All-arthroscopic, guided Eden-Hybbinette procedure using suture-button fixation for revision of failed Latarjet

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.

Arthroscopic Autologous Iliac Bone Grafting With Double-Row Elastic Fixation and Double Antirotating Anchors for Recurrent Anterior Shoulder Dislocation With Massive Glenoid Bone Defect

The management of recurrent anterior shoulder dislocations with massive glenoid bone defects typically involves arthroscopic intervention. Autologous iliac bone grafting with double-row elastic fixation reportedly yields excellent outcomes. In this article, we introduce a specialized technique for iliac bone grafting that uses double-row elastic fixation and double antirotating anchors. Implementation of this technique prevents the occurrence of iliac graft rotation.

Surgical considerations for glenoid bone loss in anterior glenohumeral instability: a narrative review

PURPOSE

Treatment algorithms may consider many factors like glenoid and humeral bone loss, or scores such as the instability severity index score (ISIS). As most studies only evaluate a part of these factors, there is still no evidence-based consensus estalished. Our study aims to summarize the surgical options for treatment of glenoid bone loss (GBL) in anterior shoulder instability.

METHODS

Based on the current available literature, surgical options including Bankart repair and glenoid bone augmentation should be considered while taking into consideration the degree of bone loss which has been divided into < 10%, 10-20% and > 20%.

RESULTS

There are many new techniques evolving including arthroscopic anatomic glenoid reconstruction with bone blocks.

CONCLUSION

Future long-term outcome studies and randomized controlled trials comparing established techniques will be needed for new evidence-based treatment algorithms.

Arthroscopic Posterior Glenoid Reconstruction With Distal Clavicle Bone-Block

Posterior glenoid bone loss is a potential cause for failure in arthroscopic capsulolabral repair. Although multiple techniques have been described to reconstruct posterior bone defects, they do not reliably yield improved patient outcomes and have high complication rates. We present a technique to reconstruct posterior glenoid bone loss using a distal clavicle autologous bone graft harvested by a mini-open approach and secured arthroscopically with suture buttons. The graft is positioned extra-articularly by repairing the posterior labral complex with a knotless fixation using labral tape.

Arthroscopic Distal Clavicle Bone Bock Combined With Hill-Sachs Remplissage for Primary Anterior Shoulder Instability Treatment

Arthroscopic distal clavicle transfer is an effective option to treat anterior shoulder instability with glenoid bone loss. The use of this free bone graft in an all-inside procedure, with a cortical button fixation makes the construct simpler to perform and allows to be combined with a Hill-Sachs Remplissage to address humeral bone defect. The morbidity of the donor site is low and provide the biologic capacity of an autograft. We report a step-by-step procedure, and the rationale are discussed.

Surgical management of recurrent instability following Latarjet procedure - A systematic review of salvage procedures

Background

Failed Latarjet procedures pose a surgical challenge due to complex anatomical issues. This systematic review investigates salvage techniques for recurrent instability following a Latarjet procedure.

Methods

A search was conducted on MEDLINE and PubMed Central following the methodology registered to International Prospective Register of Systematic Reviews. Inclusion criteria focused on identifying revision procedures following a Latarjet procedure. Exclusion criteria filtered out irrelevant studies, such as those focused on Bankart procedures. After a multistage selection process, 10 eligible studies were included for data extraction.

Results

The most frequently utilized technique for salvage was variations of the Eden-Hybinette procedure. Complications associated with these salvage procedures include graft-related problems and donor site morbidity. Patients reported significant improvements in multiple patient-reported outcome scores, and multiple studies indicated high rates of return to sports activities. However, it is noteworthy that there remains an average recurrence rate of 7%.

Discussion

The review emphasizes the limited therapeutic options available largely due to shoulder anatomy alterations. Despite promising trends in patient-reported outcomes, recurrence remains possible post-salvage surgeries.

Conclusion

Addressing recurrent instability after a Latarjet procedure continues to be a unique surgical challenge. However, this systematic review highlights encouraging indications, with positive trends evident in patient-reported outcomes.

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.

