on the glenoid track measurement and coracoid graft suitability. The coracoid graft is considered suitable if it preserves the conjoint tendon insertion, does not show osteolysis, and is large enough to reconstruct the glenoid surface. Adding a remplissage is recommended for those cases with a coracoid graft insufficient to convert large off-track Hill-Sachs lesions into on-track. If the coracoid graft is suitable to reconstruct bone defects in terms of size and viability but is poorly positioned or avulsed, graft repositioning can be a valid option. In patients with unsuitable coracoid bone graft, free bone graft is the revision technique of choice. The size of the graft should be large enough to restore the glenoid surface and to convert any off-track Hill-Sachs lesion into on-track. There is a small group of patients in whom bone defects were properly addressed but Latarjet failed due to hyperlaxity or poor soft tissue quality. Extraarticular capsular reinforcement is suggested in this population.

Influence of Graft Positioning during the Latarjet Procedure on Shoulder Stability and Articular Contact Pressure: Computational Analysis of the Bone Block Effect

The Latarjet procedure is the most popular surgical procedure to treat anterior glenohumeral (GH) instability in the presence of large anterior glenoid bone defects. Even though the placement of the bone graft has a considerable influence on its efficacy, no clear indications exist for the best graft position. The aim of this study was to investigate the influence of the medial-lateral positioning of the bone graft on the contact mechanics and GH stability due to the bone block effect. Four finite element (FE) models of a GH joint, with a 20% glenoid bone defect, treated by the Latarjet procedure were developed. The FE models differed in the medial-lateral positioning of the bone graft, ranging from a flush position to a 4.5 mm lateral position with respect to the flush position. All graft placement options were evaluated for two separate shoulder positions. Anterior GH instability was simulated by translating the humeral head in the anterior direction, under a permanent compressive force, until the peak translation force was reached. Joint stability was computed as the ratio between the shear and the compressive components of the force. The lateralization of the bone graft increased GH stability due to the bone block effect after a 3 mm lateralization with respect to the flush position. The increase in GH stability was associated with a concerning increase in peak contact pressure due to the incongruous contact between the articulating surfaces. The sensitivity of the contact pressures to the medial-lateral positioning of the bone graft suggests a trade-off between GH stability due to the bone block effect and the risk of osteoarthritis, especially considering that an accurate and consistent placement of the bone graft is difficult in vivo.

Relationship of the SIRSI Score to Return to Sports After Surgical Stabilization of Glenohumeral Instability

BACKGROUND

Literature is scarce regarding the influence of psychological readiness on return to sports after shoulder instability surgery.

PURPOSE

To evaluate the predictive ability of the Shoulder Instability-Return to Sport after Injury (SIRSI) score in measuring the effect of psychological readiness on return to sports and to compare it between athletes who returned to sports and athletes who did not return to sports.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective analysis was performed of patients who underwent an arthroscopic Bankart repair or a Latarjet procedure between January 2019 and September 2020. Psychological readiness to return to play was evaluated using the SIRSI instrument. Preoperative and postoperative functional outcomes were measured by the Rowe, Athletic Shoulder Outcome Scoring System, and Western Ontario Shoulder Instability Index scores. The predictive validity of the SIRSI was assessed by the use of receiver operating characteristic (ROC) curve statistics. The Youden index was calculated and used to determine a SIRSI score cutoff point that best discriminated psychological readiness to return to sports. A logistic regression analysis was performed to evaluate the effect of psychological readiness on return to sports and return to preinjury sports level.

RESULTS

A total of 104 patients were included in this study. Overall, 79% returned to sports. The SIRSI had excellent predictive ability for return-to-sport outcomes (return to sports: area under ROC curve, 0.87 [95% CI, 0.80-0.93]; return to preinjury sports level: area under ROC curve, 0.96; [95% CI, 0.8-0.9]). A cutoff level of ≥55 was used to determine whether an athlete was psychologically ready to return to sports and to return to preinjury sports level (Youden index, 0.7 and 0.9, respectively). Of those who returned to sports, 76.8% were psychologically ready to return to play, with a median SIRSI score of 65 (interquartile range, 57-80). In comparison, in the group that did not return to sports, only 4.5% achieved psychological readiness with a median SIRSI score of 38.5 (interquartile range, 35-41) (P < .001). Regression analysis for the effect of SIRSI score on return to sports was performed. For every 10-point increase in the SIRSI score, the odds of returning to sports increased by 2.9 times. Moreover, those who did not achieve their preinjury sports level showed poorer psychological readiness to return to play and SIRSI score results.

