Modified Arthroscopic Latarjet Procedure: Suture-Button Fixation Achieves Excellent Remodeling at 3-Year Follow-up

Short-Term Complications of Arthroscopic Bristow or Latarjet Procedure with Screw Versus Suture-Button Fixation: A Prospective Study of 308 Consecutive Cases by a Single Surgeon

BACKGROUND

This study aimed to investigate the short-term complications (minimum 1-year follow-up) after either an arthroscopic Bristow or Latarjet procedure for anterior shoulder instability utilizing screw or suture-button fixation.

METHODS

Patients undergoing arthroscopic Bristow or Latarjet procedures between November 2016 and April 2021 were enrolled. Data were collected at baseline, 3 months, 6 months, and every year after surgery. Risks of postoperative complications and unplanned reoperations were assessed. A multivariable regression model was used to identify risk factors for complications and to determine the association of complications with patient-reported outcomes.

RESULTS

A total of 412 patients (425 shoulders) undergoing arthroscopic Bristow or Latarjet procedures performed by a single surgeon between November 2016 and April 2021 were reviewed. Two hundred and ninety-nine patients (308 shoulders, 76.2% of 404 eligible) with a mean follow-up of 22.3 ± 4.2 months were included for analysis. Two hundred and sixty-nine shoulders (87.3%) underwent a Bristow procedure (165 with screw and 104 with suture-button fixation), while 39 (12.7%) underwent a Latarjet procedure (18 with screw and 21 with suture-button fixation). Eighty-two patients (83 shoulders) reported a total of 85 complications within 2 years after surgery, with an overall complication rate of 26.9%. The rates of recurrent dislocation or subluxation and infection were 1.9% and 0.6%, respectively, while a total of 4 (1.3%) of the shoulders had unplanned reoperations. The most common complications were graft-related (11.7%), followed by complications involving neurologic symptoms (10.7%). The overall, graft, and neurologic complication rates following Bristow or Latarjet procedures were 27.1% versus 25.6%, 12.3% versus 7.7%, and 10.0% versus 15.4%, respectively. Compared with the Bristow technique with screw fixation, Bristow with suture-button fixation yielded a lower risk of any complications (odds ratio [OR], 0.55; p = 0.04). Paying with rural insurance and poor sleep quality prior to surgery were associated with increased risk of any complications.

CONCLUSIONS

Compared with arthroscopic Bristow procedures with screw fixation, Bristow procedures with suture-button fixation resulted in a lower overall complication risk. Both patient demographic and implant-specific factors were associated with the development of a complication.

LEVEL OF EVIDENCE

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

The Arthroscopically Guided Bristow-Latarjet Procedure With Cortical Button Fixation: A Minimum 10-Year Follow-up

BACKGROUND

Despite improved visualization, the use of arthroscopic surgery to perform the Latarjet procedure has not decreased the rates of complications and glenohumeral osteoarthritis (OA) in the long term. Many of the reported complications are related to the use of screws for bone block fixation with freehand drilling.

PURPOSE

To evaluate the long-term (at a minimum 10-year follow-up) clinical and radiological outcomes of the arthroscopic Bristow-Latarjet procedure using a posterior guided drilling technique and suture button for coracoid bone graft fixation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients who underwent the arthroscopic Bristow-Latarjet procedure with suture button fixation between 2011 and 2013 were reviewed by 2 independent evaluators. Complications and revision surgery were recorded, and we evaluated patient-reported outcomes including subjective scores, recurrence of shoulder instability (dislocation or subluxation), range of motion limitations, and return to sports. Patients had radiographs taken at least 10 years after surgery to assess glenohumeral OA according to the Samilson-Prieto classification system and computed tomography scans to assess bone block positioning and healing.

RESULTS

A total of 65 consecutive patients (68 shoulders) with a mean follow-up of 135 months (range, 120-156 months) were included. The mean age at the time of surgery was 25 ± 8 years; 7 patients had previous failed Bankart repair. At follow-up, 94% (64/68) of the shoulders had no recurrence of instability. The 4 cases of instability recurrence were traumatic and occurred at 3 weeks (a fall), 4 months, 2 years, and 7 years after surgery. No hardware failures, coracoid fractures, or neurological complications were observed. Overall, 61 patients (94%) were still participating in sports, with 44 (68%) at the same or higher level. Range of motion showed nonsignificant restrictions in external rotation with the arm at the side (7° ± 9°) and with the arm at 90° of abduction (9° ± 10°) compared with the contralateral side. Additionally, 11 shoulders (16%) had some residual anterior apprehension on clinical examination. At last follow-up, 77% (47/61) of the shoulders had no OA development or progression. Previous failed Bankart repair was a risk factor for the development of OA. Patients with OA had significantly lower Subjective Shoulder Value scores (79% vs 91%, respectively; P = .01) and decreased external rotation with the arm at the side (40° vs 65°, respectively; P = .001) compared with patients with no or little OA.

CONCLUSION

The arthroscopically guided Bristow-Latarjet procedure with suture button fixation is a safe and durable surgical treatment method for recurrent anterior shoulder instability, allowing a high rate of return to sports without significant motion restrictions and no or little OA in the long term.

Arthroscopic Autologous Iliac Crest Grafting With an Adjustable-Loop Suspensory Device Yields Favorable Outcomes for Anterior Shoulder Instability With Glenoid Defects

PURPOSE

To evaluate the clinical and radiologic outcomes of the arthroscopic autologous iliac crest grafting (AICG) procedure with an adjustable-loop suspensory fixation device in the treatment of anterior shoulder instability with glenoid bone defects.

METHODS

A retrospective review was conducted on the patients who underwent arthroscopic AICG with an adjustable-loop suspensory fixation device from January 2017 to December 2020. Patients with traumatic anterior shoulder instability, significant glenoid bone defects, and a minimum follow-up of 24 months were included. Patient-reported outcomes, including the Oxford Shoulder Instability Score (OSIS), the Rowe score, the Walch-Duplay score, the Constant score, and the visual analog scale score, were compared preoperatively and postoperatively. Radiologic assessments using computed tomography were performed before and after the procedure. Additional data on active range of motion, recurrence events, and complications were recorded.

RESULTS

A total of 42 patients were included in the study, with a mean follow-up time of 35.2 months, ranging from 25.1 to 55.9 months. Mean preoperative OSIS, Rowe score, Walch-Duplay score, and Constant score significantly improved from 24.4 ± 7.2, 25.0 ± 9.0, 25.2 ± 9.8, 87.5 ± 7.1 to 42.4 ± 4.9, 92.4 ± 8.1, 87.9 ± 8.3, and 93.6 ± 4.5 at the last follow-up, respectively. All patients exceeded the minimal clinically important difference for OSIS, Rowe, and Walch-Duplay scores. The graft union rate was 100%, and the glenoid area increased significantly from 82.5% preoperatively to 100.1% at the final follow-up. No patient experienced a recurrence of instability. Two recorded complications included one case of dysesthesia around the donor site and one case of postoperative shoulder stiffness.

