Arthroscopically-assisted Latarjet: an easy and reproducible technique for improving the accuracy of graft and screw placement

Arthroscopically Assisted Anterior Bone Block for Shoulder Instability

Background:

Shoulder instability is a common complaint, with treatment depending on the severity of the bony defect. Advancements in arthroscopic techniques have allowed for a less invasive surgery with decreased postoperative pain, improved graft placement, and better visualization.

Indications:

Large bony defects of the glenoid require bone block augmentation to reduce recurrent instability. In this presentation, arthroscopically assisted anterior bone block was performed with a distal tibial allograft to address recurrent anterior shoulder instability with a large glenoid defect.

Technique Description:

The patient is placed in a lateral decubitus position. Standard arthroscopic portals are made. The bone block is fashioned from a distal tibial allograft. Using a guide, drill holes are placed in the bone block. The guide is inserted from the posterior portal and placed parallel to the joint surface. Using drill sleeves, superior and inferior screw holes are drilled and a metal cannula is left in place to allow for shuttling of suture. Two anchors are placed on the glenoid to allow for capsule labral junction to be brought up to the graft once the graft is in place. The bone block is delivered through a dilated anterior portal and reduced. The sutures are tensioned. A button is placed on each set of looped sutures, a Nice knot is placed into each, and a tensioning device is tensioned. Once compression is achieved, knots are tied to perform final fixation over the buttons. A suture passing device is used to grab inferior capsule and labrum to the priorly placed anchor on the inferior glenoid and tied.

Results:

Arthroscopically assisted anterior bone block for shoulder instability has been demonstrated to have similar clinical and radiographic outcomes when compared with open treatment. However, arthroscopically assisted Latarjet has been shown to have decreased soft tissue disruption and possible improvements in graft placement.

Discussion/Conclusion:

Arthroscopically assisted anterior bone block is a technically demanding surgery but has been shown to have similar outcomes when compared with open treatment. In this video, we demonstrate an arthroscopically assisted anterior bone block for recurrent anterior shoulder instability.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

A biomechanical comparison of steel screws versus PLLA and magnesium screws for the Latarjet procedure

INTRODUCTION

The fixation of the coracoid process onto the glenoid is an important step of the Latarjet procedure, and implant-associated complications are a relevant and severe problem. This study compares the fixation strength and failure mode of two biodegradable materials with stainless-steel screws.

METHODS

24 Fresh-frozen cadaveric scapulae were divided into three groups of equal size and received a coracoid transfer. Cadavers were matched according to their bone mineral density (BMD). In group 1, small-fragment screws made of stainless steel were used. In the second group, magnesium screws were used, and in the third group, screws consisted of polylactic acid (PLLA). A continuously increasing sinusoidal cyclic compression force was applied until failure occurred, which was defined as graft displacement relative to its initial position of more than 5 mm.

RESULTS

At 5-mm displacement, the axial force values showed a mean of 374 ± 92 N (range 219-479 N) in group 1 (steel). The force values in group 2 (magnesium) had a mean of 299 ± 57 N (range 190-357 N). In group 3 (PLLA), failure occurred at 231 ± 83 N (range 109-355 N). The difference between group 1 (steel) and group 2 (magnesium) was not statistically significant (P = 0.212), while the difference between group 1 (steel) and group 3 (PLLA) was significant (P = 0.005).

CONCLUSION

Stainless-Steel screws showed the highest stability. However, all three screw types showed axial force values of more than 200 N. Stainless steel screws and PLLA screws showed screw cut-out as the most common failure mode, while magnesium screws showed screw breakage in the majority of cases.

EVIDENCE

Controlled laboratory study.

Variation in technique and postoperative management of the Latarjet procedure among orthopedic surgeons

BACKGROUND

The Latarjet procedure has become a treatment of choice for glenohumeral instability in the setting of large glenoid osseous defects (>20%) and for prior failed soft tissue repairs. However, surgical techniques and postoperative rehabilitation protocols vary among expert shoulder surgeons. The purpose of this survey study was to characterize the variation in current practice patterns among fellowship-trained orthopedic shoulder surgeons and identify factors related to variation.

METHODS

A 9-question survey was created (SurveyMonkey, San Mateo, CA, USA) and distributed to orthopedic surgeons who are active members of the American Shoulder and Elbow Surgeons or American Orthopaedic Society for Sports Medicine. The survey asked questions regarding surgeon experience with the Latarjet procedure, fellowship training, open vs. arthroscopic approach, method of coracoid-to-glenoid fixation, period of sling use postoperatively, and time before clearance to return to sport. Subgroup analysis was performed to determine whether further variation was evident between surgeons who completed sports medicine vs. shoulder and elbow fellowship training.