CONCLUSION

The SIRSI was a useful tool for predicting whether patients were psychologically ready to return to sports after glenohumeral stabilization surgery. Patients who returned to sports and those who returned to their preinjury sports level were significantly more psychologically ready than those who did not return. Therefore, we believe that the SIRSI score should be considered along with other criteria that are used to decide whether the patient is ready to return to sports.

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.

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.

Use of Cannulated Screws for Primary Latarjet Procedures

Background

Rapid consolidation of the bone block is paramount for the success of the Latarjet procedure. Noncannulated screws have shown satisfactory long-term bone block fusion, while cannulated screws are challenged with inferior mechanical properties and fusion rates.

Purpose

To report outcomes of the Latarjet procedure using cannulated screws, notably bone block fusion and complication rates at 3 months, as well as clinical scores and return to sports at minimum 2 years postoperatively.

Study Design

Case series; Level of evidence, 4.

Methods

We reviewed the records of 124 consecutive patients (124 shoulders) who underwent primary Latarjet procedures using cannulated screws between 2015 and 2018. All patients underwent clinical examination at 3 months postoperatively, including range of motion and radiographs to assess graft fusion. The Walch-Duplay score, Rowe score, Subjective Shoulder Value, and visual analog scale for pain were collected at a minimum follow-up of 2 years.

Results

Overall, 9 patients (7%) required reoperation: 7 (6%) had screw removal for unexplained residual pain, 1 (0.8%) had lavage for deep infection, and 1 (0.8%) had evacuation to treat a hematoma. Furthermore, 3 patients (2.4%) had recurrent instability, none of whom underwent reoperation. At 3-month follow-up, all 124 shoulders showed complete radiographic graft fusion, and at 40 ± 11 months (mean ± SD; range, 24-64 months), 88% of patients had returned to sport (109/124), the Walch-Duplay score was 86 ± 14, Rowe was 84 ± 15, Subjective Shoulder Value was 88 ± 11, and visual analog scale for pain was 1 ± 1.

Conclusion

The clinical relevance of these findings is that 4.5-mm cannulated screws are safe and effective for primary Latarjet procedures and grant adequate graft healing, with low recurrence of instability and a high rate of return to sports.

Avaliação do posicionamento dos parafusos na cirurgia de Latarjet: Existe correlação entre paralelismo à glenoide e complicações radiográficas?*

Objetivo Avaliar se o paralelismo dos parafusos com a glenoide na cirurgia de Latarjet interfere no posicionamento do enxerto e verificar a reprodutibilidade de um método de mensuração da posição dos parafusos.

Métodos Estudo retrospectivo, multicêntrico, de pacientes com instabilidade anterior do ombro submetidos à cirurgia de Latarjet modificada e no mínimo 1 ano de seguimento pós-operatório. Dois médicos radiologistas analisaram as imagens tomográficas pós-operatórias, adquiridas em um banco de dados, para avaliação do posicionamento dos parafusos e das complicações radiográficas.

Resultados Foram avaliados 34 pacientes, com idades entre 21 e 60 anos, sendo que um deles tinha acometimento bilateral dos ombros, totalizando 35 ombros avaliados. A avaliação tomográfica dos ângulos de inclinação dos parafusos não apresentou diferença entre os observadores. Houve concordância intra e interobservador para avaliação dos seguintes parâmetros cirúrgicos: posição do enxerto, presença ou não de complicações radiográficas.

Conclusão A técnica descrita para mensuração do paralelismo dos parafusos na cirurgia de Latarjet apresentou uma concordância intra e inter observador muito boa e excelente, respectivamente. O paralelismo do parafuso com a glenoide é recomendado; no entanto, não é condição obrigatória e única para se evitar as complicações radiográficas.

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 Latarjet procedure in competitive athletes younger than 20 years old with a significant glenoid bone loss

PURPOSE

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes younger than 20 years old with a significant glenoid bone loss.

