Can a Drill Guide Improve the Coracoid Graft Placement During the Latarjet Procedure? A Prospective Comparative Study With the Freehand Technique

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.

Use of 3D-Printed Patient-Specific Guide for Latarjet Procedure in Patients With Anterior Shoulder Instability: Technical Note

Anterior shoulder instability can lead to anterior glenoid bone loss associated with humeral posterior deformity (bipolar bone loss). Latarjet procedure is a commonly used surgical option in such cases. However, the procedure is associated with complications in up 15% of the cases often associated with inadequate positioning of coracoid bone graft and screws. Considering that acknowledgment of patient anatomy and use of surgical planning intraoperatively can reduce such complications, we describe the use of 3D printing tools to obtain a 3D Patient-Specific Surgical Guide to aid in the Latarjet procedure. Such tools present advantages and limitations compared to other tools available, which are also discussed in this article.

Biomechanical comparison between various screw fixation angles for Latarjet procedure: a cadaveric biomechanical study

BACKGROUND

The Latarjet procedure is a reliable treatment for the management of anterior glenohumeral instability with glenoid bone loss. However, the biomechanical properties of different fixation angles between screw and glenoid surface (α angle) have rarely been studied. The aim of the study was to investigate and compare the fixation stability, failure load, and failure mechanism between different α angles for Latarjet procedures, which were performed on cadaver specimens.

METHODS

Twenty-four shoulder specimens (8 in each of 3 groups) were dissected free of all soft tissue, and a 25% glenoid defect was created. The coracoid process was osteomized and fixed with 2 screws at 3 different α angles: 0° (group A), 15° (group B), and 30° (group C). Specimens were mounted to a testing apparatus, and cyclic loading (100 cycles at 1 Hz) was applied with a staircase protocol (50, 100, 150, and 200 N). Gross graft displacement and interface displacement were measured. The ultimate failure loads and failure mechanisms were recorded.

RESULTS

There was no significant difference in gross displacement under any cyclic load between 3 groups. However, a significant larger interface displacement was noted in group C than in group A in 150-N cyclic loading (P = .017). Under failure strength testing, all 24 specimens failed because of screw cutout from the glenoid, and the ultimate failure load was similar among the three groups.

CONCLUSION

Compared with the 0° α angle, the displacement after cyclic loading did not significantly increase when the α angle was increased to 15° but significantly increased at 30° for Latarjet procedures, which were performed on cadaver specimens. The results suggest that surgeons should apply the screws as parallel as possible to the glenoid surface when performing the Latarjet procedure. Although mild deviation may not reduce fixation stability, α angles greater than 30° should be avoided.

Use of Cannulated Screws for Primary Latarjet Procedures

Background

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

Purpose

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

Study Design

Case series; Level of evidence, 4.

Methods

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

Results

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

Conclusion

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

Arthroscopic Trillat technique for chronic post-traumatic anterior shoulder instability: outcomes at 2 years of follow-up

BACKGROUND

The purpose of this study was to assess the outcomes of a new arthroscopic Trillat technique at a 2-year follow-up. Our current hypothesis was that this technique could be used for the effective treatment of chronic post-traumatic unidirectional anterior shoulder instability, and that the recurrence and complication rates, external rotation, and functional outcomes would be as good as those of the reference technique.

METHODS

Between April 2012 and August 2016, all patients older than 16 years who underwent the arthroscopic Trillat technique for unidirectional chronic post-traumatic anterior shoulder instability at the Dijon University Hospital (France), after the failure of well-conducted medical and rehabilitation treatment with at least 24 months of follow-up, were included. Criteria for noninclusion were association with posterior and/or inferior instabilities, voluntary instabilities, and glenoid bone loss greater than 20%. Patients attended follow-up with their surgeon before the intervention, in the immediate postoperative period, at 6 weeks, 3 and 6 months, and then by an independent observer for the last evaluation. Patients were then examined clinically with scores such as Constant, Rowe and Walch-Duplay scores, and subjective shoulder value, for shoulder range of motion, and radiographically (anteroposterior and Lamy's lateral x-rays of the operated shoulder).

