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

Screw Fixation for the Latarjet Procedure May Reduce Risk of Recurrent Instability but Increases Reoperation Rate Compared to Suture-Button Fixation: A Systematic Review

PURPOSE

To perform a systematic review to compare clinical outcomes, complications, and reoperation rates of patients undergoing the Latarjet procedure with screw vs suture-button fixation.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies directly comparing screw vs suture-button fixation for the Latarjet procedure. The search terms used were shoulder screw suture button. Patients were evaluated based on reoperation rate, complication rate, recurrent instability, radiologic outcomes, and patient-reported outcomes. Graft and screw position were assessed via computed tomography.

RESULTS

Seven studies (1 Level II, 6 Level III) met inclusion criteria, with 845 patients undergoing the Latarjet procedure with screw fixation (screw group) and 279 patients with suture-button fixation (suture-button group). Mean patient age ranged from 21.2 to 29.6 years. Mean follow-up time ranged from 6.0 to 40.8 months. The recurrent instability rate ranged from 0% to 2.5% in the screw group and 0% to 8.3% in the suture-button group. The reoperation rate ranged from 0% to 7.7% in the screw group compared to 0% to 1.9% in the suture-button group. One study reported significantly lower visual analog scale pain scores in the suture-button group compared with the screw group (1.5 vs 1.2, P = .003). No other studies reported significant differences in any patient-reported outcomes. There was no significant difference in horizontal or vertical graft position, graft union rate, or complication rate between groups in any study.

CONCLUSIONS

The Latarjet procedure with screw fixation may result in a lower risk of recurrent instability compared to suture-button fixation, although screw fixation may also have a higher reoperation rate due to hardware-related complications.

LEVEL OF EVIDENCE

Level III, systematic review of Level II to III studies.

Arthroscopic Latarjet Versus Arthroscopic Free Bone Block Procedures for Anterior Shoulder Instability: A Proportional Meta-analysis Comparing Recurrence, Complication, and Reoperation Rates

BACKGROUND

Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet.

PURPOSE

To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: "Arthroscopic" AND "Bone Block" OR "Bone Graft," and "Arthroscopic" AND "Glenoid Augmentation" OR "Glenoid Reconstruction," and "Arthroscopic" AND "Latarjet" OR "Coracoid Graft" OR "Coracoid Transfer." Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias.

RESULTS

Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age (P = .07), sex (P = .14), glenoid bone loss (P = .14), number of preoperative dislocations (P = .62), proportion of primary and revision procedures (P = .95), length of follow-up (P = .81), modified Coleman Methodology Score (P = .21), and level of evidence (P = .49). There was no difference in the recurrence (P = .88), reoperation (P = .79), and complication (P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation (P = .01).

CONCLUSION

The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation.

REGISTRATION

CRD42022368153 (PROSPERO).

Suture Button Fixation in Latarjet Has Similar Load to Failure and Clinical Outcomes but Lower Bone Resorption Compared With Screw Fixation: A Systematic Review

PURPOSE

To compare the 2 Latarjet fixation techniques-screw fixation (SF) versus suture button (SB) -for clinical, biomechanical, and radiologic outcomes.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic and Meta-Analyses guidelines using MEDLINE and Embase databases and was prospectively registered on PROSPERO. Only comparative clinical and biomechanical studies of Latarjet with SF and SB were included. Studies were appraised using the Methodical Index for Non-Randomised Studies (MINORS) tool.

