Arthroscopic Anatomic Glenoid Reconstruction: Analysis of the Learning Curve

Arthroscopic Bone Block Stabilization for Anterior Shoulder Instability with Subcritical Glenohumeral Bone Loss

PURPOSE OF REVIEW

The management options for anterior shoulder instability with minimal bone loss or with critical bone loss are well established. However, there is less clear evidence to guide management for patients with subcritical bone loss, the spectrum of pathology where soft tissue repair alone is prone to higher rates of failures. In this range of bone loss, likely around 13.5% to 20%, the goal of surgery is to restore function and stability while limiting morbidity. As with many procedures in the shoulder, this decision should be tailored to patient anatomy, functional goals, and risk factors. This article provides a review of our current understanding of subcritical bone loss and treatment strategies as well as innovations in management.

RECENT FINDINGS

While surgeons have largely understood that restoration of anatomy is important to optimize outcomes after stabilization surgery, there is increasing evidence that reconstructing bony anatomy and addressing both osseous and soft tissue structures yields better results than either alone. Even in the setting of subcritical bone loss, there is likely a benefit to combined osseous augmentation with soft tissue management. Additionally, there is new evidence to support management of even on-track humeral lesions when the distance to dislocation is sufficiently small, particularly for athletes. Surgeons must balance bony and soft tissue restoration to achieve optimal outcomes for anterior instability with subcritical bone loss. There are still significant limitations in the literature and several emerging techniques for management will require further study to prove their long-term efficacy. Beyond surgery, there should be a focus on a collaborative treatment strategy with the surgeon, patient, and therapists to achieve high-level function and minimize recurrence.

Current Evidence and Techniques for Arthroscopic Bone Augmentation

The indications for bone block augmentation of the glenoid following recurrent anterior shoulder instability are expanding. Arthroscopic anatomic glenoid reconstruction (AAGR) is an evolving technique with similar clinical results to the Latarjet procedure and other open bone block procedures. Multiple types of bone grafts and fixation techniques have been described, with varying results on bony integration, resorption, articular congruity, and recurrence rates. This review focuses on biomechanics, patient workup, indications, current evidence, and the authors' preferred surgical technique for AAGR.

Osteochondral allografts for the treatment of shoulder instability

Aims

To systematically review the predominant complication rates and changes to patient-reported outcome measures (PROMs) following osteochondral allograft (OCA) transplantation for shoulder instability.

Methods

This systematic review, following PRISMA guidelines and registered in PROSPERO, involved a comprehensive literature search using PubMed, Embase, Web of Science, and Scopus. Key search terms included "allograft", "shoulder", "humerus", and "glenoid". The review encompassed 37 studies with 456 patients, focusing on primary outcomes like failure rates and secondary outcomes such as PROMs and functional test results.

Results

A meta-analysis of primary outcomes across 17 studies revealed a dislocation rate of 5.1% and an increase in reoperation rates from 9.3% to 13.7% post-publication bias adjustment. There was also a noted rise in conversion to total shoulder arthroplasty and incidence of osteoarthritis/osteonecrosis over longer follow-up periods. Patient-reported outcomes and functional tests generally showed improvement, albeit with notable variability across studies. A concerning observation was the consistent presence of allograft resorption, with rates ranging from 33% to 80%. Comparative studies highlighted similar efficacy between distal tibial allografts and Latarjet procedures in most respects, with some differences in specific tests.

Conclusion

OCA transplantation presents a promising treatment option for shoulder instability, effectively addressing both glenoid and humeral head defects with favourable patient-reported outcomes. These findings advocate for the inclusion of OCA transplantation in treatment protocols for shoulder instability, while also emphasizing the need for further high-quality, long-term research to better understand the procedure's efficacy profile.

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).

Clinical and radiographic outcomes of primary vs. revision arthroscopic anatomic glenoid reconstruction with distal tibial allograft for anterior shoulder instability with bone loss

BACKGROUND

The purpose of this study was to assess the clinical and radiographic outcomes of arthroscopic anatomic glenoid reconstruction (AAGR) used for primary vs. revision surgery for addressing anterior shoulder instability with bone loss.

METHODS

We performed a retrospective review on consecutive patients who underwent AAGR from 2012 to 2020. Patients who received AAGR for anterior shoulder instability with bone loss and had a minimum follow-up of 2 years were included. Exclusion criteria included patients with incomplete primary patient-reported outcome scores (PROs), multidirectional instability, glenoid fracture, nonrigid fixation and concomitant humeral avulsion of the glenohumeral ligament, or rotator cuff repair. Our primary outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) scores. Secondary outcomes included postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) scores, complications, recurrence of instability and computed tomographic (CT) evaluation of graft position, resorption, and healing.