Recurrent Instability after the Latarjet Procedure

The Latarjet procedure is a favored approach for managing chronic and recurrent dislocation, especially in the presence of bone loss. Although generally yielding excellent results, the procedure carries a 15 to 30% complication rate. Although recurrent instability is a major concern, various complications such as infection, nerve injuries, and hardware impingement can also necessitate revision after a Latarjet procedure. Strategies for addressing this issue include glenoid bone grafting, using autogenous bone grafts from the iliac crest or distal clavicle, and allografts, with fresh lateral distal tibial allografts offering advantages because of their osteochondral nature. In addition, soft-tissue procedures offer another solution for recurrent instability, suitable for patients lacking substantial bone loss or those experiencing multidirectional instability. This review aims to provide a comprehensive overview of the causes and management strategies for recurrent instability following a failed Latarjet procedure.

Remodeling process and clinical outcomes following all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and 1-tunnel double Endobutton fixation system

BACKGROUND

Arthroscopically modified Eden-Hybinette procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments, a double Endobutton fixation system has been used clinically to secure bone graft to the glenoid rim placed through a specifically designed guide. The purpose of this report was to evaluate clinical outcomes and serial glenoid remodeling process following all-arthroscopic anatomical glenoid reconstruction using autologous iliac crest bone grafting technique through 1-tunnel fixation.

METHODS

Forty-six patients with recurrent anterior dislocations and significant glenoid defects greater than 20% underwent arthroscopic surgery with a modified Eden-Hybinette technique. Instead of firm fixation, autologous iliac bone graft was fixed to the glenoid by double Endobutton fixation system through 1-tunnel placed in the glenoid surface. Follow-up examinations were performed at 3, 6, 12, and 24 months. The patients were followed up for a minimum of two years using the Rowe score, the Constant score, the Subjective Shoulder Value, and the Walch-Duplay score; patient satisfaction with the procedure outcome was also rated. Graft positions, healing, and absorption were evaluated postoperatively with computed tomography imaging.

RESULTS

At a mean follow-up of 28 months, all patients were satisfied and had a stable shoulder. The Constant score improved from 82.9 to 88.9 points (P ＜ .001), the Rowe score, improved from 25.3 to 89.1 points (P < .001), the Subjective Shoulder Value improved from 31% to 87% (P < .001), and the Walch-Duplay score improved from 52.5 to 85.7 points (P ＜ .001). One donor-site fracture occurred during the follow-up period. All grafts were well-positioned and achieved optimal bone healing with zero excessive absorption. The preoperative glenoid surface (72.6% ± 4.5%) increased significantly immediately after surgery to 116.5% ± 9.6% (P ＜ .001). After a physiological remodeling process, the glenoid surface remained significantly increased at the last follow-up (99.2% ± 7.1%) (P ＜ .001). The glenoid surface area appeared to decrease serially when compared between the first 6 months and 12 months postoperatively, while there was no significant interval change between 12 and 24 months postoperatively.

CONCLUSION

Patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through one-tunnel fixation system with double Endobutton. Graft absorption mostly occurred on the edge and outside the ''best-fit'' circle of the glenoid. Glenoid remodeling occurred within the first year after all-arthroscopic glenoid reconstruction with an auto iliac bone graft.

Arthroscopic Remnant Coracoid Autograft for Revision of the Failed Latarjet Procedure With Persistent Glenoid Bone Loss

Recurrence of anterior instability after a Latarjet procedure with persistent glenoid bone loss can be related to coracoid bone block resorption, migration, or malposition. Multiple options are available to address anterior glenoid bone loss, including autograft bone transfers (such as iliac crest graft, distal clavicle autograft) or allografts (distal tibia allograft). Here, we present the use of the remnant coracoid process as an option for consideration in the treatment of glenoid bone loss after failed Latarjet procedure with persistent glenoid bone loss. The remnant coracoid autograft is harvested and transferred inside the glenohumeral joint, through the rotator interval, and fixed using cortical buttons. This arthroscopic procedure includes using 1) glenoid and coracoid drilling guides to optimize graft positioning and making the procedure more reproducible and safer and 2) a suture tensioning device to provide intraoperative graft compression and ensure bone graft healing.

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 Autologous Iliac Crest Grafting Results in Similar Outcomes and Low Recurrence Compared to Remplissage Plus Bankart Repair for Anterior Shoulder Instability With Bipolar Bone Defects

PURPOSE

To compare the functional outcomes, range of motion (ROM), recurrence rates, and complication rates of arthroscopic autologous iliac crest grafting (AICG) and Remplissage plus Bankart repair (RB) for anterior shoulder instability with bipolar bone defects.