METHODS

Between 2010 and 2017, 60 competitive athletes younger than 20 years old with a significant glenoid bone loss were operated with the Latarjet procedure. Return to sports, range of motion, and the Rowe and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

RESULTS

The mean follow-up was 58 months and the mean age was 16.3 years. Overall, 93% were able to return to sports and 84% returned at the same level. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P <  .001). The total complication rate was 22% and the revision rate was 1.6%. The recurrence rate was 3.3%. The bone block healed in 93% of the cases.

CONCLUSIONS

In competitive athletes younger than 20 years old with a significant glenoid bone loss, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences. However, this procedure is associated with a significant rate of complications and should preferably be performed by experienced surgeons.

Tensioning device increases coracoid bone block healing rates in arthroscopic Latarjet procedure with suture-button fixation

BACKGROUND

There is growing interest in using suture buttons for coracoid fixation to avoid the complications associated with screws during the Latarjet procedure. However, achieving bone block healing is critical for successful shoulder stabilization and return to sport. The purpose of this study was to assess and compare the healing rates and positioning of the coracoid bone block fixed with cortical suture buttons that were either manually tensioned (using a knot pusher) or mechanically tensioned (using a tensioning device) during arthroscopic Latarjet procedures.

METHODS

This prospective, nonrandomized, comparative study enrolled 69 consecutive patients (mean age, 27 years) who underwent an arthroscopic guided Latarjet procedure with suture-button fixation. Hand tensioning was performed in the first 34 shoulders, whereas the next 35 shoulders underwent mechanical tensioning. Twelve patients (17%) had a history of failed Bankart stabilization. The characteristics of the patients in each group in terms of age, sex, type of sport, bone loss, number of previous failed surgical procedures, smoking, and length of follow-up were comparable. Intraoperatively, the tensioning device was set at 100 N successively 3 times until complete immobilization of the bone block was confirmed, as assessed with a probe. The primary outcome measure was coracoid bone block union and position on computed tomography scan images at 6 months' follow-up. Secondary outcome measures included functional outcome scores, shoulder stability, return to sports, and complications at last follow-up.

RESULTS

Overall, the rate of bone block healing was 74% (25 of 34 patients) in the hand-tensioning group and 94% (33 of 35 patients) in the mechanical tensioning group (P = .043). Smoking was an independent risk factor associated with nonunion (P < .001) in each group. Patient age, size of the preoperative glenoid bone defect (<20% or >20%), and a history of surgery were not found to have any influence. The tensioning modality did not affect the bone block position, which was subequatorial in 92% of the cases and flush with the glenoid rim in 92%. At a mean of 34 months of follow-up (range, 24-62 months), 96% of the patients (65 of 69) had a stable shoulder and 87% returned to sports. At final follow-up, no significant difference in clinical scores was noted between the groups; no neurologic or hardware complications were observed.

CONCLUSION

Mechanical tensioning achieves significantly higher healing rates than hand tensioning during the arthroscopic Latarjet procedure with suture-button fixation. The use of a suture-tensioning device is a key step to the suture-button fixation technique during arthroscopic Latarjet procedures. By making the suture-button construct rigid, the tensioning device transforms the initially flexible suture into a "rigid fixation", similar to a bolt (or a rivet).

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%).

Salvage Iliac Crest Bone Grafting for a Failed Latarjet Procedure: Analysis of Failed and Successful Procedures

BACKGROUND

The Latarjet is a successful procedure but can be associated with significant complications, including failure. Iliac crest bone grafting (ICBG) is one of the salvage options for such failure.

PURPOSE

To analyze factors associated with failure or success to restore shoulder stability with ICBG after Latarjet failure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty consecutive patients with recurrence of instability after a Latarjet procedure underwent revision using ICBG. Sixteen patients (80%) with a mean age of 35.0 years (range, 25-55) could be personally reexamined clinically and radiographically (including computed tomography scan) after a mean follow-up of 4.5 years (range, 2-8). Twelve patients had redislocation and 4 had recurrent subluxation after the Latarjet.