CONCLUSIONS

The outcomes of the arthroscopic AICG procedure, which uses an adjustable-loop suspensory fixation device, demonstrated stable bone graft fixation, high rates of graft integration, favorable clinical results, and a low incidence of complications. Moreover, the remodeling of the graft during the follow-up period significantly restored the width and concavity of the inferior glenoid, contributing to the overall recovery.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Mechanistic study of the effect of flexible fixation and load-bearing stress environment on fracture healing and shaping

BACKGROUND

The biomechanical environment created by suture-button fixation Latarjet is conducive to the healing and shaping of the transplanted coracoid, but its mechanism remains unclear. The latest research has found that the absence of stem cell chemokine (CXCL12) impeded bone regeneration in Sonic Hedgehog (SHH)-deficient animals. However, whether the biomechanical environment affects SHH and CXCL12 function has not been studied.

METHODS

Rat fracture models were constructed to simulate stress environments under non-load-bearing and load-bearing conditions. The fracture healing and shaping, as well as the expression levels of SHH and CXCL12, were assessed through gross viewing, micro-computed tomography (micro-CT), and histochemical staining.

RESULTS

Under flexible fixation, the relative bone volume (BV/TV) of rats exposed to the load-bearing stress environment was significantly higher than that of rats under a non-load-bearing stress environment (p ≤ 0.05). Adverse bone shaping was not observed in rats subjected to flexible fixation. The levels of SHH and CXCL12 in load-bearing rats exhibited significant elevation (p ≤ 0.05). Under a load-bearing stress environment, no significant difference was observed in the BV/TV between the flexible fixation group and the rigid fixation group (p ≥ 0.05), but there was excessive hyperplasia of the fracture callus in the rigid fixation group. The levels of SHH and CXCL12 in rats subjected to rigid fixation were significantly elevated (p ≤ 0.05).

CONCLUSIONS

Flexible fixation and load-bearing stress environment may contribute to bone healing and shaping by influencing the levels of SHH and CXCL12, suggested that this mechanism may be relevant to the healing and shaping of the transplanted coracoid after suture-button fixation Latarjet.

Suture Button Congruent Arc Latarjet Procedure in the Treatment of Recurrent Anterior Shoulder Instability With Glenoid Bone Loss Greater Than 25

It is generally believed that glenoid bone loss (GBL) greater than 25% can be defined as a massive GBL. For this type of recurrent anterior shoulder instability, the traditional Latarjet technique is usually inadequate to restore the GBL. Although the congruent arc Latarjet technique is able to reconstruct a wider glenoid defect with good clinical outcomes, this technique had not been widely applied due to the limited bone width of the coracoid graft and high rate of coracoid osteotomy and screw fixation-related complications. The emerging suture button flexible fixation technique has been proven to achieve good clinical outcomes and is technically friendly. It can significantly reduce the requirements for large coracoid graft bone mass, and the Latarjet procedure's application scope is expanded. We introduce the suture button congruent arc Latarjet technique for treatment of massive GBL in this Technical Note.

Modified Suture-Button Latarjet Procedure With Coracoacromial Ligament and Pectoralis Minor Preservation Achieves Good Clinical Outcomes at 2-Year Follow-Up: Case Series of Latarjet Technique

PURPOSE

To evaluate whether the modified suture-button Latarjet procedure with coracoacromial ligament (CAL) and pectoralis minor (PM) preservation could achieve excellent outcomes at the 2-year follow-up.

METHODS

During January 2019 to January 2021, the data of patients who underwent modified suture-button Latarjet with CAL and PM preservation in our department were collected. The glenoid bone loss of these patients was greater than 20% or greater than 10% with high demands for exercise. Partial coracoid osteotomy was based on the results of a preoperative 3-dimensional computed tomography evaluation of the glenoid defect area and corresponding coracoid process morphology. The preoperative and postoperative clinical results were assessed. The minimal clinically important difference (MCID) was used to compare improvement in clinical outcomes. Graft-glenoid union and remodeling were assessed using postoperative 3-dimensional computed tomography, and magnetic resonance imaging was performed to confirm the integrity of the CAL and PM postoperatively.

RESULTS

In total, 35 patients were included in this study; the mean follow-up time was 26.9 ± 1.9 months. No case of recurrent dislocation or sublaxity. Significant improvements were observed in mean visual analog scale (VAS) scores for pain during motion, American Shoulder and Elbow Surgeons (ASES) score, Rowe score, and Walch-Duplay score (P < .001). The percentage of patients achieving at least an MCID improvement in clinical outcomes was VAS 85.71%, ASES 97.14%, Rowe 100%, and Walch-Duplay 97.14%. Thirty-three patients (94.3% of all cases) were able to return to their preoperative sport levels, 34 grafts (97.1%) achieved bone union (1 soft union) in 6.3 ± 2.2 months, and the coracoid grafts restored 97.1 ± 4.0% of the perfect-fitting circle at the last follow-up. Postoperative computed tomography scan showed that 31 grafts (88.6%) were placed ideally in vertical view. In the axial view, 25 grafts (82.9%) were flushed to the glenoid, whereas 1 and 5 grafts were fixed medially and laterally, respectively. The CAL and PM were visualized postoperatively. No arthropathy was observed in any patient at the last follow-up.

CONCLUSIONS

The modified suture-button Latarjet procedure with CAL and PM preservation obtained good clinical and radiological results without recurrence or complications. A substantial number of patients (>85%) achieved the MCID for the VAS, ASES, Rowe, and Walch-Duplay scores. In addition, the malpositioned graft (17.1%) did not cause arthropathy of the joints at 2-year follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

Congruent Concavity Restoration of the Reconstructed Glenoid After the Latarjet Procedure: Compensation for the Position of the Graft

BACKGROUND

Few clinical studies have addressed concavity restoration by natural remodeling after a Latarjet procedure. This study investigated the fibrous tissue and osseous remodeling of the reconstructed glenoid and concavity restoration after a Latarjet procedure using postoperative computed tomographic arthrography (CTA).

METHODS

This retrospective study included 31 patients who underwent immediate postoperative computed tomographic (CT) scanning followed by CTA at 6 months postoperatively. We investigated whether fibrous tissue was newly created over the graft, whether the created fibrous tissue restored the congruity of the articular surface and the osseous remodeling of the graft to the glenoid level (whether the osseous portion of the graft was remodeled flush to the glenoid level) and the concavity of the glenoid using the radius of a best-fit circle on the articular surface, and the relationship between the amount of created fibrous tissue and the position of the graft.