RESULTS

There were 73 patients (52 primary and 21 revision) finally included. Both groups had comparable demographics and preoperative WOSI and DASH scores. The primary group had significantly better postoperative WOSI and DASH scores at final follow-up when compared to the revision group (WOSI: 21.0 vs. 33.8, P = .019; DASH: 7.3 vs. 17.2, P = .001). The primary group also showed significantly better WOSI scores than the revision group at the 6-month, 1-year, and 2-year time points (P = .029, .022, and .003, respectively). The overall complication rate was 9.6% (5 of 52) in the primary group and 23.8% (5 of 21) in the revision group. Both groups showed good graft healing and placement in the anterior-to-posterior and mediolateral orientation and had a similar rate of graft resorption and remodeling. There was no difference between the groups in the remainder of the CT measurements.

CONCLUSION

Functional outcome scores and stiffness were significantly worse in patients undergoing an AAGR procedure after a failed instability surgery when compared with patients undergoing primary AAGR. There were no differences in postoperative recurrence of instability or radiographic outcomes. As a result, AAGR should be considered as a primary treatment option within current treatment algorithms for shoulder instability.

Controversies in surgical management of anterior shoulder instability. State of the Art

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

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.

Learning curve in the arthroscopic Latarjet procedure: An analysis of the first 171 cases

Background

Arthroscopic Latarjet procedure is accepted as effective and safe. However, it is more likely to be challenging in execution. Therefore, the analysis of the learning curve remains to be worth examination.

Objective

To examine the learning curve in the arthroscopic Latarjet procedure through an analysis of the correlation between the average operative time, complications rate, and the total number of performed surgeries and execution frequency.

Materials and method

A total of 171 patients who underwent arthroscopic Latarjet surgery between 2013 and 2020 were included. Clinical findings were recorded postoperatively. We fixed the operative time with account taken of the execution frequency and the number of intra- and postoperative complications. All procedures were completed by one surgeon.

Results

By statistical analysis, a significant association between the operative time and the number of surgical interventions was found (p < 0.05). After 120 procedures, the average operative time demonstrated a constant reduction and reached 62.8 min (p < 0.05). We detected the relation between the average operative time and surgery frequency. The significant correlation between the number of intraoperative complications and the number of procedures performed manifests after the 20th surgery (p < 0.05). In total, 13 episodes of complications were recorded (7.6 %). 9 cases of intraoperative complications (5.3 %) conversed into the open Latarjet procedure. 4 episodes of postoperative complications (2.3 %) were documented, among them 2 hematomas which were treated conservatively, and 2 cases of recurrent shoulder instability. There were no neurological, neurovascular, and infection complications seen in our cohort.

Discussion

It took more than 120 arthroscopic procedures to reach the stable and reproducible indices in operative time, and more than 20 surgeries to achieve a significant reduction in the intraoperative complications rate. There was no correlation between the postoperative complication rate and the number of performed procedures. The overall level of complications did not exceed the level mentioned in the literature. The high surgical activity could be considered as a favorable factor to increase the efficiency of the learning process.

Conclusion

Gaining clinical experience with the passing of the learning stages impacts significantly the rate of intraoperative complications and operative time. The arthroscopic Latarjet procedure is safe and characterized with good clinical results even within the initial stages of the learning curve.

Acromion and Distal Clavicle Grafts for Arthroscopic Glenoid Reconstruction

BACKGROUND

We intended to determine if an acromion or distal clavicle bone graft could restore large glenoid defects using two novel, screw-free graft fixation techniques.

METHODS

Twenty-four sawbone shoulder models were divided into four groups (n = 6 per group) according to fixation technique and bone graft: (1) modified buckle-down technique with clavicle graft, (2) modified buckle-down technique with acromion graft, (3) cross-link technique with acromion graft, (4) cross-link technique with clavicle graft. Testing was performed sequentially in (1) intact models, (2) after creation of a 30% by-width glenoid defect and (3) after repair. The shoulder joint was translated anteriorly, and glenohumeral contact pressures and load were measured to quantify the biomechanical stability.

RESULTS

Maximum contact pressures were restored to 42-56% of intact glenoid using acromion and clavicle grafts with novel fixation techniques. Acromion grafts attained higher maximum contact pressures than clavicle grafts in all groups. Peak translational forces increased by 171-368% after all repairs.