RESULTS

Eleven studies met eligible criteria: 7 clinical studies (SB, n = 279; SF, n = 845) and 4 biomechanical. In total, 80.9% (SB) and 84.2% (SF) of patients were male. Follow-up ranged from 6 to 63.6 months. The overall recurrent instability rate for SB ranged from 0 to 8.3% and for SF ranged from 0 to 2.75%. Only one study demonstrated a greater recurrent instability rate with SB (P = .02). Overall SB complication rates ranged from 0 to 12.5% and SF ranged from 0 to 27%. Two studies reported greater complications and reoperations with SF related to hardware. Summary forest plots from 4 studies showed no significant difference in Walch Duplay score (mean difference, range -5.00 to 1.20 [95% confidence interval {CI} -12.13 to 8.56], I2 inconsistency = 0%), Rowe score (mean difference, range -2.00 to 4.00 [95% CI -7.37 to 7.66], I2 inconsistency = 45%), and VAS for pain (mean difference, range -0.10 to 0.60 [95% CI -0.72 to 1.33], I2 inconsistency = 0%). There was no statistically significant difference between SB and SF in the postoperative range of motion. Radiologically, there was no significant difference in graft positioning and union at final follow-up, but graft resorption was greater in SF (range 25.2%-47.6%) compared with SB (range 10.1%-18.5%). Biomechanical studies showed no significant difference in maximum load to failure (SB, range 184-266 N vs SF, range 148-288 N).

CONCLUSIONS

Clinically, SB fixation demonstrated similar functional outcome and range of motion when compared with SF, with the potential benefit of lower rates of graft resorption and hardware-related complications. Biomechanically there was no difference in maximum load to failure.

LEVEL OF EVIDENCE

Level III, systematic review of Level III and biomechanical studies.

Editorial Commentary: Suture Button Fixation for the Latarjet Procedure Is Superior to Screw Fixation

An increasing body of evidence suggests that suture button fixation is comparable with screw fixation in Latarjet and potentially associated with reduced graft resorption. Suture button fixation may facilitate performing the Latarjet procedure, particularly when done in an arthroscopic manner. The use of suture button fixation technique theoretically facilitates improved positioning of the graft on the glenoid, as it frees the surgeon from the potential of the soft-tissue envelope to impact positioning of the graft, which can occur with screw-based guides. The bone graft can be shuttled into an optimal position and then tensioned with relative ease in comparison with screw-based techniques. Suture button fixation results in lower complication rates compared with screw fixation; almost one third of the screw fixation complications are hardware-related, and screw fixation results in a high rate of hardware removal. Moreover, the arthroscopic Latarjet suture button literature is published by experienced surgeons. Arthroscopic Latarjet has a significant learning curve, reducing the translatability of studies that report superior findings with any one technique. The generalizability of results reminds us that evidence-based medicine should be practiced through the lens of not only patient preferences, but also through an honest appraisal of a surgeon's own ability.

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.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV.

The arthroscopic double-button Latarjet does not modify the static posterior translation of the humeral head

INTRODUCTION

The Latarjet procedure treats anterior instability of the shoulder and is based on a triple anterior lock, where the conjoint tendon straps the lower third of the subscapularis muscle. Excessive posterior translation of the humeral head is a known risk factor for shoulder osteoarthritis. No in vivo study has investigated the effect of the bone block on the posterior static translation of the humeral epiphysis. The purpose of this study was to evaluate the effect of the bone block on the static posterior translation of the humeral head. The hypothesis was that this procedure increased this translation.

MATERIALS AND METHODS

This retrospective study included patients treated arthroscopically for anterior shoulder instability by a double-button Latarjet. An independent examiner analyzed the CT scans preoperatively, at 15 days, and at least 6 months postoperatively according to a standardized protocol. The analysis focused on the position of the bone block in the axial and coronal planes relative to the glenoid. The posterior translation was automatically calculated using the Blueprint© planning software.

RESULTS

Thirty-five patients were included with a mean age of 25 years (16-43), according to a 4M/1F sex ratio. The graft was perfectly flush to the subchondral bone in 63% (n=22) of cases and subequatorial in 91% (n=32). Preoperative posterior humeral translation was 52%. The mean immediate postoperative posterior humeral translation was 56%, and 57% at more than 6 months. The change in mean posterior humeral translation between preoperative/6 months was +0.94% [-20%; +12%] (p=0.29) and immediate postoperative/6 months +0.34% [-18%; +15%] (p=0.84). Gender, hypermobility and the axial position of the bone block did not influence the change in posterior humeral translation. The equatorial position of the bone block appeared to increase posterior humeral translation by +10%±5.2% [-0.427; 20.823] (p=0.07).