RESULTS

In all patients, the fibrous tissue on the graft yielded a smooth articular surface, as revealed by the CTA. The mean radius of the entire glenoid, including the transferred graft, was significantly smaller (p = 0.010) at 33.2 ± 8.5 mm than that of the glenoid posterior to the osseous step-off at 37.6 ± 9.4 mm, which is presumed to be the glenoid before the surgical procedure. Despite the congruity of the articular surfaces due to fibrous tissue seen in the CTA, 14 (45%) of 31 patients showed a subchondral osseous step-off on either the medial side or the lateral side in the immediate postoperative CT scans. However, through osseous remodeling, 8 of the 10 grafts with a lateral step-off and 2 of the 4 grafts with a medial step-off converted to a flush position. The position of the step-off was correlated with the thickness of the fibrous tissue, with a tendency for thicker tissue in cases of a step-off on the medial side (p = 0.014).

CONCLUSIONS

Fibrous tissue formation plus remodeling of the transferred graft resulted in the restoration of a congruent concavity after a Latarjet procedure by compensating for initially non-flush positioning of the graft. However, due to the small sample size in our study, clinical outcomes could not be correlated with radiographic findings, and our recommendation is to continue placing the graft as anatomically as possible.

LEVEL OF EVIDENCE

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

Stability of novel cow-hitch suture button coracoid bone graft fixation in Latarjet procedures: a biomechanical study

BACKGROUND

The Latarjet procedure is widely used to address anterior shoulder instability, especially in case of glenoid bone loss. Recently, cortical suture button fixation for coracoid transfer has been used to mitigate complications seen with screw placement. The aim of this biomechanical study was to evaluate the stability of a novel and cost-effective cow-hitch suture button technique, designed to be performed through a standard open deltopectoral approach, and compare this to a well-established double suture button technique.

MATERIALS AND METHODS

We randomly assigned 12 fresh frozen cadaveric shoulders to undergo the Latarjet procedure with either 4 suture button (S&N EndoButton) fixations (SB group; n = 6, age 72 ± 9.8 years) or cow-hitch suture button technique using a 1.7-mm FiberTape looped sequentially in 2 suture buttons (Arthrex Pectoralis Button) placed from anterior on the posterior glenoid (CH-SB group; n = 6, age 73 ± 9.3 years). After fixation, all shoulders underwent biomechanical testing with direct loading on the graft via a material testing system. Cyclic loading was performed for 100 cycles (10-100 N) to determine axial displacement with time; each graft was then monotonically loaded to failure.

RESULTS

The maximum cyclic displacement was 4.3 ± 1.6 mm for the cow-hitch suture button technique and 5.0 ± 1.7 mm for the standard double suture button technique (P = .46). Ultimate load to failure and stiffness were, respectively, 190 ± 82 N and 221 ± 124 N/mm for the CH-SB technique and 172 ± 48 N and 173 ± 34 N/mm for the standard double SB technique (P = .66 and .43). The most common failure mode was suture cut-through at the anteroinferior aspect of the glenoid for both fixation groups.

CONCLUSIONS

The cow-hitch suture button technique resulted in a similar elongation, stiffness, and failure load compared to an established double suture button technique. Therefore, this cost-effective fixation may be an alternative, eligible for open approaches, to the established double suture button techniques.

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.

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.

Clinical Outcomes, Union Rates, and Complications of Screw Versus Button Fixation in the Bristow-Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review and Meta-Analysis

Background

The Latarjet procedure is a common procedure for treating critical glenoid bone loss in anterior shoulder instability. Implants such as the screw and cortical button are widely used. The aim of this study was to compare studies on screw versus button fixation techniques in the Bristow-Latarjet procedure for anterior shoulder instability in terms of clinical outcomes, union rates, and complications.

Methods

The PubMed, Scopus, and Embase databases were searched to find comparative studies that reported outcomes of using screw versus button fixation in the Bristow-Latarjet procedure following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies that directly compared the screw and button fixation techniques and provided postoperative patient-reported outcomes, union rates, or complications were included. The Methodology Index for Non-Randomized Research (MINORS) criteria were used to assess the quality of the included studies. Odds ratios (ORs) were calculated for dichotomous outcomes whereas mean differences were calculated for continuous outcomes.

Results

Five articles included a total of 877 shoulders. All five studies had level 3 evidence. There was no statistically significant difference between the two techniques using the Walch-Duplay score, visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, range of motion, and graft union rates. However, the button fixation technique had statistically significantly higher recurrence rates than the screw fixation technique (OR, 0.24; 95% confidence interval, 0.10-0.58; p = 0.001).

Conclusions

The screw fixation technique had statistically significantly lower recurrence rates than the button fixation technique. However, there was no significant difference between screw and button fixation techniques regarding postoperative patient-reported outcomes, range of motion, graft union rates, nerve injury rates, infection rates, and reoperation rates.

Arthroscopic Latarjet procedure: current concepts and surgical techniques

The Latarjet procedure is a surgical procedure that can effectively restore glenohumeral stability, especially in patients with anterior shoulder instability and glenoid bone loss. Many studies have shown comparable clinical outcomes between patients undergoing the arthroscopic Latarjet procedure and those undergoing traditional open methods or other glenohumeral joint stabilization procedures. However, the arthroscopic Latarjet procedure is a challenging technique due to the unfamiliar portal placements, proximity of neurovascular structures, and serious postoperative complications. The arthroscopic Latarjet procedure has not yet been widely applied, and a clear understanding of the anatomical structure and the precise methods is required prior to operation performance. Satisfactory clinical outcomes can be achieved by thorough preoperative planning and proper implant fixation methods.

Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of return to sports after coracoid transfer

PURPOSE

This study aims to determine the rate of different levels of return to sports (RTS) in athletes undergoing the modified arthroscopic Bristow procedure and the factors associated with the level of RTS.

METHODS

The study was performed retrospectively on patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow procedure with a minimum follow-up of 2 years. The RTS rate, the level of return and the timing of return were assessed. Additionally, factors such as preoperative basic information, clinical outcomes, graft position, graft healing and graft absorption were analysed to investigate their correlation with the level of RTS. Multivariate regression models were used to evaluate the factors affecting the level of RTS.

RESULTS

In total, this study included 182 shoulders of 177 athletes undergoing the modified arthroscopic Bristow procedure. Of these patients, 142 (78.0%) shoulders of 137 athletes were enrolled, with a mean of 3.3-year follow-up. At the final follow-up, 134 (94.4%) shoulders were able to RTS, 123 (86.6%) shoulders were able to RTS to the pre-injury level, 52 (36.6%) shoulders could be completely "forgotten" without any psychological barrier during exercise. The multivariate logistic regression analysis identified the variable associated with RTS at the pre-injury level as previously failed arthroscopic Bankart repair (p < 0.001). As for the "forgetting" operated shoulder, the duration from first dislocation to surgery was a significant independent predictor (p = 0.034).

CONCLUSION

Although a large majority of athletes were able to RTS at the pre-injury level after the modified arthroscopic Bristow procedure, about two-thirds of the athletes felt difference in shoulders on both sides and could not completely "forget" the operated shoulder during exercise. Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of RTS after the modified arthroscopic Bristow procedure.