RESULTS

In total, 242 surgeons completed the survey. Of these, 55% indicated performing a sports medicine fellowship and 39% indicated completing a shoulder and elbow fellowship. Among all surgeons, the classic open Latarjet procedure was the strongly preferred technique (79%), followed by the open congruent-arc (17%) and all-arthroscopic (3%) techniques. With respect to fixation, 98% used screw fixation and only 1% indicated cortical button use. With respect to the postoperative course, >85% of surgeons preferred immobilization for 3-6 weeks after the procedure and 42% of respondents stated they waited ≥6 months prior to clearing their patients to return to sport. Subgroup analysis revealed that surgeons who completed a shoulder and elbow fellowship performed the classic open technique 89% of the time compared with 63% of those who completed a sports medicine fellowship (P < .001).

CONCLUSION

The results of our survey study indicate an overall strong preference for the open classic Latarjet technique as well as an overall strong preference for screw fixation of the coracoid graft to the glenoid among all surgeons. Shoulder and elbow fellowship-trained surgeons are significantly more likely to perform open surgery with a classic technique compared with sports medicine fellowship-trained surgeons. Furthermore, the significant variation in postoperative sling use and return to sport suggests that further research is needed to develop an evidence-based postoperative Latarjet rehabilitation protocol.

Comparison of Coracoid Graft Position and Fixation in the Open Versus Arthroscopic Latarjet Techniques: A Cadaveric Study

BACKGROUND

Since the description of the arthroscopic Latarjet technique, discussion about the superiority of the open or arthroscopic procedure has arisen. The appropriate placement of the coracoid graft (CG) on the anterior glenoid neck is reported to be the most important step of the Latarjet procedure.

PURPOSE

To verify if there are differences in the parameters that may affect the final position and fixation of CG obtained from the open and arthroscopic Latarjet techniques.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty fresh-frozen human paired cadaveric shoulder specimens were randomly distributed in 2 surgery groups (open group [OG] and arthroscopic group [AG]) with 10 specimens in each. Two surgeons, each with experience performing open and arthroscopic Latarjet techniques, executed these procedures: one surgeon performed all open techniques, and the other performed all arthroscopic techniques, respectively. After surgery, a computerized tomography scan was performed. The surgical time, the position of each CG, a series of variables that might affect the CG fixation, and the level of the subscapularis muscle split were evaluated.

RESULTS

The mean surgical time was significantly longer in the AG (mean, 26 minutes for OG and 57 minutes for AG). Three intraoperative complications (30%) were identified in the AG, consisting of graft fractures. The CG was determined to be in an optimal cranial-caudal position in 90% of specimens of the OG and 44% of the AG (Fisher, P = .057). In both groups, the CG was placed in an optimal medial-lateral position in all specimens. In the OG, the degree of parallelism between the major axes of the glenoid surface and CG was significantly greater than in the AG (mean, 3.8º for OG and 15.1º for AG). No significant differences were observed in superior and inferior screw orientation between the groups. In the longitudinal and transverse directions, significant differences were found in the centering of the superior screw, being closer to the ideal point in the OG than in the AG. The location where the longitudinal subscapularis muscle split was performed was significantly higher in the AG.

CONCLUSION

The open Latarjet technique required less surgical time; presented a lower number of intraoperative complications; and allowed more adequate placement of the CG, better centering of the screws, and a subscapularis muscle split closer to the ideal position.

CLINICAL RELEVANCE

The reported benefits of the arthroscopic Latarjet technique seem less clear if we take into account the added surgery time and complications.

Arthroscopic Latarjet Procedure: A Technique Using Double Round ENDOBUTTONs and Specific Glenoid and Coracoid Guides

The Latarjet procedure is a method used for the treatment of shoulder instability in the presence of bone loss. A decade after the first description of the fully arthroscopic Latarjet procedure, modifications to the technique were reported to decrease the risk of complications and improve the position of the bone block. A recent trend toward the use of buttons to fix the coracoid has been reported. The technique described here is an arthroscopic Latarjet procedure that uses 2 pairs of round buttons as an alternative to screw fixation or the use of a single button, and the technique aims to combine the original procedure with safe and stable fixation.

A new mini-open technique of arthroscopically assisted Latarjet

BACKGROUND

The aim is to describe a new arthroscopically assisted Latarjet technique.

METHODS

We evaluated the clinical and radiological findings of 60 patients with chronic recurrent anterior gleno-humeral instability who underwent, between September 2013 and November 2014, an arthroscopically-assisted Latarjet procedure with double round endobutton fixation. Inclusion criteria were: chronic anterior recurrent instability, Instability Severity Index Score (ISIS) greater than three points, a glenoid bone defect > 15% or a Hill Sachs lesion with concomitant glenoid bone defect > 10%. During surgery the joint capsule and the anterior glenoid labrum were detached. Two drill tunnels perpendicular to the neck of the glenoid were made through a guide. An accessible pilot hole through the glenoid was created to allows the passage of guidewires for coracoid guidance and final fixation onto the anterior glenoid. Through a restricted deltopectoral access a coracoid osteotomy was made. Finally, the graft was prepared, inserted and secured using half-stitches.