RESULTS

Salvage ICBG failed in 7 patients because of recurrent dislocations, with 5 necessitating reoperations: 2 arthrodeses, 1 reverse total shoulder arthroplasty, 1 repeat ICBG, and 1 Hill-Sachs allograft reconstruction and Bankart repair. Factors associated with ICBG failure were multidirectional instability (n = 2), subscapularis insufficiency (n = 1), uncontrolled seizures (n = 1), static inferior glenohumeral subluxation (n = 1), total graft resorption (n = 1), and voluntary dislocation attributed to schizoaffective disorder (n = 1). The initial Latarjet graft was malpositioned (too medial) in 3 of these patients. In patients without recurrent instability (n = 9), reasons for Latarjet failure were graft related: 6 graft avulsions, 2 graft resorptions, and 1 medial graft malpositioning. The mean absolute Constant score (62 to 87 points, P = .012) and relative Constant score (66% to 91%, P = .012), pain (10 to 15 points, P < .001), and Subjective Shoulder Value (31% to 85%, P = .011) in the group with a successful procedure were significantly improved over the preoperative state, and the total Western Ontario Shoulder Instability Index averaged 64% at final follow-up. Except in 1 case of major resorption, mild graft resorption or none was observed in successful procedures. Axial and sagittal graft positioning was good in all 9 patients.

CONCLUSIONS

Salvage ICBG for failed Latarjet procedures failed in 7 of 16 patients. It was successful in patients with clearly graft-related factors of the initial Latarjet procedure. However, patients with unclear instability symptoms, subscapularis insufficiency, inferior subluxation, uncontrolled seizures, or psychological disorders were poor candidates for salvage ICBG, underlining the importance of careful patient selection for the initial Latarjet procedure and for salvage ICBG.

[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.

Early outcomes of the arthroscopic Latarjet procedure in a series of 37 patients with shoulder instability

Background

Anterior shoulder dislocation remains a clinical challenge. This study aimed to assess the graft position and clinical outcomes of the arthroscopic Latarjet procedure and capsular repair for the treatment of recurrent anterior shoulder dislocation with significant glenoid bone loss in 37 patients.

Methods

Between 2017 and 2017, 37 patients underwent arthroscopic Latarjet plus capsular repair procedure for recurrent anterior shoulder dislocation combined with significant glenoid bone loss. In follow-up examinations, Walch-Duplay scores, subjective shoulder value (SSV) scores, Rowe scores, and active range of motion (AROM) were assessed. Three-dimensional computed tomography (CT) was used to evaluate coracoid graft position and bone resorption. A new method of evaluating the position of the coracoid bone block after Latarjet (H-Z method) was developed.

Results

Thirty-seven patients were included in this study. Follow-up ranged from 6 to 36 months postoperatively (with an average of 13 months). No recurrent dislocation occurred at the final follow-up, and there was no significant effect on the AROM (all p > 0.05). Rowe (from 42.2 ± 5.6 to 91.1 ± 3.3), Walch-Duplay (from 31.5 ± 8.0 to 92.6 ± 3.7), and SSV (from 63.9 ± 6.1 to 79.3% ± 5.0%) scores were improved significantly after surgery (all p < 0.001). CT showed that the 29 patients had varying degrees of bone resorption, and 23 recovered to the preinjury level of motional function within 6–12 months after surgery.

Conclusions

In active patients with recurrent anterior shoulder dislocations and significant glenoid bone loss, the arthroscopic Latarjet procedure plus capsular repair could restore shoulder stability satisfactory.

Complications of Superior Capsule Reconstruction for the Treatment of Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs).

METHODS

This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I² statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively.

RESULTS

Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I² = 84.9%). Image-verified graft retear ranged from 8% to 70%, I² = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I² 76.6%) compared to autograft (8%-29%, I² = 66.1%). Reoperation (0%-36%, I² = 73.4%), revision surgeries (0%-21%, I² = 81.2%), medical complications (0%-5%, I² = 0.0%), and infections (0%-5%, I² = 0.0%) were also calculated.

CONCLUSIONS

SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV or better investigations.