LEVEL OF EVIDENCE

IV.

Open Latarjet with Metal-Free Cerclage Fixation

Despite multiple modifications, the Latarjet is still the most popular procedure for recurrent anterior shoulder instability with glenoid bone loss. Partial or subtotal resorption of the graft is common, potentially leading to hardware prominence and risk of anterior soft-tissue impingement. To minimize the technical difficulties and morbidity associated with metallic implants, a coracoid and conjoint tendon transfer with a mini-open approach using Cerclage tape suture is described, as an alternative for the Latarjet procedure typically performed with metal screws and plates.

Complications Related to Latarjet Shoulder Stabilization: A Systematic Review

BACKGROUND

In cases of recurrent anterior shoulder instability with a glenoid defect, Latarjet procedures are widely used for stabilization. Although complications with this procedure have been reported, few studies have comprehensively analyzed issues related to the Latarjet procedure.

PURPOSE

To identify the overall complication rate of the Latarjet procedure used for anterior shoulder instability and to compare the rate of complications between arthroscopic and open approaches.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed by using the PubMed, EMBASE, Scopus, and Cochrane Library databases. Data on complications were extracted and classified as intraoperative, postoperative, or instability-related for further analysis. Quality assessments were performed with criteria from the Methodological Index for Nonrandomized Studies (MINORS). A quantitative synthesis of data was conducted to compare the complication rates between arthroscopic and open approaches.

RESULTS

A total of 35 articles were included in this analysis. The MINORS score was 11.89. A total 2560 Latarjet procedures (2532 patients) were included. The overall complication rate was 16.1% (n = 412). The intraoperative complication rate was 3.4% (n = 87) and included a 1.9% (n = 48) incidence of nerve injuries and a 1.0% (n = 25) incidence of iatrogenic fractures. Screw problems, vascular injuries, and conversion arthroscopic to open surgery each occurred at a rate of <1%. The postoperative complication rate was 6.5% (n = 166), and the most common complication was nonunion (1.3%; n = 33). The instability-related complication rate was 6.2% (n = 159) and included a 1.5% (n = 38) rate of redislocation, a 2.9% (n = 75) rate of positive apprehension test, and a 1.0% (n = 26) rate of instability. Overall, 2.6% (n = 66) of patients required an unplanned secondary operation after the initial surgery. The arthroscopic approach was associated with a higher rate of intraoperative complications compared with the open approach (5.0% vs 2.9%; P =.020) and a lower rate of instability-related complications (3.1% vs 7.2%; P < .001).

CONCLUSION

The Latarjet procedure for anterior shoulder instability results in an overall complication rate of 16.1% and a reoperation rate of 2.6%. However, serious complications at short-term follow-up appear rare. When the arthroscopic approach was used, the rate of intraoperative complications was higher, although instability-related complications were lower when compared with the open approach.

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.

Arthroscopic double-button Latarjet osteolysis and remodeling at 1-year follow-up

HYPOTHESIS

The aim of this study was to evaluate the osteolysis rate, graft remodeling, and risk factors for osteolysis at the 1-year threshold after an arthroscopic Latarjet procedure with double-button fixation.

METHOD

In this multicenter, retrospective study, postoperative computed tomography scans obtained after an arthroscopic Latarjet procedure with double-button fixation to treat anterior shoulder instability were analyzed at 15 days and at 3, 6, and 12 months. Graft volume, dimensions, and morphologic remodeling were analyzed.

RESULTS

Twenty-seven patients were included (mean age, 26 years). At 1 year, osteolysis occurred in 19 of 27 patients (70%). The volume initially decreased until 6 months' follow-up (-35%; range, -75% to +26%) and then increased until our last follow-up. At 1 year, the graft volume decreased by 17% (range, -61% to +56%) compared with the immediate postoperative volume. In multivariate analysis, the rate of osteolysis was inversely associated with an unhealed graft at 3 months (P = .02; β coefficient = -44.50 [95% confidence interval, -81 to -8]). The maximal height of the graft significantly grew 0.2 cm (range, -55 to +124 mm) (P = .015). In the sagittal plane, osteolysis occurred in the superior part in 100% of patients (27 of 27) whereas bone formation occurred in the inferior part. In the axial plane, osteolysis occurred in the anterior part whereas bone formation occurred in the posterior part. In the articular part, the observed remodeling was aimed to obtain a new anatomic and congruent glenoid.

CONCLUSIONS

At 1 year after an arthroscopic Latarjet procedure with double-button fixation, osteolysis occurred in 70% of patients. The rate of osteolysis was 17% of the initial volume. Osteolysis occurred mainly during the first 6 months, in the anterior and superior parts. Remodeling led to a circular anatomic glenoid. This osteolysis did not cause any recurrence of instability or require revision surgery.

Morphometric and Biomechanical Comparison of the Scapular Spine and Coracoid Graft in Anterior Shoulder Instability

BACKGROUND

The scapular spine has been described as a relatively new bone graft alternative used in glenoid augmentation. The classic Latarjet procedure, which transfers the coracoid as a graft, is regarded as the gold standard. The comparison of these 2 techniques has not been fully reported.

PURPOSE

To compare the anatomic and biomechanical properties of glenoid augmentation using scapular spine graft or coracoid graft.

STUDY DESIGN

Controlled laboratory study.

METHODS

The study used 20 fresh-frozen human cadaveric shoulders. A 25% anterior glenoid defect was created, and the specimens were divided randomly to receive glenoid augmentation by scapular spine or coracoid grafts. For both procedures, the grafts were secured to the glenoid defect with 2 screws. Morphometric data, including the glenoid articular area, amount of restoration, and graft dimensions, were obtained. A biomechanical test was conducted in a direct-loading scenario. The construct stiffness, cyclic displacement, and ultimate failure of each specimen were collected.

RESULTS

No significant difference was found in glenoid articular restoration between the scapular spine group and the coracoid group (31% vs 33%, respectively; P = .311). Morphometric analysis indicated that coracoid grafts exhibited significantly greater thickness and height than scapular spine grafts. In biomechanical results, the scapular spine group exhibited significantly greater construct stiffness than the coracoid group (206.3 ± 58.8 vs 148.3 ± 76.0 N/mm, respectively; P = .023). The average failure load in the scapular spine group was not significantly higher than that in the coracoid group. No significant differences in cyclic displacement were found between the 2 techniques.

CONCLUSION

In a simulated 25% anterior glenoid bony defect, a scapular spine graft was comparable with the classic Latarjet procedure in restoring the glenoid articular dimension and exhibited superior construct stiffness in a cadaveric model.

CLINICAL RELEVANCE

The scapular spine may serve as an alternative graft choice in glenoid augmentation surgery considering the amount of articular restoration and initial fixation stability.