RESULTS

Forty-nine patients and 52 shoulders were included, with a mean follow-up of 40 months (range, 24-71 months). The recurrence rate of instability was 3.8% (2 of 52). No conversion to arthrotomy was necessary. No intraoperative complications, postoperative neurological lesions, or sepsis were observed. The mean Constant score was 92.1 (77.5-100) points, Walch-Duplay 82.9 (40-100), Rowe 81.73 (5-100), and subjective shoulder value 86.1 (50-100) at the last follow-up. The arm at side external rotation limitation averaged 8.4° (-25° to 40°) and the external rotation with 90° arm abduction limitation 0.34° (-5° to 15°). Forty-one patients (79%) resumed their sports activity at the same level. Fifty patients (96%) were satisfied to very satisfied. One patient developed nonunion of the coracoid process and subsequently underwent a Latarjet procedure with a good outcome.

CONCLUSIONS

The arthroscopic Trillat procedure offers good outcomes as a first-line treatment for chronic anterior post-traumatic glenohumeral instability. It should be excluded in cases of glenoid loss greater than 20%.

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%).

A hybrid open-arthroscopic latarjet coracoid bone-block technique using "HyLa" instrumentation

Latarjet coracoid bone-block is a gold-standard procedure for anteroinferior instability of the shoulder. Nowadays, it can be performed as open surgery or entirely under arthroscopy. The pure arthroscopic technique has the advantage of allowing concomitant intra-articular surgery, but involves a long learning curve. Here we present a hybrid concept using dedicated instrumentation comprising a specific guide with or without arthroscopic step, and notably ensuring the safety and reproducibility of the procedure, whatever the modality. This technique offers an alternative to arthroscopic coracoid bone block, performing the more complex steps as open surgery without major change to Latarjet's original technique, so as to enable concomitant intra-articular surgery if needed while getting around some of the limitations of the purely arthroscopic procedure.

Open Classic Latarjet Procedure Performed Using Freehand Technique-Surgical Technique and Outcome

INTRODUCTION

Latarjet procedure is commonly performed for recurrent anterior shoulder instability with glenoid side bone loss. Classic Latarjet procedure can be performed using specially designed drill guides, jigs, or by freehand technique. Here we have described a technical note on classic Latarjet procedure performed with freehand technique utilizing simple rulers and caliper. The functional and radiological outcomes of our patients have also been analysed.

MATERIAL AND METHODS

149 open classic Latarjet procedures were performed using our technique between March 2015 and July 2018. The mean age of the patients was 32.95 years (Range 22-59 years). The functional outcome of the patients was measured using Western Ontario Shoulder Instability (WOSI) and Oxford Shoulder Instability Score (OSIS) at 2 years of follow-up. Screw and graft positioning were studied in 24 consecutive patients with a postoperative computed tomography (CT) scan.

RESULTS

There was no incidence of recurrent subluxation or dislocation post-surgery. Mean OSIS score increased from 15.63 ± 3.20 preoperatively to 42.44 ± 3.88 postoperatively (p value < 0.05). WOSI score decreased significantly from 62.54% ± 8.24 to 10.26 ± 6.33 postoperatively at 2-year follow-up (p value < 0.05). Postoperative CT scan also showed satisfactory screw placement in all patients.

CONCLUSION

Open Latarjet procedure performed using freehand technique provides good functional and radiological outcomes in patients with recurrent anterior shoulder instability with glenoid side bone loss.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00385-7.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures

BACKGROUND

Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain.

PURPOSE/HYPOTHESIS

The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders.

RESULTS

Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment.

CONCLUSION

The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

Immediate self-rehabilitation after open Latarjet procedures enables recovery of preoperative shoulder mobility at 3 months

PURPOSE

To evaluate short-term clinical outcomes of shoulders treated for anterior instability by open Latarjet procedures (OLP) followed by immediate self-rehabilitation. The hypothesis was that patients would recover preoperative function at 3 months with no adverse events related to self-rehabilitation.

METHODS

The authors retrieved clinical and radiographic records of 307 consecutive shoulders treated by the same surgeon for anterior instability by OLP with immediate self-rehabilitation. Four shoulders did not meet eligibility criteria and 38 were lost to follow-up, leaving a study cohort of 265 shoulders. Patients performed self-rehabilitation exercises at home from the first postoperative day. Follow-ups at 1 and 3 months evaluated recurrence of instability, postoperative complications, pain, active forward elevation (AFE), passive forward elevation (PFE), external rotation (ER) and internal rotation (IR).