Extra-articular Soft Arthroscopic Latarjet Technique: More Versatility and Closer Reproducibility of Classic Latarjet Procedure than Its Intra-articular Counterpart

The recent innovative concept of dynamic anterior stabilization of the shoulder by long head of biceps tendon for anterior gleno-humeral instability management has gained growing popularity among shoulder surgeons. Different techniques using this concept have been reported. Nevertheless, these techniques share common steps of tenotomy, re-routing, trans-subscapularis transfer and bony glenoid fixation of long head of biceps. Lately, a simplified procedure of intra-articular soft arthroscopic Latarjet technique has been introduced to refer to soft tissue tenodesis of long head of biceps to subscapularis tendon by 2 simple stitches of nonabsorbable sutures following Bankart repair. For more technical simplicity and closer reproducibility of gleno-humeral restabilization mechanisms of Latarjet procedure; the current Technical Note describes the extra-articular soft arthroscopic Latarjet technique, whereby long head of biceps is retrieved to the subpectoral region following intra-articular tenotomy; whip-stitched; rerouted deep to pectoralis major; and passed within subscapularis window into the gleno-humeral joint, where it is sutured over itself around upper subscapularis tendon. The currently reported technique offers potential advantages of versatility, steep learning curve, low cost (no hardware), feasibility of concurrent gleno-humeral restabilization procedures, and technical easiness of revision management; however; it is nonanatomic and should be biomechanically and clinically investigated to validate its long-term versatile utility.

Soft Arthroscopic Latarjet Procedure: Technical Note on Biceps Tendon as a Modified Sling for Restoration of Glenohumeral Stability

As an alternate to sling glenohumeral restabilization mechanism of Latarjet procedure, recent different arthroscopic soft-tissue reconstructive techniques have been described for the management of glenohumeral instability. One of these techniques is trans-subscapularis bony tenodesis of long head of biceps (instead of coracoid graft transfer) to the anteroinferior glenoid. For simplification of the latter technique, the current article reports an alternative arthroscopic technique for management of glenohumeral instability in patients with type V SLAP lesion or poor soft-tissue quality of the anterior capsulolabral complex. In this technique, Bankart repair is followed by soft-tissue tenodesis of long head of biceps to upper border of subscapularis tendon by 2 simple stitches of non-absorbable sutures. Compared with previous ones, the currently reported technique is versatile, quick, technically simple, entirely intra-articular, and cost-saving; however, it is nonanatomic and should be investigated in biomechanical and cohort clinical studies to clarify its long-term validity.

Autologous free iliac crest bone grafting of glenoid through the rotator interval using double-barrelled cannula

PURPOSE

The primary aim of this study is to prove that reconstructing the anterior glenoid defect with iliac crest graft arthroscopically using double-barrelled cannula through the rotator interval is safe and prevents both recurrence of instability and the neurovascular injury because subscapularis muscle is not split and procedure is far away from important structures.

METHODS

Thirteen patients with anterior shoulder instability and engaging Hill-Sachs lesion were reviewed after arthroscopic reconstruction of the anterior glenoid with iliac crest autogenous graft. Patient satisfaction and Western Ontario İnstability Score (WOSI) were evaluated on clinical examination. Computed tomography was used to analyse graft position on sagittal and axial planes.

RESULTS

The mean follow-up was 28.7 months (SD 7.1), and age at surgery was 31 years (21 to 64 years). Post-operatively there was only one dislocation due to trauma. There was statistically significant improvement of WOSI scores (p: 0.001). There was not any neurological injury. Graft position on the axial plane was described as flush in 5 cases (41%), lateral in 2 (16%), too lateral in one (8%) and medial in 4 of the cases (33%). Graft position could be accepted as high in only three patients (23%).

CONCLUSION

Arthroscopic reconstruction of glenoid defect using autogenous iliac bone graft, through rotator interval, without splitting subscapularis is safe and effective without any neurological injury, producing substantial graft position and good functional outcomes in patients.

Arthroscopic Latarjet Procedure: Indications, Techniques, and Outcomes

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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.

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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.

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

Recurrence and Revision Rates With Arthroscopic Bankart Repair Compared With the Latarjet Procedure in Competitive Rugby Players With Glenohumeral Instability and a Glenoid Bone Loss <20

BACKGROUND

There is a lack of evidence in the literature comparing outcomes between the arthroscopic Bankart repair and the Latarjet procedure in competitive rugby players with glenohumeral instability and a glenoid bone loss <20%.