[Short-term effectiveness of modified arthroscopic Latarjet procedure with double EndoButtons for recurrent anterior shoulder dislocation]

Objective

To evaluate the short-term effectiveness of modified arthroscopic Latarjet procedure with double EndoButtons for recurrent anterior shoulder dislocation.

Methods

Between January 2019 and November 2020, 36 patients with recurrent anterior shoulder dislocation were treated by modified arthroscopic Latarjet procedure with double EndoButtons. There were 26 males and 10 females, with an average age of 27.8 years (range, 18-36 years). The number of shoulder dislocations ranged from 3 to 12 times, with an average of 6.5 times. The disease duration ranged from 5 to 36 months, with an average of 16.2 months. Preoperative shoulder fear test was positive, and the Beighton score of joint relaxation was 0-4, with an average of 1.3. Imaging examination showed that the defect width of the ipsilateral glenoid bone was 16%-28%, with an average of 21.5%. Postoperative complications, recurrent dislocation, subluxation, and instability of shoulder joint were recorded. Shoulder range of motion was examined, including forward flexion, external rotation at side, external rotation at 90° abduction, and internal rotation. Shoulder joint function was evaluated by Walch-Duplay score, American Association for Shoulder and Elbow Surgery Score (ASES), and ROWE score. X-ray film and CT images were taken to observe the shaping of coracoid process graft.

Results

All incisions healed by first intention, and no vascular or nerve injury occurred. All patients were followed up 12-28 months, with an average of 19.9 months. During follow-up, no shoulder dislocation recurred, and shoulder fear test was negative. At last follow-up, there was no significant difference in shoulder forward flexion, external rotation at side, external rotation at 90° abduction, and internal rotation when compared with preoperative values (P>0.05). The Walch-Duplay score, ASES score, and ROWE score of shoulder function significantly improved (P<0.05). Postoperative imaging examination showed that coracoid process graft was at the same level with the glenoid in 33 cases (91.7%), medial in 1 case (2.8%), and lateral in 2 cases (5.6%); the center of coracoid process graft was mainly located between 3 to 5 o'clock in 33 cases (91.7%), higher than 3 o'clock in 1 case (2.8%), and lower than 5 o'clock in 2 cases (5.6%). There was no obvious glenohumeral joint degeneration during follow-up, and the coracoid process graft gradually formed concentric circles with the humeral head.

Conclusion

The modified arthroscopic Latarjet procedure with double EndoButtons can effectively treat recurrent anterior shoulder dislocation, and the short-term effectiveness is satisfactory, and the position of coracoid process graft is accurate.

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.

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).

LUtarjet-limit unique coracoid osteotomy Latarjet (With video)

Background

The Latarjet procedure is an effective technique for the treatment of recurrent anterior shoulder dislocation with glenoid bone loss. However, the inevitable destruction of the coracoacromial arch may result in humeral head translation. The aim of the study is to introduce a modified Latarjet technique with coracoacromial arch preservation as well as its short term clinical outcomes.

Methods

We propose a novel individualized flexible arthroscopic suture button fixation Latarjet technique called `LUtarjet' with video. Precise measurements of the coracoid process, glenoid deficiency and osteotomy plane were made preoperatively. Only three arthroscopic portals were needed and limit unique coracoid osteotomy was performed with coracoacromial arch preservation. The mini window splitting of the subscapularis was performed from the posterior to the anterior direction and the split window was as small as 8–10 mm in length.

Results

A total of 27 patients (25.6 ± 5.4 years) were included in the study. The average surgical duration was 55.6 ± 6.3 min and the mean follow-up time was 8.1 ± 1.5 months. The functional score was significantly improved at the last follow-up. Radiologic evidence showed that the bone graft healing was placed in the desired position. No complications were found.

Conclusions

We present a fast, easy, accurate, safe arthroscopic ‘LUtarjet’ technique called FEAST that can simplify the arthroscopic Latarjet process and achieve a satisfactory bone graft position and satisfactory short-term clinical outcomes.

Level of evidence

IV, case series.

Distal Clavicle Autograft Fixed with Buttons for the Management of Shoulder Instability with Glenoid Defect: A Case Report

CASE

In this case report, we presented the case of a 39-year-old male lawyer who presented to our tertiary care clinic with recurrent instability of his right shoulder and significant glenoid bone loss. This patient was treated with arthroscopic glenoid bone augmentation with his distal clavicle fixed with arthroscopic suture buttons.

CONCLUSION

Use of a distal clavicle autograft with arthroscopic fixation using buttons is a novel and promising solution for the management of patients with shoulder instability and associated glenoid bone loss.

A review of bone grafting techniques for glenoid reconstruction

BACKGROUND

Traumatic anterior shoulder dislocations can cause bony defects of the anterior glenoid rim and are often associated with recurrent shoulder instability. For large glenoid defects of 20-30% without a mobile bony fragment, glenoid reconstruction with bone grafts is often recommended. This review describes two broad categories of glenoid reconstruction procedures found in literature: coracoid transfers involving the Bristow and Latarjet procedures, and free bone grafting techniques.

METHODS

An electronic search of MEDLINE and PubMed was conducted to find original articles that described glenoid reconstruction techniques or modifications to existing techniques.

RESULTS

Coracoid transfers involve the Bristow and Latarjet procedures. Modifications to these procedures such as arthroscopic execution, method of graft attachment and orientation have been described. Free bone grafts have been obtained from the iliac crest, distal tibia, acromion, distal clavicle and femoral condyle.

CONCLUSION

Both coracoid transfers and free bone grafting procedures are options for reconstructing large bony defects of the anterior glenoid rim and have had similar clinical outcomes. Free bone grafts may offer greater flexibility in graft shaping and choice of graft size depending on the bone stock chosen. Novel developments tend towards minimising invasiveness using arthroscopic approaches and examining alternative non-rigid graft fixation techniques.

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

Background:

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

Purpose:

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

Study Design:

Cohort study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of Modified Arthroscopic Latarjet on Acromiohumeral Distance at 5-Year Follow-up

Background:

It is unclear whether coracoacromial ligament release during the Latarjet procedure will increase superior translation of the shoulder joint.

Purpose:

To evaluate whether a modified suture button Latarjet procedure can decrease the acromiohumeral distance (AHD).

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective analysis was conducted among 155 patients who underwent a modified suture button Latarjet procedure between 2013 and 2015. AHD was measured on bilateral computed tomography scans taken preoperatively and on scans of the affected shoulder taken on postoperative day 1 and postoperative month (POM) 6, POM 36, and POM 60. At each time point, we recorded pain on a visual analog scale (VAS) and objective shoulder function using the American Shoulder and Elbow Surgeons, Rowe, and Walch-Duplay scores. Preoperative and final follow-up VAS and functional scores were compared using the paired t test. Pairwise comparison of AHD values at each follow-up time point were compared with the preoperative intact side using the paired t test. Intra- and interobserver reproducibility of the AHD measurements was evaluated using the intraclass correlation coefficient.