RESULTS

The mean follow-up was 32.5 months (range 24-32 months). At a mean follow-up, 56 of the 60 subjects claimed a stable shoulder without postoperative complaints, two (3.3%) had an anterior dislocation after new traumatic injury, and two (3.3%) complained of subjective instability. At the latest follow-up, four subjects complained of painful recurrent anterior instability during abduction-external rotation with apprehension. At 1 year, the graft had migrated in one patient (1.7%) and judged not healed and high positioned in another patient (1.7%). Moreover, a glenoid bony gain of 26.3% was recorded. At the latest follow-up, three patients had grade 1 according to Samilson and Prieto classification asymptomatic degenerative changes. Nerve injuries and infections were not detected. None of the 60 patients underwent revision surgery. Healing rate of the graft was 96.7%.

CONCLUSIONS

This technique of arthroscopically assisted Latarjet combines mini-open and arthroscopic approach for improving the precision of the bony tunnels in the glenoid and coracoid placement, minimizing any potential risk of neurologic complications. It can be an option in subjects with anterior gleno-humeral instability and glenoid bone defect. Further studies should be performed to confirm our preliminary results.

TRIAL REGISTRATION

Trial registration number 61/int/2017 Name of registry: ORS Date of registration 11.5.2017 Date of enrolment of the first participant to the trial: September 2013 'retrospectively registered' LEVEL OF EVIDENCE: IV.

Anatomic considerations for arthroscopic glenoid reconstruction using iliac crest grafts: a radiologic study

BACKGROUND

Arthroscopic glenoid reconstruction using autografts is an advanced procedure that requires experience and preparation. Knowledge about anatomic pitfalls is therefore important to establish well-positioned portals and prevent neurovascular damage.

METHODS

We included 43 computed tomography scans from 43 patients. The distance between the tip of the coracoid process and a perpendicular line representing the anteroinferior glenoid was measured. From these results an anteroinferior working portal was designed, and the angulation needed for screw insertion to fixate a hypothetical graft was measured. In a second step, 9 patients underwent magnetic resonance imaging scans 34 ± 10 months after glenoid reconstruction, and the distance between the screw approach path and the neurovascular bundle was measured.

RESULTS

In the analyzed scans, average defect size was 23%, and the coracoid process to the anteroinferior glenoid distance was 32 ± 7 mm. We thus hypothesized that a corridor 20 to 30 mm inferior to the coracoid process would be the ideal position for a working portal. Through this portal, 85% of screws could be applied with 0° to 30° angulation. When the postoperative scans were analyzed, the distance from the neurovascular bundle showed an average of 26 ± 6 mm for the superior screw and 21 ± 5 mm for the inferior screw.

CONCLUSIONS

The ideal distance between the coracoid process and an anteroinferior working portal is 32 mm. Having established the portal, instruments should not be inserted pointing in a medial direction of the coracoid process due to the proximity of the neurovascular bundle.

Anthropometric and Radiologic Measurements of Coracoid Dimensions and Clinical Implications in an Indian Population

Background:

Recurrent shoulder dislocation and anterior instability are most commonly attributed to pathology of the capsulolabral complex with the presence of bony loss at the humeral and glenoid surfaces. Unassessed bone loss has been a cause of failure of primary soft tissue procedures or recurrence of symptoms, despite adequate address of soft tissue pathology.

Purpose:

To study the anthropometric and radiologic dimensions of the coracoid in relation to glenoid bone loss, its adequacy in filling glenoid defects in an Indian population, and whether the choice of surgical technique (congruent arc vs classical) and graft positioning alters the surgical results. This study also intended to establish whether computed tomography measurements correlate with actual anthropometric measurements.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 64 participants with 108 healthy shoulders were included in this study. Additionally, 100 skeletally mature bone specimens of the scapula were measured to assess glenoid diameter as well as coracoid width and length in 2 perpendicular planes with a humeral subtraction 3-dimensional en face glenoid view.

Results:

Specimen and participant measurements proved that the congruent arc technique was able to fill up to 50% more glenoid bone loss than the classical technique in an Indian population (mean ± SD, 13.45 ± 6.97 vs 7.96 ± 4.89 mm, respectively), with computed tomography being the best and most accurate modality to study it. The mean difference in the bone block length restoration of the glenoid bony arc was 5.41 ± 2.08 mm. Radii of curvature were congruent in populations of the Indian subcontinent.

Conclusion:

The congruent arc technique can be performed in an Indian population but with caution and careful presurgical assessment of bone loss. However, adequate coracoid dimension to accommodate the implant for fixation without failure must be ensured, as anthropometry suggests the existence of a subset of the population in whom the graft may have compromised width for accommodating standard implants for fixation.