PURPOSE

To compare return to sport, functional outcomes, and complications between the arthroscopic Bankart repair and the Latarjet procedure in competitive rugby players with glenohumeral instability and a glenoid bone loss <20%.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between June 2010 and February 2018, 130 competitive rugby players with anterior shoulder instability were operated on in our institution. The first 80 patients were operated on with the arthroscopic Bankart procedure and the other 50 with the open Latarjet procedure. Return to sport, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences, reoperations, and complications were also evaluated.

RESULTS

In the total population, the mean follow-up was 40 months (range, 24-90 months) and the mean age was 24.2 years (range, 16-33 years). Ninety-two percent of patients were able to return to rugby, 88% at their preinjury level of play. Eighty-nine percent of patients in the Bankart group and 87% in the Latarjet group returned to compete at the same level (P = .788). No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and ASOSS scores showed statistical improvement after operation (P < .01). No significant difference in functional scores was found between the groups The Rowe score in the Bankart group increased from a preoperative mean (± SD) of 41 ± 13 points to 89.7 points postoperatively, and in the Latarjet group, from a preoperative mean of 42.5 ± 14 points to 88.4 points postoperatively (P = .95). The ASOSS score in the Bankart group increased from a preoperative mean of 53.3 ± 3 points to 93.3 ± 6 points postoperatively, and in the Latarjet group, from a preoperative mean of 53.1 ± 3 points to 93.7 ± 4 points postoperatively (P = .95). There were 18 recurrences (14%). The rate of recurrence was 20% in the Bankart group and 4% in the Latarjet group (P = .01). There were 15 reoperations (12%). The rate of reoperation was 16% in the Bankart group and 4% in the Latarjet group (P = .03). There were 6 complications (5%). The rate of complications was 4% in the Bankart group and 6% in the Latarjet group (P = .55). The proportion of postoperative osteoarthritis was 10% in the Bankart group (8/80 patients) and 12% (6/50 patients) in the Latarjet group (P = .55).

CONCLUSION

In competitive rugby players with glenohumeral instability and a glenoid bone loss <20%, both the arthroscopic Bankart repair and the Latarjet procedure produced excellent functional outcomes, with most athletes returning to sport at the same level they had before the injury. However, the Bankart procedure was associated with a significantly higher rate of recurrence (20% vs 4%) and reoperation (16% vs 4%) than the Latarjet procedure.

A New Guide for the Arthroscopically Assisted Latarjet Procedure

The Latarjet procedure is a commonly used treatment for recurrent shoulder instability. However, its neurological complication rate has been reported to be as high as 10%. During the Latarjet procedure, the neurovascular structures are relocated inferiorly and medially. I hypothesized that the risk of nerve injury would be reduced by assisting the inferior-medial relocation of the neurovascular structures intraoperatively.

Methods

Seventeen consecutive patients with shoulder instability accompanied by glenoid bone loss were treated with an all-arthroscopic Latarjet procedure assisted by the novel low-profile SaSumata (SS) guide. The SS guide is inserted through a portal made above the coracoid process and is attached to the coracoid process by 2 pre-fix screws (i.e., temporary pre-fixation screws). Unlike previous techniques, the SS guide is not shuttled from 1 portal to the other to redirect the bone graft from the donor site to the recipient site; instead, it remains attached to the graft throughout the procedure. The SS guide brings the coracoid graft along an inferior-medial trajectory, pushing aside the neurovascular structures with the help of a switching stick. Owing to its semicircular pronged head, the SS guide holds the graft until the pre-fix screws are exchanged with permanent screws. All patients were clinically assessed and underwent computed tomography (CT) scans.

Results

This maneuver was performed arthroscopically in 17 patients, with no conversion to open surgery and no neurological injuries. No patient had recurrence of dislocation after follow-up for a minimum of 24 months. The mean Subjective Shoulder Value was 87.5% ± 11.7%. The mean Rowe score was 88 ± 15.7. The bone block was optimally positioned between 3 o'clock and 5 o'clock and was flush with the glenoid facet in 16 of the 17 patients. There was 1 fracture of the bone block. The mean operation time after the first 5 patients was 125 ± 23 minutes.

Conclusions

The SS guide was a useful tool for performing the arthroscopically assisted Latarjet procedure for recurrent anterior shoulder instability, with good functional results.

Level of Evidence

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

High Rate of Return to Sports and Low Recurrences With the Latarjet Procedure in High-Risk Competitive Athletes With Glenohumeral Instability and a Glenoid Bone Loss <20

Purpose

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%.