Results:

A total of 104 patients who met the criteria completed the final follow-up, which occurred at 62.6 ± 2.4 months (mean ± SD). When compared with presurgery, the VAS and all functional scores improved significantly at the last follow-up (P < .001 for all). Intra- and interobserver intraclass correlation coefficients indicated good reliability for the ADH measurements. Preoperatively, there were no differences in AHD values between the intact and affected shoulders (7.8 ± 0.8 mm for both; P = .851). The AHD values at postoperative day 1 and POM 6, POM 36, and POM 60 were 9.6 ± 0.7 mm, 8.6 ± 0.9 mm, 8.0 ± 0.8 mm, and 7.9 ± 0.8 mm, respectively, all of which were larger than those of the preoperative intact side (P < .001 for all).

Conclusion:

The modified suture button Latarjet procedure not only offered satisfactory therapeutic effects but also did not decrease the AHD at 5-year follow-up.

Arthroscopic Iliac Crest Bone Graft Augmentation Using All-Suture Anchors for Shoulder Instability Caused by Glenoid Bone Loss

Augmentation of the anterior glenoid with bone graft is an established treatment for recurrent anterior instability due to critical glenoid bone loss. Both open and arthroscopic techniques have been described. Fixation with metal screws through an open approach is the most common technique, but the risk of metal screw-related complications remains a concern. A variety of arthroscopic techniques using suspensory fixation or suture anchors have been described in the literature. However, they all require a posterior incision to insert a targeting device or to manage sutures. We describe a technique for arthroscopic bone grafting of the anterior glenoid via a purely anterior approach with 2 linked knotless suture anchors, thereby avoiding posterior suture management and glenoid metalwork complications.

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.

Radiological outcomes of iliac crest bone graft augmentation for glenoid bone loss using an open all-suture anchor and washer fixation technique

Background

Many of the complications related to bone block augmentation for recurrent shoulder instability are related to metal screw fixation. Alternative fixation techniques using suspensory fixation have been described with good results, although they require an additional posterior incision to manage the button. It was postulated that the use of an all-suture anchor would remove the requirement for a posterior incision, whilst providing equivalent union rates. Thus, the aim of this study was to evaluate the radiological outcome of a technique using all-suture anchor fixation of iliac crest autograft.

Methods

Eleven patients (mean age 28 years, 10 males, 1 female) underwent open anterior shoulder stabilization using an autologous iliac crest bone graft that was fixed with all-suture anchors and supplemented by 2-hole tibial plate. Union of the graft was evaluated 6 months postoperatively using computed tomography.

Results

There were no intraoperative complications and none of the participants needed further surgery. All patients reported a stable shoulder at 6 months follow-up. The grafts united in 10 out of the 11 patients.

Conclusion

An all-suture anchor construct is a viable alternative to metal screw fixation for iliac crest bone grafting in shoulder instability with critical bone loss, and unlike suspensory techniques does not require a second posterior incision.

The Latarjet Procedure Without Remplissage Is Effective to Restore Stability in Athletes With Glenoid Bone Defects Greater Than 25% and Off-Track Hill-Sachs Lesions

PURPOSE

There were 2 main purposes in this study: (1) to report on clinical outcomes of the Latarjet procedure without remplissage in athletes with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions and (2) to determine whether the isolated Latarjet procedure converted off-track Hill-Sachs lesions to on-track Hill-Sachs lesions as measured on computed tomography (CT).

METHODS

During the study period, a total of 29 athletes who had anterior glenohumeral instability with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions, who underwent Latarjet surgery, and who had a minimum follow-up period of 24 months were included in this study. The glenoid track was analyzed before and 3 months after the procedure using 3-dimensional CT. Return to sport and range of motion, as well as the Rowe score, visual analog scale score for pain during sports activity, and Athletic Shoulder Outcome Scoring System score, were used to assess functional outcomes. Recurrences were also evaluated.

RESULTS

The mean follow-up period was 35 months (standard deviation [SD], 6 months), and the mean age was 30 years (SD, 2 years). Of the patients, 27 (93%) were able to return to sports and 25 (86%) returned to the same level as before their injury. No significant difference in shoulder range of motion was found between preoperative and postoperative results. The Rowe, visual analog scale, and Athletic Shoulder Outcome Scoring System scores showed statistically significant improvements after surgery (P < .001). The mean width of the glenoid pathway changed significantly from 21.5 mm (SD, 2.54 mm) in the preoperative period to 35.1 mm (SD, 5.46 mm) at 3 months' follow-up. All the Hill-Sachs lesions remained on track, and no patient had recurrence of instability at the end of follow-up. No complications occurred in this series.

CONCLUSIONS

The Latarjet procedure was effective to restore stability in athletes with recurrent glenohumeral instability with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions, avoiding recurrence in all patients after an average follow-up period of 35 months. Moreover, the Latarjet procedure converted all off-track Hill-Sachs lesions to on-track Hill-Sachs lesions as measured on CT.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic Autologous Scapular Spine Bone Graft Combined With Bankart Repair for Anterior Shoulder Instability With Subcritical (10%-15%) Glenoid Bone Loss

PURPOSE

The purpose of our study is to prove that the autologous scapular spine bone graft is an alternative for the treatment of anterior shoulder instability and the clinical and radiological results are promising.

METHOD

From July 2016 to August 2018, patients who were diagnosed as having anterior shoulder instability with subcritical (10%-15%) glenoid bone loss were treated by arthroscopic repair with autologous scapular spine bone graft. The inclusion criteria were (1) anterior shoulder instability underwent arthroscopic autologous scapular spine bone graft; (2) glenoid bone loss was within 10% to 15% (measured by Sugaya's method); (3) three complete sets of computed tomography (CT) scans (preoperative, 1 week after surgery, and 1 year after surgery) available; and (4) clinical follow-up time was at least 2 years. The exclusion criteria were (1) concomitant rotator cuff tear; (2) concomitant remplissage or SLAP repair; (3) previous surgery of the affected shoulder; (4) open surgery; and (5) incomplete radiological or clinical follow-up. The preoperative and postoperative Constant-Murley score, dietary approaches to stop hypertension (DASH) score, visual analog scale (VAS) score, and range of motion (ROM) were recorded. CT scans with 3-dimensional reconstruction were obtained at the first week after operation and at 1 year after operation; the graft resorption rate was consequently calculated.

RESULTS

Twenty-seven patients were qualified and enrolled in the study. No severe complication was recorded during follow-up. No redislocation or subluxation was found, and the apprehension tests were all negative. At the last follow-up, the mean Constant-Murley score was 89.74 ± 3.71, the mean DASH score was 9.77 ± 5.31, the mean VAS score was 0.74 ± 0.64, which are all improved significantly compared with preoperative scores (P = .00,.00,.00, respectively). At the last follow-up, the ROM including anterior flexion, external rotation by side, and the internal rotation were well restored without significant difference compared with the contralateral shoulder (P =.48, .08, .47, respectively). At 1 year after operation, the resorption rate of the bone graft was 19.4%.