METHODS

This study enrolled patients undergoing arthroscopic AICG or RB with 13.5-25% glenoid bone defect combined with Hill-Sachs lesion between January 2013 and April 2020, who had a minimum 2-year follow-up. Patient-reported outcomes were evaluated by Subjective Shoulder Value (SSV), Oxford Shoulder Instability Score (OSIS), Rowe score, Constant score, and visual analog scale (VAS) for pain. Active ROM, return to sports, recurrence, self-reported apprehension, and complications were recorded.

RESULTS

This study included 60 patients, including 28 AICG (Group A) and 32 RB (Group R). Mean glenoid bone defect was similar (17.7% ± 3.1% vs 16.6% ± 2.4%; P = .122). Both groups showed significant postoperative improvement in Rowe score, SSV, OSIS, and Constant score. No significant difference was found in postoperative Rowe Score (87.7 vs 85.2; P = .198). A total of 20/28 (71.4%) patients in Group A versus 26/32 (81.3%) patients in Group R met the Patient Acceptable Symptomatic State determined by VAS pain score (P = .370). Both groups showed high return-to-sports rates (67.8% vs 71.8%; P = .735) and slightly decreased ROM. There were two cases of recurrence in Group A versus one in Group R (P = .594). Group R had insignificantly higher positive self-reported apprehension rate (40.6% vs 17.9%; P = .055).

CONCLUSION

For anterior shoulder instability with bipolar bone defects, both arthroscopic AICG and RB can result in satisfactory clinical outcomes, good postoperative ROM, and low recurrence and complication rates.

LEVEL OF EVIDENCE

Level III; retrospective cohort study.

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.

Anterior glenoid bone reconstruction and anterior latissimus transfer for failed Latarjet associated with irreparable subscapularis tear

Background

Management of combined persistent anterior glenoid bone deficiency with irreparable subscapularis tear can be very complicated and challenging especially if associated with arthritis. The objective of this study was to report the outcome of combined reconstruction of the anterior glenoid with bone autograft or allograft with additional anterior latissimus transfer to reconstruct irreparable subscapularis tear with or without humeral head replacement.

Methods

Nineteen patients (average age 29 years old) who underwent open anterior glenoid bone reconstruction with iliac crest bone autograft or ostechondral bone allograft (distal tibia or glenoid allograft), with anterior latissimus transfer to reconstruct irreparable subscapularis tear with or without humeral head replacement were included in this study. Outcome measures included preoperative and postoperative pain score, visual analog scale, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, and Constant Score.

Results

Out of the 19 patients, 5 patients underwent humeral resurfacing arthroplasty. Anterior glenoid bone reconstruction was performed with iliac crest bone autograft in 8 patients, glenoid osteochondral allograft in 7 patients, and tibial plafond in 4 patients. At mean 31-month follow-up of (13-63 months), 15 patients (79%) considered their shoulder stable and were able to return to their work and 14 (74%) patients returned to their sport activity. Redislocation had occurred in 1 of the 18 shoulders (5%), subluxation had occurred in 3 patients (16%) of the shoulders and apprehension was reported for 4 patients, 21% of the operated shoulders. All outcome measures showed significant improvement compared to before surgery. No intraoperative or immediate postoperative complications were observed. Four patients (21%) had to be revised to reverse shoulder arthroplasty.

Conclusion

The combination of anterior latissimus transfer, anterior glenoid bone grafting with or without humeral head resurfacing is an effective salvage surgical reconstruction that can stabilize shoulders in the setting of recurrent anterior instability after a failed Latarjet with an irreparable subscapularis tear. This could be a potential alternative reconstruction option that might be offered to patients with this difficult problem. Long-term outcome is needed to better evaluate the validity of this technique.