CONCLUSIONS

This controlled laboratory study on sawbone models found that both the acromion and distal clavicle are suitable autologous bone graft options for treating large anterior glenoid defects, having appropriate dimensions and contours for reconstructing the glenoid arc. The modified buckle-down and cross-link techniques are two graft fixation techniques that restore stability to the shoulder joint upon repairing a large glenoid defect and are advantageous in being screw-free and simple to execute.

Arthroscopic anatomic glenoid reconstruction has a lower rate of recurrent instability compared to arthroscopic Bankart repair while otherwise maintaining a similar complication and safety profile

OBJECTIVES

The primary purpose of this study was to determine the frequency and type of complications, including subluxation, infection, hardware complication, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness following an Arthroscopic Bankart Repair (ABR) or an Arthroscopic Anatomic Glenoid Reconstruction (AAGR) using a distal tibia allograft for recurrent anterior shoulder instability. Secondary purposes were to determine the frank dislocation rate and the associations of post-operative complications with demographic patient factors.

METHODS

Demographic and clinical data were reviewed using means ± standard deviations or frequencies in patients with recurrent anterior shoulder instability who underwent either an ABR or an AAGR. Post-operative patient records were analysed to identify any post-operative complications. The numerical variables of the two groups were compared using the independent t-test or Mann-Whitney U test. Categorical variables and complications were tested using the chi-square test, Fisher's exact test, or the two-sided Monte Carlo test with a significance level of 0.05.

RESULTS

We included 174 patients in this cohort, with 61.5% of patients receiving ABR and 38.5% receiving AAGR. Most of our patients were male (70.1%) with an average age of 23.41 ± 8.26 years in the ABR group and 29.37 ± 13.54 years in the AAGR group (p = 0.001). The two groups were similar with respect to their post-operative complication rates when excluding frank dislocation (ABR: 11%, AAGR: 12%). The AAGR group had statistically significantly higher rates of hardware removal compared to the ABR group (p = 0.004). The ABR group had 25 post-operative frank dislocations, with none reported in the AAGR cohort (p < 0.001). The total complication rate for each procedure was found to be 35% for ABR and 12% for AAGR.

CONCLUSION

AAGR has a comparable safety profile to the ABR when assessing post-operative complications such as subluxation, infection, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness. AAGR is superior to ABR with respect to rates of recurrent instability and should be considered as a first-line treatment in certain patients with specific risk factors such as younger age, competitive contact sports participation, and higher number of instability events pre-operatively.

LEVEL OF EVIDENCE

Level III.

Fixation Type Does not Affect the Learning Curve and Short-Term Radiographic Outcomes for Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibia Allograft

Purpose

The purpose of this study was to compare the learning curves and radiographic variables between screw and suture button fixation of the allograft for surgeons learning the all-arthroscopic anatomic glenoid reconstruction (AAGR) technique for anterior shoulder instability. We compared the surgical times of these two fixation techniques, as well as the graft placement in the vertical and medial-lateral directions.

Methods

This was a retrospective review of patients who underwent AAGR for recurrent anterior shoulder instability. Start and end times were recorded for each procedure, and learning was assessed through the change in operative time over successive surgeries and by variability of operative time. Graft placement, in terms of vertical positioning, medial-lateral step formation, and obliquity of fixation (alpha angle), was evaluated using 3-dimensional CT scans at approximately 6 months postoperation.

Results

A total of 43 patients were included in our study. Twenty-seven had screw fixation, and 16 had suture button fixation. The surgical duration of the button fixation technique was comparable to that of screw fixation (P = .72), with no significant difference in the variability of surgical time in either cohort (P > .05). Both groups showed similarly optimal vertical positioning of the graft onto the lower third of the glenoid (P = .89). Desired obliquity of graft fixation was identified more frequently with button fixation (P < .001). Both fixation methods provided clinically acceptable medial-lateral step formations, with suture-button fixation being significantly larger (P = .03).

Conclusions

Suture button fixation of the allograft is a potential alternative to screw fixation for the management of glenoid bone loss in recurrent anterior shoulder instability. The results of this study show that this method has a comparable learning curve, with a similar surgical duration, while not compromising the optimal accuracy of vertical and medial-lateral placement of the graft and achieves a superior alpha angle of fixation.

Level of Evidence

Level III, retrospective cohort study.

Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibial Allograft and Hybrid Fixation

Glenoid grafting is the standard surgical treatment for recurrent shoulder instability with significant glenoid bone loss. Arthroscopic anatomic glenoid reconstruction using a distal tibial allograft for anatomic glenoid reconstruction has recently been gaining attention. This article describes the use of a hybrid graft fixation technique with 1 suture-EndoButton device and 1 compression screw in arthroscopic anatomic glenoid reconstruction using distal tibial allograft.

Treatment of Failed Latarjet With Arthroscopic Anatomic Glenoid Reconstruction

PURPOSE

Various methods have been described for the treatment of anterior shoulder instability with glenoid bone loss. The incidence of recurrent dislocations following surgical intervention is high and, therefore, necessitates a reliable and replicable revision procedure. The purpose of this Technical Note is to describe a method of arthroscopic anatomic glenoid reconstruction using a distal tibial allograft and screw fixation in the setting of a failed Latarjet procedure with significant glenoid bone loss.

METHODS

We describe in detail patient positioning, portal placement, steps of the diagnostic arthroscopy, and graft preparation using imaging and a detailed intraoperative arthroscopic technique.

LEVEL OF EVIDENCE

Level 1, Shoulder; Level 2, Instability.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV; systematic review.

Clinical outcome and repair integrity after arthroscopic rotator cuff repair significantly improved during the surgeon's learning curve

HYPOTHESIS AND BACKGROUND

Whether learning curve could affect the surgical outcome after arthroscopic rotator cuff repair is still unknown. The purpose of this study was to evaluate surgical learning curve for clinical outcome and retear rate after arthroscopic rotator cuff repairs that were performed by the beginner shoulder surgeon. We hypothesized that clinical outcome and retear rate would improve over time with the accumulation of a surgeon's experience.

METHODS

This retrospective study consisted of 200 consecutive patients who had arthroscopic rotator cuff repairs, performed by a single surgeon between 2011 and 2018. We included symptomatic rotator cuff tears involving the supraspinatus/infraspinatus and/or subscapularis tendon and follow-up magnetic resonance imaging evaluations of repair integrity 6 months after surgery. Surgeon's learning was evaluated with calculation of cumulative retear rate and cumulative summation (CUSUM) analysis. Clinical outcomes and the retear rates were compared between group A (the first-half 100 patients) and group B (the latter-half of 100 patients).

RESULTS

The mean follow-up period was 21 months (range, 12-55). The overall retear rate was 13% (26 patients). The CUSUM analysis showed that after patient number 97, the curve was maintained below the level of acceptable failure rate, suggesting the competency was obtained consistently. Comparing between groups, retear rate showed significant decrease from 18% in group A to 8% in group B (P = .036). Notably, retear rate in small to medium-sized tears (<3 cm) significantly decreased from 26% (12 of 46 patients) in group A to 2% (1 of 49 patients) in group B (P = .001). However, analysis in large to massive tears (≥3 cm) failed to show difference between groups (30%, 6 of 20, in group A and 25%, 6 of 24, in group B; P = .711). In multivariate analysis, higher fatty infiltration of the supraspinatus muscle (P = .008), more severe muscle atrophy of the teres minor (P = .010), and belonging to group A (P = .011) were associated with retear.

CONCLUSION

Clinical outcomes and retear rate after arthroscopic rotator cuff repairs significantly improved during the learning curve period of a beginner shoulder surgeon.

[Shoulder instability: review of current concepts of diagnosis and treatment]

OBJECTIVE

To conduct a systematic review of modern literature data on the modern approaches in diagnosis and treatment of shoulder instability.

MATERIAL AND METHODS

Searching for literature data was performed using the Pubmed and Google Scholar databases.

RESULTS

The authors analyzed the results of conservative treatment of patients with shoulder instability and emphasized higher risk of instability recurrence, degeneration of anatomical structures and functional impairment in these patients. Surgery is advisable to restore shoulder stability and normalize its function. Several methods for stabilizing the shoulder have been proposed.

The approaches to diagnosis and treatment of shoulder instability have been updated.

CONCLUSION

Successful treatment of shoulder instability is based on qualitative and complete assessment of soft tissues and bone structures. An individual approach considering bone tissue deficiency and individual needs of the patient is required.

