A biomechanical assessment of superior shoulder translation after reconstruction of anterior glenoid bone defects: The Latarjet procedure versus allograft reconstruction

[Early-term effectiveness of Latarjet procedure by coracoid osteotomy with preserving coracoacromial ligament for recurrent anterior shoulder dislocation]

Objective

To evaluate the early-term effectiveness of Latarjet procedure with double EndoButtons fixation for recurrent anterior shoulder dislocation by coracoid osteotomy with preserving coracoacromial ligament.

Methods

Between January 2021 and June 2023, 19 patients with recurrent anterior shoulder dislocations were treated by arthroscopic Latarjet procedure with double EndoButtons fixation, all of which underwent coracoid osteotomy with preserving the coracoacromial ligament. There were 11 males and 8 females, with an average age of 23.3 years (range, 17-32 years). Shoulder dislocations ranged from 3 to 11 times, with an average of 6.4 times. The disease duration ranged from 3 to 35 months, with an average of 12.9 months. All apprehension tests were positive. Imaging examination showed that the defect width of the ipsilateral glenoid bone was 13%-26%, with an average of 19.8%. After operation, the shoulder range of motion was examined, including flexion lift, lateral external rotation, extension 90° external rotation, and internal rotation. Shoulder joint function was evaluated by Walch-Duplay score, American Association for Shoulder and Elbow Surgery (ASES) score, and Rowe score. Imaging examinations were taken to observe the position and shaping of coracoid.

Results

All incisions healed by first intention and no nerve or vessel injury occurred. All patients were followed up 9-24 months (mean, 14.5 months). There was no recurrence of shoulder dislocation and the apprehension tests were negative during follow-up. There was no significant difference in the shoulder range of motion (flexion lift, lateral external rotation, extension 90° external rotation, and internal rotation) between preoperation and at last follow-up ( P>0.05). The Walch-Duplay score, ASES score, and Rowe score significantly improved when compared with those before operation ( P<0.05). Postoperative imaging showed that coracoid graft was at the same level with the glenoid in all cases; the center of coracoid graft was located between 3 to 5 o'clock. During follow-up, there was no glenohumeral joint degeneration, the acromiaohumeral distance was not reduced when compared with preoperation, and the coracoid bone gradually formed concentric circles with the humeral head.

Conclusion

The Latarjet procedure with double EndoButtons fixation can effectively treat recurrent anterior shoulder dislocation by coracoid osteotomy with preserving coracoacromial ligament, and the early-term effectiveness is satisfactory.

Changes in Scapular Function, Shoulder Strength, and Range of Motion Occur After Latarjet Procedure

Purpose

To evaluate the current literature on the effects of anatomic changes caused by the Latarjet procedure and to identify areas for future research.

Methods

English-language studies that addressed the consequences of anatomic alterations after the open Latarjet procedure were included. Articles written in languages other than English, reviews, and case reports were excluded. Titles and abstracts were screened by 2 authors. Studies that met the inclusion criteria were screened by the same authors. The following data were extracted from the included studies: authors, year of publication, journal, country of origin, aims or purpose, study population and sample size, methods, procedure, intervention type, and key findings that relate to the scoping review questions.

Results

Twenty-two studies were included for analysis, yielding the following findings: First, the Latarjet procedure may change the position of the scapula owing to pectoralis minor tenotomy and/or transfer of the conjoint tendon. Second, dissection of the coracoacromial ligament may result in increased superior translation of the humeral head. The impact of this increased translation on patients' function remains unclear. Third, the subscapularis split shows, overall, better internal rotation strength compared with subscapularis tenotomy. Fourth, passive external rotation may be limited after capsular repair. Fifth, despite the movement of the conjoint tendon, elbow function seems unchanged. Finally, the musculocutaneous nerve is lengthened with a changed penetration angle into the coracobrachialis muscle, but the clinical impact seems limited.