CONCLUSION

This work refutes our initial hypothesis. The change in static posterior humeral translation after arthroscopic Latarjet bone block remains stable at more than 6 months of follow-up. This procedure does not alter the anatomical position of the humeral head in relation to the glenoid. On the other hand, a more cranial positioning of the bone block could have an influence.

LEVEL OF EVIDENCE

IV.

Latarjet in women for anterior shoulder instability: a case series analysis

PURPOSE

The Latarjet procedure is traditionally used to treat chronic anterior shoulder instability associated with glenoid bone loss. However, few series have analyzed outcomes in a female-only population. The objective of this study was to evaluate the clinical and radiological outcomes of a Latarjet bone block in this specific population.

METHODS

This single-center retrospective study included 15 women (mean age 35 ± 11.3; 19-60) reviewed with a minimum follow-up of 2 years. The procedure was performed using the open bone block screw technique (n = 7) or by arthroscopy with cortical button (n = 8). Clinical evaluation was based on active range of motion measurements, Rowe and Walch-Duplay scores, and subjective shoulder value (SSV). Radiographic analysis explored bone block healing at the last follow-up.

RESULTS

At a mean follow-up of 48 months (32-86), no recurrence was reported. The mean Rowe score was 91 points (70-100), Walch-Duplay 90 points (60-100), and SSV 87% (70-100). The active mobilities reached 169° (± 9°) in elevation, 57° (± 15°) in external rotation at side, and 89° (± 6°) in abduction. The return-to-sport rate was 91%. Five patients experienced persistent anterior pain, with screws requiring hardware removal in 2 (p = 0.02). Radiological assessment detected one case of nonunion (7%).

CONCLUSION

Women treated with the Latarjet procedure experienced satisfactory midterm clinical outcomes. The arthroscopic technique using cortical button fixation seems to avoid residual anterior pain requiring hardware removal.

Arthroscopic Latarjet yields better union and prevention of instability compared to arthroscopic bony Bankart repair in shoulders with recurrent anterior instability: a systematic review

PURPOSE

To determine whether arthroscopic Latarjet procedure or arthroscopic bony Bankart repair provide better outcomes in terms of rates of recurrent instability, non-union and complications, as well as clinical scores and range of motion.

METHODS

An electronic literature search was performed using PubMed, Embase®, and Cochrane databases, applying the following keywords: "Arthroscopic bony Bankart" OR "Arthroscopic osseous Bankart" AND "Arthroscopic Latarjet" OR "Arthroscopic coracoid bone block".

RESULTS

The systematic search returned 1465 records, of which 29 were included (arthroscopic bony Bankart repair, n = 16; arthroscopic Latarjet, n = 13). 37 datasets were included for data extraction, on 1483 shoulders. Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair had significantly higher instability rates (0.14; CI 0.10-0.18; vs 0.04; CI 0.02-0.06), significantly lower union rates (0.63; CI 0.28-0.91 vs 0.98; CI 0.93-1.00), and significantly lower pain on VAS (0.42; CI 0.17-0.67 vs 1.17; CI 0.96-1.38). There were no significant differences in preoperative glenoid bone loss, follow-up, complication rate, ROWE score, ASES score, external rotation, and anterior forward elevation between arthroscopic Latarjet and arthroscopic bony Bankart repair.

CONCLUSION

Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on VAS (0.45 vs 1.17). There were no differences in complication rates, clinical scores, or postoperative ranges of motion.

LEVEL OF EVIDENCE

IV.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

PURPOSE

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure.

METHODS

Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up.

RESULTS

No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P = .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P = .030 and P = .034, respectively).

CONCLUSIONS

Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Primary Stability and Bone Contact Loading Evaluation of Suture and Screw based Coracoid Graft Fixation for Anterior Glenoid Bone Loss

BACKGROUND

Reconstruction techniques for anterior glenoid bone loss have seen a trend from screws to suture-based fixations. However, comparative biomechanical data, including primary fixation and glenoid-graft contact pressure mapping, are limited.