Chapter 6: Attritional Glenoid Bone Loss in the Shoulder: Operative Considerations

Patients with recurrent anterior shoulder instability often have glenoid bone loss present in addition to soft tissue pathologies. It is known that patients with significant glenoid bone loss are best treated with a boney augmentation procedure as opposed to a soft tissue Bankart repair because of the high rate of recurrent instability that results from a Bankart repair. Although the Latarjet technique has been the gold-standard treatment for patients with glenoid bone loss because of the low incidence of recurrent instability, it has a high complication rate and a steep learning curve. Herein, the authors present the technique and outcomes for arthroscopic anatomic glenoid reconstruction that has a similar complication rate to the Bankart repair but with a low recurrence rate similar to the Latarjet. This procedure is safe, has a short learning curve, low recurrence rate, and positive patient-reported outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Arthroscopic Anatomic Glenoid Reconstruction Using Distal Tibial Allograft for Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes

BACKGROUND

The all-arthroscopic anatomic glenoid reconstruction technique using a distal tibial allograft avoids damage to the subscapularis muscle and allows repair of the capsulolabral tissue.

PURPOSE

To analyze the clinicoradiologic outcomes of patients who underwent this procedure to treat anterior shoulder instability with glenoid bone loss with a minimum 2-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over 6 years, 73 patients (52 male and 21 female; mean age, 28.8 years) under the care of the same surgeon underwent arthroscopic stabilization with capsulolabral Bankart repair and bony allograft augmentation of the glenoid for recurrent shoulder instability with significant bone loss. Pre- and postoperative patient-reported functional assessment was performed using 2 questionnaires, the Western Ontario Shoulder Instability Index (WOSI) and the Disabilities of the Arm, Shoulder and Hand, and radiological assessment was performed using radiographs and computed tomography scans obtained preoperatively and approximately 1 year later (mean ± SD, 0.9 ± 1.1 years).

RESULTS

The mean follow-up was 4.7 ± 1.1 years. The mean pre- and postoperative WOSI scores were 71.1 ± 17.5 and 25.6 ± 21.9, respectively (P < .001). There were no recurrences of dislocation, although 1 patient had symptoms of subluxation; however, 5 patients had hardware complications that required screw removal. There were no cases of nerve injury. Postoperative computed tomography scans were available for 66 patients. Seven patients were lost to follow-up. The graft union rate was 100%. Overall, graft resorption was <50% in 86% of patients (57/66). Eighteen patients (27%) had no resorption (grade 0), 39 (59%) had <50% (grades 1 and 2), and 9 (14%) had ≥50% (grade 3); however, none had symptoms of instability. The mean alpha angle of the screw between the screw shaft axis and the native glenoid axis was 18.3°± 5.7°. Graft positioning was flush with the glenoid in 61 of 66 patients (92.4%), and vertical positioning was excellent in 64 of 66 patients (97.0%) (3- to 5-o'clock position).

CONCLUSION

Arthroscopic stabilization using distal tibial allograft augmentation resulted in excellent clinicoradiologic outcomes at a 2-year follow-up. This procedure has the advantages of being an anatomic reconstruction that addresses bony and soft tissue instability. However, long-term follow-up studies are necessary for better assessment of outcomes.

Arthroscopic Anatomic Glenoid Reconstruction in the Setting of a Failed Latarjet Using Distal Tibial Allograft

Treatment of traumatic anterior glenohumeral dislocation has evolved over the years in terms of surgical approaches and methods of repair. Recurrence of instability following surgical repair remains challenging with conventional methods of open reconstruction. We describe the utilization of arthroscopic anatomic glenoid reconstruction using a distal tibial allograft after a failed Latarjet procedure. Preoperative and operative methodology are described with relevant imaging investigations and a detailed intraoperative arthroscopic technique.

Innovative Approaches in the Management of Shoulder Instability: Current Concept Review

PURPOSE OF REVIEW

This article summarises the latest innovations and concepts in the management of shoulder instability associated with glenoid bone loss.

RECENT FINDINGS

The management of shoulder instability has undergone significant evolution in the last century with rapid strides being made in the last few decades due to the transition from open to arthroscopic techniques allowing management of pathological entities which were previously untreatable. However, there is no consensus on treatment methods, especially in the presence of glenoid bone loss. The complication profile associated with non-anatomic glenoid bony reconstruction procedures has triggered research for alternate techniques using free bone grafts. Open Latarjet procedure continues to be the gold standard in the face of glenoid bone loss; however, arthroscopic anatomic glenoid reconstruction with bone block grafts is gaining in popularity and is associated with excellent short-term clinico-radiologic outcomes. Arthroscopic anatomic glenoid reconstruction using bone grafts has been proposed as an alternative to the complex all-arthroscopic Latarjet procedure with excellent short-term results, minimal complications and a relatively easier learning curve. Capsular reconstruction has emerged as option for the management of instability with poor quality or absent capsular tissue. Future long-term outcome studies and randomised comparative trials will determine if these innovations stand the test of time.