Conclusions

The Latarjet procedure leads to anatomic and biomechanical changes in the shoulder. Areas of future research may include better documentation of scapular movement (bilateral, as well as preoperative and postoperative) and elbow function, the effect of (degenerative) rotator cuff ruptures after the Latarjet procedure on shoulder function, and the impact of capsular closure and its contribution to the development of glenohumeral osteoarthritis.

Clinical Relevance

This comprehensive overview of anatomic changes after the Latarjet procedure, with its effects on shoulder and elbow function, showed gaps in the current literature. Orthopaedic shoulder surgeons and physical therapists could use our findings when providing patient information and performing future clinical research.

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

Background:

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

Purpose:

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Distal clavicle autograft for anterior-inferior glenoid augmentation: A comparative cadaveric anatomic study

INTRODUCTION

The aim of this study was to anatomically compare distal clavicle and coracoid autografts and their potential to augment anterior-inferior glenoid bone loss.

METHODS

Ten millimeters of distal clavicle and 20 mm of coracoid were harvested bilaterally from 32 cadavers. Length, weight, and height were measured and surface area and density were calculated. For each graft, ipsilateral measurements were compared and the ability to restore corresponding glenoid bone loss was calculated.

RESULTS

Distal clavicle grafts were larger than coracoid grafts with respect to length (22.3 mm versus 17.7 mm; p < 0.001), height (12.49 mm versus 9.65 mm; p < 0.001), mass (2.72 g versus 2.45 g; p = 0.0437), and volume (2.36 cm³ versus 1.96 cm³; p = 0.002). Coracoid grafts had larger widths (14.56 mm versus 10.52 mm; p < 0.001) and greater density (1.24 g/cm³ versus 1.18 g/cm³; p < 0.001). Distal clavicle surface area was greater on both the articular (2.93 cm² versus 1.5 cm²; p < 0.001) and superior surfaces (2.76 cm² versus 1.5 cm²; p < 0.001) when compared to lateral coracoid surface area.

DISCUSSION

Distal clavicle grafts were larger and restored larger bony defects but had greater variability and lower density than coracoid grafts. Clinical studies are needed to compare these graft options.

Reconstruction of the Coracoacromial Ligament during a Modified Latarjet Procedure for the Treatment of Shoulder Instability: Clinical Outcome at Minimum 5 Years Follow-Up

OBJECTIVE

The function of the coracoacromial ligament (CAL) in superior shoulder stability has been well established, and the release of the CAL with the Latarjet procedure leads to increased superior humeral translation. A surgical technique was developed recently to reconstruct the CAL during a modified Latarjet procedure, and the clinical outcome of this technique at medium-term follow-up is yet to be determined.

METHODS

Twenty-six patients with chronic post-traumatic anterior shoulder instability were included in this retrospective case-control study. Patients in group 1 (n = 12) were surgically treated with the classic congruent-arc Latarjet, where the CAL is sacrificed. In group 2 (n = 14), the CAL was reconstructed using a pectoralis minor fascia flap (PMFF). Primary outcomes were the return to sports activity and functional assessment based on the Western Ontario Shoulder Instability Index (WOSI) and the Constant Score (CS) at minimum 5 years follow-up. Patient's demographics, sport activities, duration of surgery, the rate of recurrent dislocations, and specific complications related to the surgical technique were recorded as secondary variables.

RESULTS

There was a decrease of the WOSI in both groups, indicating a decrease of symptoms at follow-up compared to the preoperative level. There was no statistically significant difference between groups 1 and 2 for the total WOSI as well as for all subscales. There was an increase of the CS in both groups in all four items at follow-up compared to preoperatively, indicating an increase in shoulder function at follow-up. There was a statistically significant difference between groups 1 and 2 for the total CS, as well as for the items power, mobility, and activity, but not for pain. Most patients (n = 20) returned to their preoperative sports activity, 13 at the same level. However, seven patients who used to perform their sports competitively chose to perform their activity at a noncompetitive level after the Latarjet procedure. All were younger than 35 years of age. Six patients did not return to their preoperative sports activity. All except one were over 35 years of age. The duration of surgery ranged from 75 to 125 minutes with a mean ± SD of 94.23 ± 15.06 minutes for both groups with no significant difference between the groups (p = 0.117). None of the patients had intra- or postoperative complications related to the surgical procedure. Especially, no patient had recurrent dislocations of the affected shoulder following the Latarjet procedure.