CONCLUSION

This study found that anterior shoulder instability with subcritical (10%-15%) glenoid bone loss treated with arthroscopic autologous scapular spine bone graft with suture anchor fixation is safe and could achieve satisfactory result at short-term follow-up.

LEVEL OF EVIDENCE

Therapeutic case series.

Modification of the Traditional Open Latarjet Technique with the Use of Sutures and Cortical Buttons Instead of Screws

In this article we describe a modification of the open Latarjet technique, using sutures and cortical buttons, for the fixation of the coracoid. The transfer of the coracoid to the anterior glenoid is a popular technique used for complex shoulder instability. The technique is proven to be effective with consistently good results but complications have been reported related to the screws used for the fixation of the coracoid. Recent studies confirm that the suture-button technique for the fixation of the coracoid is biomechanically comparable to the screw fixation. The proposed technique combines the advantages of the open approach and avoids the use of metal screws, potentially minimizing hardware-related complications.

Short-Term Bone Fusion With Arthroscopic Double-Button Latarjet Versus Open-Screw Latarjet

BACKGROUND

Recently, arthroscopic double-button Latarjet (AL) has provided an alternative to conventional open Latarjet (OL) in the treatment of anterior shoulder instability with glenoid bone loss. Therefore, theoretically, the faster fusion is obtained, the sooner return to sports under safe conditions can occur. The emerging flexible fixation of the bone block has clearly offered a new approach to achieve bone fusion. However, the period required to achieve this goal remains controversial.

PURPOSE/HYPOTHESIS

The purpose was to compare computed tomography (CT) scan results of AL and OL in the early postoperative period. It was hypothesized that the bone block fusion with AL would require a longer time than that with OL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In a retrospective 1-year study, the authors compared 17 primary double-button AL to 22 primary 2-screw OL procedures indicated for anterior shoulder instability in patients with an Index Severity Instability Score >3 points. These patients were reviewed with a CT scan at 1 day, 3 months, and 6 months postoperatively. The characteristics for the 2 groups were comparable. CT scans aimed to analyze graft position, bone contact area with the scapula, and fusion at 3 and 6 months. Clinical assessment was based on the Walch-Duplay and Rowe scores.

RESULTS

The mean preoperative Index Severity Instability Score was 5.3 ± 1.9 points, with a mean anterior glenoid bone loss of 9.1% ± 4.6%. At 3 months, the rates of fusion were 41% and 100% for the AL and OL groups, respectively (P < .001). This rate increased to 70% in the AL group at 6 months (P = .006). In the axial and sagittal planes, there was no difference in graft position between the AL group and the OL group. The bone block was longer and there was a more extensive bone contact area in the OL group (AL, 131 mm² vs OL, 223 mm²; P < .001). At 6 months of follow-up, no significant difference in clinical scores was noted between the groups: Walch-Duplay score, 93.0 ± 10.9 points versus 91.8 ± 12.5 points (P = .867); and Rowe score, 99.0 ± 2.2 points versus 95.0 ± 8.4 points (P = .307) for the AL and OL groups, respectively.

CONCLUSION

AL required more time to achieve bone block fusion than OL. This finding should be taken into account when considering this procedure for patients in a hurry to return to sports involving the shoulder.

[Radiographic study of effect of lateral placement of bone graft on shoulder joint degeneration after modified arthroscopic Latarjet surgery with elastic fixation]

OBJECTIVE

To investigate the mid-term effect of lateral placement of bone graft on shoulder joint degeneration after modified arthroscopic Latarjet surgery with elastic fixation for recurrent anterior shoulder dislocation with an anterior glenoid bone defect.

METHODS

According to the inclusion and exclusion criteria, 18 patients with recurrent anterior shoulder dislocation and anterior glenoid bone defect who received the modified arthroscopic Latarjet surgery with elastic fixation between January 2015 and November 2016 were enrolled in this study. There were 12 males and 6 females with an average age of 26.2 years (range, 19-37 years). The number of shoulder dislocation ranged from 4 to 30 times (mean, 8.8 times). The disease duration was 8-49 months (mean, 23.8 months). The mean anterior glenoid bone defect was 25.2% of the glenoid surface (range, 20%-29%). The mean preoperative Instability Severity Index Score (ISIS) was 7.6 (range, 7-10). According to Samilson-Prieto classification, the shoulder joint degeneration was rated as grade 0 in 13 cases, grade Ⅰ in 3 cases, and grade Ⅱ in 2 cases. Before and after operation, the visual analogue scale (VAS) score, American Society of Shoulder and Elbow Surgery (ASES) score, Walch-Duplay score, Rowe score, and shoulder mobility were used to evaluate the effectiveness. Imaging examination was performed to observe the shoulder joint degeneration, the position of the bone graft, and the postoperative shaping of the scapular glenoid.

RESULTS

All patients were followed up 55-62 months, with an average of 59.6 months. There was no neurovascular injuries, infections, fixation-related and bone graft-related complications. No re-dislocation and revision occurred. All patients returned to normal life, 17 of whom returned to sport. The VAS score was significantly decreased and ASES, Walch-Duplay, and Rowe scores were significantly improved at last follow-up ( P<0.05). No significant difference was found in range of motion of forward flexion, abduction, lateral rotation at 90° abduction, internal rotation at 90° abduction, or lateral rotation at 0° between pre- and post-operation ( P>0.05). Three-dimensional CT showed that the centers of all bone grafts were between 3∶30 and 4∶30 (right shoulder) or between 7∶40 and 8∶20 (left shoulder) and no bone grafts were positioned superiorly or inferiorly in the glenoid En-face view. All bone grafts were positioned lateral to the scapular glenoid with an average distance of 3.5 mm (range, 2.3-4.6 mm) in cross-sectional imaging by CT. Compared with the preoperative Samilson-Prieto classification results, all cases showed no progression of shoulder joint degeneration at 36, 48 months and last follow-up. All bone grafts remodeled to a steady state within 24 months after operation. The bone graft and glenoid finally remodeled analogous to the shape of the intact glenoid in the En-face view and became flush with the glenoid rim, remodeling to a curved shape congruent to the humeral head in cross-sectional imaging by CT. The shape of the remodeled glenoid at last follow-up was not significantly different from that at 24 months after operation.

CONCLUSION

The lateral placement of the bone graft during modified arthroscopic Latarjet surgery with elastic fixation do not accelerate the imaging changes of shoulder joint degeneration.

Traditional versus congruent-arc Latarjet anatomic and biomechanical perspective

The congruent-arc Latarjet (CAL) allows reconstruction of a greater percentage of glenoid bone deficit because the inferior surface of the coracoid is wider than the lateral edge of the coracoid used with the traditional Latarjet (TL).