RESULTS

The difference between mobility before surgery and at 3 months was 0° for AFE, 0° for PFE, 10° for ER, and 0 spine segments for IR. Thirteen shoulders (5%) which had not followed the self-rehabilitation protocol during the first month had significantly more pain and less improvements in mobility (p < 0.05). Multivariable analyses revealed that patients who adhered to self-rehabilitation in the first month had greater improvements of AFE, PFE, and IR (p < 0.05).

CONCLUSIONS

Immediate self-rehabilitation after open Latarjet procedures enabled recovery of preoperative shoulder mobility at 3 months. Patients who did not adhere to immediate self-rehabilitation had more pain and less improvement in mobility. Furthermore, immediate self-rehabilitation was found to be independently associated with better recovery and did not cause any adverse events.

LEVEL OF EVIDENCE

Level IV.

Editorial Commentary: Computed Tomography-based Analysis of the Arthroscopic Latarjet Procedure Suggests Graft Positioning Is More Variable than Expected

The Latarjet operation is one of the most successful techniques for the treatment of recurrent anterior shoulder instability, which has recently been translated into the arthroscopic field. Several studies suggest that its arthroscopic variant is safe and reproducible and report promising short-term and mid-term results. Some authors claim that, in addition to less soft tissue damage, positioning of the coracoid graft is more accurate during arthroscopic control. There is currently no evidence of superiority of the arthroscopic or the open technique. As with the open procedure, the arthroscopic Latarjet operation requires a substantial learning curve; therefore the arthroscopic technique should be reserved for experienced arthroscopists treating a large number of shoulder instabilities.

Arthroscopic Latarjet Techniques: Graft and Fixation Positioning Assessed With 2-Dimensional Computed Tomography Is Not Equivalent With Standard Open Technique

PURPOSE

To analyze graft and fixation (screw and EndoButton) positioning after the arthroscopic Latarjet technique with 2-dimensional computed tomography (CT) and to compare it with the open technique.

METHODS

We performed a retrospective multicenter study (March 2013 to June 2014). The inclusion criteria included patients with recurrent anterior instability treated with the Latarjet procedure. The exclusion criterion was the absence of a postoperative CT scan. The positions of the hardware, the positions of the grafts in the axial and sagittal planes, and the dispersion of values (variability) were compared.

RESULTS

The study included 208 patients (79 treated with open technique, 87 treated with arthroscopic Latarjet technique with screw fixation [arthro-screw], and 42 treated with arthroscopic Latarjet technique with EndoButton fixation [arthro-EndoButton]). The angulation of the screws was different in the open group versus the arthro-screw group (superior, 10.3° ± 0.7° vs 16.9° ± 1.0° [P < .001]; inferior, 10.3° ± 0.8° vs 15.7° ± 0.9° [P < .0001]). The angulation of the EndoButtons was 5.7° ± 0.5°; this was different from that of open inferior screws (P = .003). In the axial plane (level of equator), the arthroscopic techniques resulted in lateral positions (arthro-screw, 1.5 ± 0.3 mm lateral [P < .001]; arthro-EndoButton, 0 ± 0.3 mm lateral [P < .0001]) versus the open technique (0.9 ± 0.2 mm medial). At the level of 25% of the glenoid height, the arthroscopic techniques resulted in lateral positions (arthro-screw, 0.3 ± 0.3 mm lateral [P < .001]); (arthro-EndoButton, 0.7 ± 0.3 mm lateral [P < .0001]) versus the open technique (1.0 ± 0.2 mm medial). Higher variability was observed in the arthro-screw group. In the sagittal plane, the arthro-screw technique resulted in higher positions (55% ± 3% of graft below equator) and the arthro-EndoButton technique resulted in lower positions (82% ± 3%, P < .0001) versus the open technique (71% ± 2%). Variability was not different.

CONCLUSIONS

This study shows that the position of the fixation devices and position of the bone graft with the arthroscopic techniques are statistically significantly different from those with the open technique with 2-dimensional CT assessment. In the sagittal plane, the arthro-screw technique provides the highest positions, and the arthro-EndoButton technique, the lowest. Overall, the mean position of the bone block with the open Latarjet technique in the axial plane is slightly medial to the joint line, as recommended. Conversely, with the arthroscopic techniques, the bone grafts are more lateral with a slight overhang. The main differences are observed in the dispersion of the values (more extreme positions) with the arthro-screw technique, given the acknowledged limitations. Despite the statistical significance, the clinical significance of these differences is yet unknown.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.