Editorial Commentary: Buttoning Up After Recurrent Anterior Shoulder Instability: The Eden-Hybinette Procedure Is an Effective Salvage After Failed Latarjet

Operative management of anterior glenohumeral dislocation can confer significant improvements in subjective shoulder function, pain, and overall stability. Although the coracoid-based Latarjet procedure has long been considered the ultimate treatment for complex anterior shoulder instability with glenoid or bipolar bone loss, few authors have considered the unimaginable question: what do you do when a patient fails Latarjet? A modified arthroscopic technique of the Eden-Hybinette procedure allows for revision anterior glenoid augmentation of critical glenoid bone loss with autologous tricortical iliac crest, while suture button fixation may obviate hardware complications previously seen with bicortical screw fixation. Although distal tibial allograft provides excellent congruity, viable articular cartilage, and no harvest site morbidity, financial costs and graft availability must also be considered. With favorable patient-reported outcomes, excellent rates of radiographic union, and reliable return to sport, the Eden-Hybinette procedure with suture button-based construct offers a viable alternative for patients with advanced glenoid bone loss (>20%) or revision scenarios.

Failed Latarjet Treated With Full Arthroscopic Eden-Hybinette Procedure Using Two Cortical Suture Buttons Leads to Satisfactory Clinical Outcomes and Low Recurrence Rate

PURPOSE

To report clinical and radiologic outcomes of arthroscopic Eden-Hybinette using 2 cortical suture buttons in a series of patients with previous failed Latarjet and persistent glenoid bone loss.

METHODS

Between 2015 and 2019, patients with recurrent anterior instability after failed Latarjet underwent arthroscopic Eden-Hybinette procedure using 2 cortical buttons for graft fixation. Exclusion criteria were open and primary Eden-Hybinette and less than one year follow-up. Functional assessment was performed using Rowe and Walch-Duplay scores, subjective shoulder value, visual analog scale, and degree of satisfaction. Iliac crest bone graft placement and healing were assessed postoperatively with computed tomography imaging.

RESULTS

A total of 17 patients with a mean age of 28 years (range, 21-43 years) at time of revision were included. The mean glenoid bone loss was 23% (range, 18%-42%). Medium or deep Hill-Sachs lesion (Calandra 2 and 3) was present in 65% of cases. At a mean follow-up of 3 ± 1.6 years, all but 1 patient (94%) considered their shoulder stable, and 15 patients (88%) were satisfied or very satisfied. The subjective shoulder value increased from 51% to 87% (P < .05), the Walch-Duplay increased from 23 to 86 points (P < .05), and Rowe scores improved from 30 to 92 points (P < .05). Apprehension was still positive in 3 patients (17.6%), with this percentage being greater in the presence of Hill-Sachs Calandra 3 (P = .02). Postoperative computed tomography scans showed optimal bone autograft position in all patients (below the glenoid equator and flush to the glenoid rim). Iliac crest bone graft healed to the anterior glenoid neck in 16 shoulders (94%). The rate of recurrent instability was 11.7% but only 1 patient required revision surgery (5.8%).

CONCLUSIONS

Arthroscopic Eden-Hybinette using 2 cortical buttons leads to satisfactory clinical outcomes and a low recurrence rate after failed Latarjet, allowing successful reconstruction of the anterior glenoid rim and simultaneous treatment of capsular deficiency and humeral bone loss.

LEVEL OF EVIDENCE

Therapeutic, level IV, retrospective case series.

Free bone grafting improves clinical outcomes in anterior shoulder instability with bone defect: a systematic review and meta-analysis of studies with a minimum of 1-year follow-up

BACKGROUND

Evidence on the efficacy and safety of the free bone grafting in treating anterior shoulder instability is limited. The purpose of this study was to systematically evaluate the clinical and imaging results of free bone grafting in treating anterior shoulder instability with glenoid bone defect and to explore the incidence of complications in clinically relevant subgroups.

METHODS

This systematic review was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched up to January 29, 2021, for studies that had reported on free bone grafting in treating anterior shoulder instability with glenoid bone defect with a minimum of 1-year follow-up. Two researchers independently screened studies and extracted data. A random-effects model was used to pool data on clinical function scores, imaging results, and incidence of complications (recurrent instability and non-instability-related complications). Meta-regression analysis was used to evaluate the incidence of complications in different subgroups and investigate the sources of heterogeneity.