Methods

All the included patients were operated between 2010 and 2016. The inclusion criteria were competitive athletes with anterior glenohumeral instability, a glenoid bone defect <20% who participated in contact sports, forced overhead sports, or had a previous failed Bankart repair and had a minimum 2 years’ follow-up. Return to sports, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

Results

A total of 65 athletes were included in the study. The mean follow-up was 53 months (±13), and the mean age was 23.9 years (range, 16-31 years). Overall, 94% were able to return to sports and 84% returned at the same level. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between primary and revision cases. The total complication rate was 11% and the revision rate was 1.5% The recurrence rate was 4.6%. The bone block healed in 95% of the cases.

Conclusions

In high-risk competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences

Level of Evidence

Therapeutic case series; Level of evidence, IV

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.

Similar Results in Return to Sports, Recurrences, and Healing Rates Between the Classic and Congruent-Arc Latarjet for Athletes With Recurrent Glenohumeral Instability and a Failed Stabilization

PURPOSE

To compare the return-to-sport rate, functional outcomes, and complications of the "classic Latarjet" surgery with those of the "congruent arc Latarjet" surgery in athletes with recurrent glenohumeral instability and failed previous stabilization procedures.

METHODS

All the included patients were operated between May 2009 and April 2017. The inclusion criteria were athletes with recurrent anterior glenohumeral instability, a glenoid bone defect greater than 20%, at least 1 previous failed stabilization surgery operated with the classic or the congruent-arc Latarjet procedures, and a minimum 2 years of follow-up. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale for pain, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications were also evaluated.

RESULTS

A total of 135 athletes were included in the study (55 patients were operated with the classic technique and 80 with the congruent arc technique). The mean follow-up was 40.3 months (range, 24-88 months) and the mean age was 26.5 years (range, 18-45 years). Overall, 87% were able to return to sports and 92% returned at the same level. No significant difference regarding return to sports was found between the groups. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, visual analog scale, and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between patients operated with the classic and congruent arc procedures. There were 6 recurrences (4%). There was no significant difference in the recurrence rate between groups. The bone block healed in 92% of the cases.

CONCLUSIONS

In athletes with recurrent anterior glenohumeral instability and a failed previous operative repair, the Latarjet procedure produced excellent functional outcomes and most athletes returned to sport at their preinjury level with a very low rate of recurrences, regardless of whether the Latarjet was performed with the classic or with the congruent arc technique.

LEVEL OF EVIDENCE

Retrospective comparative study; Level of evidence, 3.

Revision guided suture-button bone block stabilization of the shoulder in the presence of significant retained glenoid metalwork

Aim

Positioning and fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, can be challenging. We present the results of a series of patients who underwent a revision bone block procedure secured with double suture buttons using a drill guide system, the position of which was calculated from a preoperative computed tomography (CT) scan.

Materials and methods

We undertook a revision bone block stabilization of the shoulder, using a guided double suture-button fixation, in 10 patients with significant retained glenoid metalwork from previous procedures. A preoperative CT scan was used to determine a position for the guide to allow a safe drill trajectory that would avoid any retained metalwork. A coracoid transfer was undertaken in 4 patients and an Eden-Hybinette in 6. Patients were assessed preoperatively and at final follow-up clinically and using the Oxford Shoulder Instability Score and the Subjective Shoulder Value score. Bone block position and healing was assessed by a CT scan at 6 months. The median follow-up was 36 months (range, 24-47 months).

Results

There were 3 female and 7 male patients with a median age of 24.5 years (17-49 years). At final follow-up, the mean Oxford Shoulder Instability Score had decreased from 25.9 (range, 21-35) to 5.8 (range, 3-14) (P < .005). The mean Subjective Shoulder Value score had risen from 87.1 (range, 10-60) to 80 (range, 60-90) (P < .05). All of the patients considered their shoulder to be stable apart from 1 patient. There had been no redislocations. The bone block positioned in the glenoid lower quadrant had healed for all of the patients on CT at 6 months.

Conclusion

Guided suture-button fixation of the bone block during revision anterior stabilization of the shoulder, in the presence of significant retained glenoid metalwork, provides a satisfactory outcome in terms of shoulder stability, graft position, and healing.