CONCLUSION

The use of a PMFF is a safe technique for reconstruction of the CAL, which does not result in a longer surgery time or higher rate of complications. The reconstruction of the CAL during the modified Latarjet procedure may lead to better functional results in medium-term follow-up.

Bony Reconstruction of the Anterior Glenoid Rim

Recurrent anterior shoulder instability is associated with glenohumeral bone loss. Glenoid deficiency compromises the concavity-compression mechanism. Medial Hill-Sachs lesions can result in an off-track humeral position. Anterior glenoid reconstruction or augmentation prevents recurrence by addressing the pathomechanics. In Bristow and Latarjet procedures, the coracoid process is harvested for conjoint tendon transfer, capsular reinforcement, and glenoid rim restoration. Complications and the nonanatomic nature of the procedure have spurred research on graft sources. The iliac crest is preferred for autogenous structural grafts. Tricortical, bicortical, and J-bone grafts have shown promising results despite the historical association of Eden-Hybinette procedures with early degenerative joint disease. Allogeneic osteochondral grafts may minimize the risk of arthropathy and donor site morbidity. Tibial plafond and glenoid allografts more closely match the native glenoid geometry and restore the articular chondral environment, compared with conventional grafts. Graft availability, cost, risk of disease transmission, and low chondrocyte viability have slowed the acceptance of osteochondral allografts.

Cryopreserved bone allograft for the treatment of shoulder instability with glenoid defect

The purpose of this study was to examine outcomes after cryopreserved tri-cortical iliac crest allograft reconstruction for glenoid bone loss in patients with shoulder instability. 10 patients completed the required assessments at a mean follow up of 4.5 years. At final follow up, mean ASES was 92 ± 12, mean WOSI was 315 ± 319, with good range of motion. None of the final radiographs demonstrated graft resorption or failure of hardware. The data demonstrated that patients who were treated with glenoid bone grafting with cryopreserved tri-cortical iliac crest allograft can expect good range of motion and functional capacity.

Arthroscopic Transfer of the Conjoined Tendon-Coracoid Tip Complex for Anterior Shoulder Instability

In the treatment of anterior shoulder instability, there are various conditions in which a sling effect is needed to enhance anterior stability. The traditional Bristow-Latarjet procedure provides a sling effect but destroys or does not purposely protect the coracoacromial (CA) arch, which may result in superior instability. To preserve the CA arch and create a sling to enhance the anterior-inferior side of the shoulder, we introduce an arthroscopic technique to transfer the conjoined tendon-coracoid tip complex (CTCTC) with the intention to keep the CA ligament intact to the utmost. The indications for CTCTC transfer are patients younger than 45 years who participate in competitive sports, require forceful external rotation and abduction movements of the shoulder, and/or have capsule-ligament insufficiency. The main steps of this procedure include detaching the CTCTC, fashioning the coracoid tip to obtain a coracoid pillar, braiding the CTCTC, creating a glenoid tunnel and socket, placing a guide suture through the glenoid tunnel and subscapularis, passing the CTCTC through the subscapularis and into the glenoid socket, and performing suspension fixation of the CTCTC.