RESULTS

A total of 29 studies were included in the meta-analysis, comprising 840 patients (845 shoulders) with average ages ranging from 21 to 34.6 years. Compared with preoperatively, free bone grafting increased the postoperative Rowe score, American Shoulder and Elbow Surgeons score, Constant score, Subjective Shoulder Value, and Oxford Shoulder Instability Score by 53.16, 31.80, 20.81, 38.63, and 4.07 points, respectively, and reduced the visual analog scale pain score by 3 points on average. During the postoperative follow-up period, the rates of return to sport and return to preoperative levels were 84.2% and 73.1%, respectively. The imaging results showed that the free bone healing rate was 98.9% and the incidence of osteoarthritis was 10.9%. The incidence rates of recurrent instability and non-instability-related complications were 3.4% and 5.6%, respectively. Meta-regression analysis showed no evidence of effect modification by the year, follow-up time, proportion of male patients, autograft or allograft, and arthroscopy or open surgery on the incidence of complications. Subgroup analysis showed that the incidence rates of recurrent instability for open surgery, arthroscopy, allograft, autograft, Latarjet revision, and non-bone block revision were 4.1%, 2.3%, 1.5%, 4.4%, 10.3%, and 3.5%, respectively.

CONCLUSION

The application of free bone grafting in treating anterior shoulder instability with glenoid bone defect can effectively improve shoulder joint function and is associated with a high return-to-sport rate and a low overall recurrence rate, but there were some differences in the complications of recurrent instability and non-instability-related complications among the subgroups. Given that these results need to be confirmed via head-to-head comparisons, we recommend that future clinical and biomechanical studies focus on comparing and investigating the advantages and disadvantages of different surgical approaches, thus providing a basis for orthopedic surgeons to make reliable choices.

Anterior Shoulder Instability Part III-Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up-An International Consensus Statement

PURPOSE

The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability.

METHODS

A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

RESULTS

The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction.

CONCLUSION

Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up.

LEVEL OF EVIDENCE

Level V, expert opinion.

Arthroscopic "Double-Inlay" Eden-Hybinette Procedure with Modified Suture Button Fixation for the Revision of Failed Bristow-Latarjet

Bristow-Latarjet procedure has been widely regarded as a reliable and satisfactory operation for recurrent anterior glenohumeral instability, especially for patients with significant glenoid bone loss or high sports demand. Once failed, however, the subsequent revision surgery could be challenging. Eden-Hybinette procedure is the most common operation for revision of failed Bristow-Latarjet. It can perfectly restore the bone defect of the failed Bristow-Latarjet by harvesting a proper size of iliac bone block. Furthermore, several studies have shown the advantages of using suture button fixation in the revision surgery for failed Bristow-Latarjet procedure. However, the potential inferior biomechanical strength of suture button fixation is still a concern. This Technical Note introduced an arthroscopic "double-inlay" Eden-Hybinette procedure with modified suture button fixation for the revision of failed Bristow-Latarjet. With its "quadruple" reinforcement effect, this procedure can achieve an excellent biomechanical strength of fixation.

Arthroscopic Distal Clavicular Autograft for Congruent Glenoid Reconstruction

Arthroscopic distal clavicular autograft (DCA) is effective in shoulder instability with glenoid bone loss. The original technique uses an osteochondral autograft, fixed with screws or suture anchors. We developed a modified procedure called "congruent arc DCA" characterized by (1) use of drilling guides to optimize graft positioning and make the all-arthroscopic procedure safer and reproducible; (2) rotation of the DCA of 90° to reach a congruent arc with its undersurface; (3) fixation of the graft with cortical buttons to simplify its intra-articular passage, avoid hardware problems, and facilitate possible revision surgery; and (4) intraoperative use of a suture tensioner to achieve satisfactory compression of the graft and increase its consolidation.

Arthroscopic bone block stabilisation procedures for glenoid bone loss in anterior glenohumeral instability: A systematic review of clinical and radiological outcomes

INTRODUCTION

Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation.

METHODS

This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20^th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5-37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0-18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92-100% in 8 out of 10 studies at mean follow up range 6-78.7 months but two reported lower rates ranging from 58.3-84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10-16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation.

CONCLUSION

Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods.

LEVEL OF EVIDENCE

IV; systematic review.