Are the Classic and the Congruent Arc Latarjet Procedures Equally Effective for the Treatment of Recurrent Shoulder Instability in Athletes?

BACKGROUND

There is a lack of evidence in the literature comparing outcomes between the classic and the congruent arc Latarjet procedures in athletes.

PURPOSE

To compare return to sports, functional outcomes, and complications between the classic and the congruent arc Latarjet procedures in athletes with recurrent glenohumeral instability.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between June 2009 and June 2017, 145 athletes with recurrent anterior glenohumeral instability underwent surgery with the Latarjet as a primary procedure in our institution. The classic procedure was used in 66 patients, and the congruent arc method was used in 79 patients. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale (VAS) for pain in sports activity, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed with computed tomography.

RESULTS

In the total population, the mean follow-up was 41.3 months (range, 24-90 months) and the mean age was 25.3 years (range, 18-45 years). In total, 90% of patients were able to return to sports; of these, 91% returned at their preinjury level of play. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, VAS, and ASOSS scores showed statistical improvement after operation (P < .001). The Rowe score increased from a preoperative mean of 42.8 points to a postoperative mean of 95.2 points (P < .01). Subjective pain during sports improved from 3.2 points preoperatively to 0.7 points at last follow-up (P < .01). The ASOSS score improved significantly from a preoperative mean of 46.4 points to a postoperative mean of 88.4 points (P < .01). No significant differences in shoulder ROM and functional scores were found between patients who received the classic vs congruent arc procedures. There were 5 recurrences (3.5%): 3 dislocations (2%) and 2 subluxations (1%). No significant difference in the recurrence rate was noted between groups. The bone block healed in 134 cases (92%).

CONCLUSION

In athletes with recurrent anterior glenohumeral instability, the Latarjet procedure produced excellent functional outcomes. Most athletes returned to sports at their preinjury level, and the rate of recurrence was very low, regardless of whether the patients received surgery with the classic or congruent arc technique.

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.

Long-term Results of the Arthroscopic Bankart Repair for Recurrent Anterior Shoulder Instability in Patients Older Than 40 Years: A Comparison With the Open Latarjet Procedure

BACKGROUND

Long-term results of the arthroscopic Bankart repair in patients older than 40 years are unknown and may be favorable in terms of postoperative glenohumeral arthritis as opposed to the long-term results of the open Latarjet procedure in patients older than 40 years.

PURPOSE

To analyze our long-term results of the arthroscopic Bankart repair for recurrent anterior shoulder instability in patients older than 40 years of age and to compare these results with previously published long-term results of the Latarjet procedure in a cohort of similar age.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 35 consecutive patients (36 shoulders) with a mean age of 47 years (range, 40-69) at time of the arthroscopic Bankart repair were studied at a mean 13.2 years (range, 8-18) after surgery. Clinical and radiographic results were then compared with those of our previous study of 39 consecutive patients (40 shoulders) of a same age group who had been treated for the same pathology with an open Latarjet procedure.

RESULTS

Six shoulders (17%) sustained a recurrent shoulder dislocation after a mean 5.3 years; subluxation occurred in 3 shoulders (8%); and apprehension persisted in 3 shoulders (8%). Revision surgery was performed in 8 patients (22%): 2 Bankart and 6 open Latarjet. The relative preoperative Constant score and Subjective Shoulder Value were significantly improved (P < .001) at final follow-up. Arthropathy of stabilization was advanced in the shoulders of 16 patients (47%) and had progressed by at least 2 grades in 21 patients (62%). There were significantly higher rates of redislocation and subluxation when compared with the open Latarjet procedure (9 vs 3; P = .037), and the mean final Subjective Shoulder Value was significantly lower in the Bankart group (86% vs 91%; P = .011). There were no significant differences in final advanced arthropathy (16 vs 14; P = .334) and revision rates (8 vs 7; P = .409) when compared with the Latarjet procedure.

CONCLUSION

Arthroscopic Bankart repair for recurrent anterior shoulder instability in patients older than 40 years was associated with reliable pain relief and patient satisfaction similar to that after the open Latarjet procedure. Restoration of stability was significantly less successful and development of arthropathy no better than the open Latarjet procedure in patients older than 40 years.

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.