Biomechanical studies have shown higher initial fixation strength between the graft and the glenoid with the TL.

In the TL, the undersurface of the coracoid, which is wider than the medial edge used with the CAL, remains in contact with the anterior edge of the glenoid, increasing the contact surface between both bones and thus facilitating bone consolidation.

The shorter bone distance around the screw with the CAL is potentially less tolerant of screw-positioning error compared to the TL. Moreover, the wall of the screw tunnel is potentially more likely to fracture with the CAL due to the minimal space between the screw and the graft wall.

CAL may be very difficult to perform in patients with very small coracoids such as small women or skeletally immature patients.

Radius of curvature of the inferior face of the coracoid graft (used with the CAL) is similar to that of the native glenoid. This may potentially decrease contact pressure across the glenohumeral joint, avoiding degenerative changes in the long term.

Cite this article: EFORT Open Rev 2021;6:280-287. DOI: 10.1302/2058-5241.6.200074

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.

Clinical and radiographic outcomes after Latarjet using suture-button fixation

Background

Latarjet has become a common treatment option for patients with shoulder instability in the setting of bone loss. The coracoid is commonly secured with screws

Methods

All patients who underwent Latarjet with suture-button fixation with minimum 1-year follow-up were eligible for inclusion. Preoperative demographic and clinical outcome data including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), and Visual Analog Scale (VAS) were recorded and compared with postoperative scores. Radiographs were reviewed for signs of nonunion. Complications were recorded.

Results

Overall 21 patients (76% male, average age: 30.4 ± 11.3 years) underwent Latarjet with suture-button fixation. Significant improvements at 1 year were seen in ASES (P < 0.001), SANE (P < 0.001), and VAS (P = 0.011) scores compared with preoperative scores. Of the 21 patients who had reached 1-year follow-up, 17 (81%) reached 2-year follow-up. For the 17 patients who reached 2-year follow-up, there were significant improvements in ASES (P = 0.001), SANE (P = 0.001), and VAS (P = 0.005) scores from preoperative values. When isolating the 17 patients with 2-year follow-up, there were no significant differences between their 1-year and 2-year ASES (P = 0.73), SANE (P = 0.17), and VAS (P = 0.37) scores. Overall, 3 patients (14%) sustained a complication (one redislocation, one with coracoid migration and a fibrous union, and one superior labral tear requiring biceps tenodesis and superior labral repair).

Conclusion

Suture-button fixation of the coracoid during the Latarjet provides encouraging clinical and radiographic outcomes at 1 and 2 years.

Outcomes of the Latarjet Procedure Versus Free Bone Block Procedures for Anterior Shoulder Instability: A Systematic Review and Meta-analysis

BACKGROUND

Free bone block (FBB) procedures for anterior shoulder instability have been proposed as an alternative to or bail-out for the Latarjet procedure. However, studies comparing the outcomes of these treatment modalities are limited.

PURPOSE

To systematically review and perform a meta-analysis comparing the clinical outcomes of patients undergoing anterior shoulder stabilization with a Latarjet or FBB procedure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed, Embase, and the Cochrane Library databases were systematically searched from inception to 2019 for human-participants studies published in the English language. The search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement including studies reporting clinical outcomes of patients undergoing Latarjet or FBB procedures for anterior shoulder instability with minimum 2-year follow-up. Case reports and technique articles were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine the proportions of recurrent instability, other complications, progression of osteoarthritis, return to sports, and patient-reported outcome (PRO) improvement.

RESULTS

A total of 2007 studies were screened; of these, 70 studies met the inclusion criteria and were included in the meta-analysis. These studies reported outcomes on a total of 4540 shoulders, of which 3917 were treated with a Latarjet procedure and 623 were treated with an FBB stabilization procedure. Weighted mean follow-up was 75.8 months (range, 24-420 months) for the Latarjet group and 92.3 months (range, 24-444 months) for the FBB group. No significant differences were found between the Latarjet and the FBB groups in the overall random pooled summary estimate of the rate of recurrent instability (5% vs 3%, respectively; P = .09), other complications (4% vs 5%, respectively; P = .892), progression of osteoarthritis (12% vs 4%, respectively; P = .077), and return to sports (73% vs 88%; respectively, P = .066). American Shoulder and Elbow Surgeons scores improved after both Latarjet and FBB, with a significantly greater increase after FBB procedures (10.44 for Latarjet vs 32.86 for FBB; P = .006). Other recorded PRO scores improved in all studies, with no significant difference between groups.

CONCLUSION

Current evidence supports the safety and efficacy of both the Latarjet and FBB procedures for anterior shoulder stabilization in the presence of glenoid bone loss. We found no significant differences between the procedures in rates of recurrent instability, other complications, osteoarthritis progression, and return to sports. Significant improvement in PROs was demonstrated for both groups. Significant heterogeneity existed between studies on outcomes of the Latarjet and FBB procedures, warranting future high-quality, comparative studies.

Latarjet Cerclage: The All-Arthroscopic Metal-Free Fixation

The Bristow-Latarjet procedure has been one of the most recognized procedures for the treatment of recurrent shoulder dislocation with anterior glenoid bone loss, revision surgery after failed Bankart repair, contact and collision sport injuries, and patients with a high risk of recurrence. Open and arthroscopic approaches have recently shown similar outcomes by several authors. However, complications related to metal implants, despite being low, are still a matter of concern. We describe an all-arthroscopic Latarjet technique with a metal-free fixation method using 2 ultra-high-strength sutures, creating a cerclage construct through 2.4mm glenoid and coracoid tunnels with a final capsulolabral complex reconstruction.

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up

PURPOSE

To investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability.

METHODS

Seventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed.

RESULTS

Fourteen patients [mean age 31.1 (range 18-50) years] were available after a follow-up period of 78.7 (range 60-110) months. The SSV averaged 87 (range 65-100) %, CS 94 (range 83-100) points, RS 89 (range 30-100) points, WD 87 (range 25-100) points, and WOSI 70 (range 47-87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a significant increase of the glenoid index from preoperative 0.8 ± 0.04 (range 0.7-0.8) to 1.0 ± 0.11 (range 0.8-1.2) at the final follow-up (p < 0.01).

CONCLUSION

Arthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting technique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid configuration was observed.

LEVEL OF EVIDENCE

IV.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Latarjet Cerclage: The Metal-Free Fixation

The Latarjet technique is a widely used technique for anterior shoulder instability with glenoid bone defects, irreparable capsuloligamentous lesion, or in patients at greater risk of recurrence. The use of this technique has been reported to obtain satisfactory clinical and biomechanical results. Although other methods exist, the coracoid process is typically fixed with 2 metal screws. Complications related to metal fixation are very frequently reported. In an attempt to avoid these complications, we developed this arthroscopically assisted metal-free Latarjet technique in which we fix a coracoid graft using four cerclage tapes to achieve a strong, stable fixation, thus mimicking a plate.

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.