Editorial Commentary: A Functional Capsule, Not the Type of Bone Graft, Determines Outcome After Shoulder Stabilization in Cases of Anterior Glenoid Bone Deficiency

Many clinical results of surgical treatment of recurrent anterior shoulder instability confirm the importance of anterior bone grafting of the glenoid defect. Some studies even propose to perform a graft, even when there is no bony defect. Short- and middle-term studies report comparable results between bone grafting and Latarjet procedure. But one of the main questions that still remains is the quality and efficiency of the capsule. If Latarjet is the gold standard in anterior shoulder stabilization with very good results at very long follow-up, it is probably because the capsule is replaced by the conjoint tendon. Because Latarjet is a difficult surgery and has some complexes and/or challenging complications and because it is a nonanatomic procedure, there is a true place for anterior bone grafting. This anterior grafting under arthroscopy provides excellent results, but it is mandatory to be sure that the shoulder capsule is working. Clinical, functional, and imaging studies of this capsule need to be performed for a better understanding of the unstable shoulder function and treatment.

Failed Latarjet procedure: a systematic review of surgery revision options

Background

Revision surgery after the Latarjet procedure is a rare and challenging surgical problem, and various bony or capsular procedures have been proposed. This systematic review examines clinical and radiographic outcomes of different procedures for treating persistent pain or recurrent instability after a Latarjet procedure.

Methods

A systematic review of the literature was performed using the Medline, Cochrane, EMBASE, Google Scholar and Ovid databases with the combined keywords “failed”, “failure”, “revision”, “Latarjet”, “shoulder stabilization” and “shoulder instability” to identify articles published in English that deal with failed Latarjet procedures.

Results

A total of 11 studies (five retrospective and six case series investigations), all published between 2008 and 2020, fulfilled our inclusion criteria. For the study, 253 patients (254 shoulders, 79.8% male) with a mean age of 29.6 years (range: 16–54 years) were reviewed at an average follow-up of 51.5 months (range: 24–208 months).

Conclusions

Eden–Hybinette and arthroscopic capsuloplasty are the most popular and safe procedures to treat recurrent instability after a failed Latarjet procedure, and yield reasonable clinical outcomes. A bone graft procedure and capsuloplasty were proposed but there was no clear consensus on their efficacy and indication.

Level of evidence

Level IV

Trial registration PROSPERO 2020 CRD42020185090—www.crd.york.ac.uk/prospero/

Anterior and posterior glenoid bone augmentation options for shoulder instability: state of the art

Bony lesions are highly prevalent in anterior shoulder instability and can be a significant cause of failure of stabilisation procedures if they are not adequately addressed. The glenoid track concept describes the dynamic interaction between the humeral head and glenoid defects in anterior shoulder instability. It has been beneficial for understanding the role played by bone defects in this entity. As a consequence, the popularity of glenoid augmentation procedures aimed to treat anterior glenoid bone defects; reconstructing the anatomy of the glenohumeral joint has risen sharply in the last decade. Although bone defects are less common in posterior instability, posterior bone block procedures can be indicated to treat not only posterior bony lesions, attritional posterior glenoid erosion or dysplasia but also normal or retroverted glenoids to provide an extended glenoid surface to increase the glenohumeral stability. The purpose of this review was to analyse the rationale, current indications and results of surgical techniques aimed to augment the glenoid surface in patients diagnosed of either anterior or posterior instability by assessing a thorough review of modern literature. Classical techniques such as Latarjet or free bone block procedures have proven to be effective in augmenting the glenoid surface and consequently achieving adequate shoulder stability with good clinical outcomes and early return to athletic activity. Innovations in surgical techniques have permitted to perform these procedures arthroscopically. Arthroscopy provides the theoretical advantages of lower morbidity and faster recovery, as well as the identification and treatment of concomitant pathologies.

Full Arthroscopic Eden-Hybinette Procedure Using 2 Cortical Suture Buttons for the Reconstruction of Anteroinferior Glenoid Defects

Therapeutic management of recurrent anterior shoulder instability with an anterior glenoid defect and a Hill-Sachs lesion requires a bone graft to restore the width of the glenoid. The Latarjet procedure is the most popular technique but an iliac crest bone graft is preferred when the coracoid process is dysplastic or too short or after failure of Latarjet or Bristow-Latarjet. The purpose of this manuscript is to describe a full arthroscopic Eden-Hybinette-guided technique with 2 cortical suture buttons for bone graft fixation. This procedure allows reconstruction of severe glenoid bone defects and treatment of concomitant capsulolabral lesions and humeral bone loss, while preserving the subscapularis muscle. In addition, the use of 2 cortical buttons for bone graft fixation simplify graft transport and positioning, provides good control of the rotation, improving healing of the iliac crest bone graft to the anterior glenoid rim.