HYPOTHESIS

Suture-based bone block cerclage (BBC) and suspensory suture button (SB) techniques provide similar primary fixation and cyclic stability to double-screw fixation but with higher contact loading at the bony interface.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 60 cadaveric scapulae were prepared to simulate anterior glenoid bone loss with coracoid autograft reconstruction. Graft fixation was performed with 3 different techniques: (1) an interconnected all-suture BBC, (2) 2 SB suspensions, and (3) 2 screws. Initial compression was analyzed during primary fixation. Cyclic peak loading with 50 N and 100 N over 250 cycles at 1 Hz was performed with a constant valley load of 25 N. Optical recording and pressure foils allowed for spatial bone block tracking and contact pressure mapping at the glenoid-graft interface. Load-to-failure testing was performed at a rate of 1.5 mm/s with ultimate load and stiffness measured.

RESULTS

Initial graft compression was higher with screw fixation (141 ± 5 N) compared with suture-based fixations (P < .001), with BBC fixation providing significantly higher compression than SB fixation (116 ± 7 N vs. 91 ± 5 N; P < .001). Spatial bone block migration and ultimate failure load were similar between the BBC and screw groups. The SB group showed significantly increased bone block translation (3.1 ± 1.0 mm; P≤ .014) and rotation (2.5°± 1.4°; P≤ .025) and significantly lower ultimate failure load (180 ± 53 N) compared with the BBC (P = .046) and screw (P = .002) groups. Both suture-based fixations provided significantly increased graft-glenoid contact loading with higher pressure amplitudes (P≤ .032) and contact pressure after cyclic loading (+13%; SB: P = .007; BBC: P = .004) compared with screw fixation.

CONCLUSION

Both SB and interconnected cerclage fixation improved dynamic contact loading compared with screw fixation in a biomechanical glenoid bone loss model. Cerclage fixation was biomechanically comparable with screw fixation but with a greater variability. SB fixation showed significantly lower primary fixation strength and greater bone block rotation and migration.

CLINICAL RELEVANCE

Suture-based bone block fixations improved graft-glenoid contact loading, but the overall clinical consequence on healing remains unclear.

Outcomes After Open Latarjet in Patients With or Without SLAP Lesions

Background

Up to 20% of shoulders with anterior instability are associated with superior labrum anterior-posterior (SLAP) lesions, and they remain untreated after an open Latarjet procedure. SLAP lesions can be responsible for pain and feelings of instability in high-demand patients.

Purpose/Hypothesis

The aim of this study was to compare the early functional outcomes and return to sport rates in athletes after the Latarjet procedure with versus without associated SLAP lesions. It was hypothesized that untreated SLAP lesions would not influence clinical results.

Study Design

Cohort study; Level of evidence, 3.

Methods

Inclusion criteria were athletes with anterior shoulder instability treated with Latarjet procedure, a minimum follow-up of 1 year, and an available preoperative computed tomography arthrogram. We recorded patient characteristics; type of sport; bone loss; Rowe, Single Assessment Numeric Evaluation (SANE), and 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; 5-point pain and satisfaction scores; reported apprehension; and return to sport. Patients with and without a preoperative type 5 SLAP lesion on imaging were compared.

Results

Fifty patients were included (mean age, 22 ± 5 years [range, 16-36 years]; mean follow-up, 27 ± 9 months [range, 12-42 months]). Thirty-four patients practiced contact sports, including 20 rugby players. Twelve patients (24%) had a preoperative SLAP lesion. Groups with (+) and without (-) a SLAP lesion were comparable in terms of age, sex, number of instability episodes, type of sport, and glenoid and humeral bone loss. The SLAP+ group had significantly worse outcomes with a lower Rowe score (79 ± 23 vs 91 ± 15; P = .018) and painless rate (50% vs 77%; P = .04). There were no significant differences between the groups in SANE score (SLAP+ vs SLAP-: 80% vs 87%), QuickDASH score (8% vs 8%), return to sport (83% vs 91%), apprehension (79% vs 50%), and reported satisfaction. There was 1 episode of postoperative subluxation in each group.

Conclusion

Patients who underwent an open Latarjet procedure with an associated SLAP tear more frequently reported postoperative pain than those without a SLAP lesion. Patients with untreated SLAP tears had significantly lower Rowe scores, although SANE score and return to sport were not significantly different between the groups.