Arthroscopic Transfer of the Long Head of the Biceps Brachii for Anterior Shoulder Instability

In the treatment of anterior shoulder instability, there are various conditions in which a sling effect is needed to enhance anterior stability. The traditional Latarjet procedure provides a sling effect but destroys the coracoacromial arch, which may result in superior instability. To preserve the coracoacromial arch and create a sling to enhance the anterior-inferior side of the shoulder, we introduce an arthroscopic technique to transfer the long head of the biceps (LHB) brachii. Indications of LHB transfer are patients younger than 45 years of age who participate in competitive sports, require forceful external rotation and abduction movement of the shoulder, and/or have capsule-ligament insufficiency, as well as patients 45 years o or older who have combined SLAP lesions (type II or IV). The main steps of this procedure include detaching the LHB, retrieving and braiding the LHB, creating a glenoid tunnel, placing a guide suture through the subscapularis and glenoid tunnel, passing the LHB through the subscapularis and into the glenoid tunnel, and suspension fixation of the LHB.

Anatomical study of the coracoid process in Mongolian male cadavers using the Latarjet procedure

Background

The Latarjet procedure addresses recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid in coracoid transfer procedures has not yet been defined in Mongolian men. The aims of this study were to describe the soft tissue attachments of the coracoid regarding the bony anatomy, define the average amount of bone available for coracoid transfer, analyze the characteristics of the pectoralis minor and coracoid, and study the relationship between the bony dimensions of the coracoid and body length in Mongolian men.

Methods

We dissected 30 shoulders from 15 male Mongolian cadavers, exposing the coracoid process and attached anatomical structures including the lateral clavicle and acromion, then measured the bony dimensions of the coracoid and the locations and sizes of the coracoid soft tissue footprints.

Results

The mean length of the coracoid available for transfer was 23.93 ± 2.32 mm. The mean length of the coracoid was 42.10 ± 2.3 mm, and the mean width and height of the coracoid midpoint were 15.29 ± 1.70 mm and 11.61 ± 1.98 mm, respectively. The pectoralis minor was part of the joint capsule and passed over the coracoid in some samples. The mutation rate of the pectoralis minor footprint, which was asymmetrical and irregular, was 23.33 %. Statistical analysis involved a multiple linear regression equation.

Conclusions

The average amount of bone available for use in coracoid transfer in Mongolian men was less than that of other populations. Mutation of the pectoralis minor may induce intraoperative capsule injury because this muscle passes over the coracoid deep to the joint capsule of the glenohumeral joint and constitutes part of the shoulder joint, strengthening the joint. Statistically, higher coracoids appeared in shorter patients and longer coracoids appeared in taller patients. Surgically, great care should be taken to consider a patient’s height to precisely implement the congruent-arc Latarjet technique.

Reconstruction of the coracoacromial ligament during a modified Latarjet procedure: a case series

Background

The coracoacromial ligament (CAL) is an important restraint to superior shoulder translation. CAL release with the Latarjet procedure leads to increased superior humeral translation. Therefore, a surgical technique was developed to reconstruct the CAL during a modified Latarjet procedure.

Methods

Between May 2010 and July 2011, six patients (five were male, one was female; age 23–41 years) with chronic post-traumatic anterior shoulder instability were treated surgically with a modified congruent-arc Latarjet procedure (modLAT) with additional reconstruction of the CAL using a newly developed procedure, the pectoralis minor fascia flap (PMFF). Clinical follow-up was performed for up to 36 months, and patients were evaluated using a Rowe score.

Results

All six patients experienced chronic, post-traumatic anterior shoulder instability and had experienced multiple re-dislocations after initial treatment. The preoperative assessment showed a defect of the anterior glenoid in three cases, and the mean Rowe score was 16.67 (5–25). Open modLAT with PMFF resulted in a stable shoulder function with no re-dislocations. The Rowe score increased from 77.5 (65–90) at 12 weeks to 95 (90–100) at 12 months and plateaued thereafter. Operative duration was 95 min (78–112 min), and there were no intra- or postoperative complications. All patients returned to their preoperative sports activity, three at the same level.

Conclusion

The PMFF is a safe technique for reconstruction of the CAL during a modLAT procedure. Patients had improved shoulder function and no re-dislocations after the surgery.