Editorial Commentary: Arthroscopic Glenoid Reconstruction With Subscapularis Tenodesis Results in Promising Clinical Outcomes, but Concerns Regarding Graft Resorption Rates Persist: A Long Way Toward a More Perfect Union

The pros and cons of open and arthroscopic shoulder stabilization procedures have been studied exhaustively. Yet, in many situations, the rates of recurrent instability and overall complications associated with these techniques remain unacceptably high. Perhaps paradoxically, the refinement of arthroscopic shoulder stabilization techniques has only intensified the debate between proponents of either open or arthroscopic approaches, and although significant (however "significant" is defined), anteroinferior glenoid bone loss has historically been thought to constitute a relatively strong indication for an open bone augmentation procedure, surgeons, to their great credit, continue to push the limits of what can be accomplished arthroscopically. Arthroscopic glenoid reconstruction has emerged as a viable option that may represent "the best of both worlds." Although modifications to the originally described arthroscopic glenoid reconstruction technique are promising, concerns persist regarding the fate of the graft and the durability of the procedure beyond short-term follow-up.

Editorial Commentary: Arthroscopic Shoulder Instability Surgery and Glenoid Bone Loss: A Paradigm Shift?

The successful treatment of shoulder instability, particularly in the setting of glenoid bone loss, is a challenging problem. There are several surgical options that are available for patients who have this clinical entity. Of these options, bone block procedures have become increasing common over the past several years, both for primary and revision surgery, with the aim to restore the native glenoid anatomy. The arthroscopic Eden-Hybinette procedure is a viable arthroscopic treatment option in patients who have anterior shoulder instability with anterior glenoid insufficiency. This technique has some distinct advantages over other bone block procedures, specifically the ability to avoid damage to the subscapularis and to preserve the coracoid process. In addition, the use of autograft has benefits over glenoid reconstruction procedures that use allograft, specifically pertaining to cost and availability.

[The causes of Latarjet surgery failure and the revision surgeries]

Objective

To review the causes of Latarjet surgery failure and various revision surgeries, in order to provide the reference for the revision of treatment options for Latarjet surgery failure.

Methods

Literature on the causes of Latarjet surgery failure and revision surgeries was extensively reviewed and analyzed.

Results

Latarjet surgery is widely used in clinical practice for recurrent anterior dislocation of shoulder with glenoid defects, especially for the defects of more than 25%. The main reasons for its failure are ununion, bone resorption, graft dislocation, trauma, and graft fracture, etc. The revision surgeries are diverse, the standard treatment has not yet been formed. The revision surgeries include open iliac bone grafting, microscopic Eden-Hybinette surgery, soft tissue reconstruction, open or arthroscopic bone grafting, etc. The differences among the revisions are mainly reflected in grafts, complications, and their costs.

Conclusion

Latarjet surgery is difficult to operate and requires high technical requirements for the surgeons. It is necessary to continuously improve the surgical technology to reduce the complications related to Latarjet surgery and its revision surgery.

Double-Sling Augmentation for Anterior Shoulder Dislocation

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

Arthroscopic Glenoid Bone Grafting With Soft Fixation for Recurrent Anterior Shoulder Dislocation

Glenoid bone defect is a common structural deficiency in cases of recurrent anterior shoulder dislocation. Glenoid bone grafting is an effective method to address glenoid defect and promote labrum regeneration. In most previous reports, firm fixation of the bone grafts was conducted, but with obvious inconvenience. Thus, we introduce a special glenoid bone-grafting technique in which the bone fragments are placed to the anterior side of the glenoid through the rotator interval, with 1 inferior graft free of fixation and 1 superior graft fixed to the glenoid by suture suspension. This technique is indicated in patients with recurrent anterior shoulder dislocation with glenoid defect or needing osseous stimulation for labrum regeneration. The critical point of this technique is the proper use of special glenoid bone grafting instruments. We believe this technique will provide a special choice in the treatment of recurrent anterior shoulder dislocation.

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.