Open Versus Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability: A Systematic Review and Meta-analysis

Background

The open Latarjet (OL) procedure and arthroscopic Latarjet (AL) procedure are able to treat recurrent anterior shoulder instability (RASI) with high success rates.

Purpose

To evaluate the clinical efficacy and postoperative revisions and complications between the OL and AL procedures in the treatment of RASI.

Study Design

Systematic review; Level of evidence, 3.

Methods

MEDLINE, Embase, and the Cochrane Library were searched to retrieve and include cohort studies comparing the OL and AL procedures for RASI. Clinical outcomes were compared, and results were reported as odds ratios (ORs) or mean differences (MDs) with 95% CIs.

Results

Eleven clinical trials with 1217 patients were included. There were no differences between the procedures in pain score, Rowe score, Walch-Duplay score, external rotation, persistent apprehension, instability, recurrence, revisions attributed to recurrent instability, overall complications, wound infection, hematoma, graft complications, screw-related complications, or osteoarthritis. When compared with the OL procedure, the AL procedure had a significantly lower nonunion rate (OR, 9.92; 95% CI, 1.71 to 57.71; P = .01); however, the AL procedure had a longer operation time (MD, -24.49; 95% CI, -48.44 to -0.54; P = .05), lower Western Ontario Shoulder Instability Index score (MD, 97.27; 95% CI, 21.91 to 172.63; P = .01), higher revision rate (OR, 0.39; 95% CI, 0.16 to 0.95; P = .04), and greater screw deviation (MD, -6.41; 95% CI, -10.25 to -2.57; P = .001).

Conclusion

For most outcome measures, no difference was seen between the OL and AL procedures. The AL procedure had a lower Western Ontario Shoulder Instability Index score and a higher revision rate and appeared to have a significant learning curve. However, the AL procedure resulted in a lower nonunion rate.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Arthroscopic Latarjet With Cortical Buttons Versus Open Latarjet With Screws: A Short-Term Comparative Study

BACKGROUND

The arthroscopic bone block procedure according to Latarjet remains a controversial subject, and few comparative studies have demonstrated the benefit of arthroscopy over open surgery.

PURPOSE/HYPOTHESIS

The objective of this study was to compare both procedures by analyzing the short-term clinical results. The hypothesis was that the arthroscopic procedure is superior to the standard open procedure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHOD

This was a retrospective comparative study. Patients treated for chronic anterior instability by arthroscopic Latarjet with double cortical buttons (group A) or open Latarjet with screws (group O) with a minimum follow-up of 12 months were included. Intraoperative (duration, complications) and postoperative (complications, pain, mobility, functional scores, resumption of sport, Patient and Observer Scar Assessment Scale scar aesthetics, satisfaction) data were compared.

RESULTS

In total, 50 patients were included (n = 24 in group A, n = 26 in group O). Operating time was longer in group A (103 vs 61 min; P = .001). The average number of days on analgesics was higher in group A (8.9 vs 5.3 days; P = .04). The complication rate was similar for the 2 groups (12.5% vs 27%; P = .46). At 3 months, the loss of external rotation was greater in group A (-33° vs -18°; P = .01), and resumption of sports was less frequent (11% vs 48%; P = .01). At 12 months, the average scores were excellent, with no significants differences between the 2 groups: Walch-Duplay average, 90 points; Rowe, 94 points; Subjective Shoulder Value (SSV), 92.5%; sport SSV, 85%; and Patient and Observer Scar Assessment Scale score, 17.2 points.

CONCLUSION

Over the short term, this comparative study did not prove the superiority of the cortical-button arthroscopic Latarjet procedure over the open Latarjet procedure. A delay in the resumption of sports, longer time to recover range of motion, and no benefit regarding postoperative pain or the aesthetic aspect of the scar were observed in this study with the arthroscopic procedure.

Use of Cannulated Screws for Primary Latarjet Procedures

Background

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

Purpose

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

Study Design

Case series; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

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).

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 "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.