Open versus arthroscopic Latarjet procedures for the treatment of shoulder instability: a systematic review of comparative studies

Background

The arthroscopic and open Latarjet procedures are both known to successfully treat shoulder instability with high success rates. The objective of this study was to compare the clinical outcomes and positioning of the coracoid graft and screws between the arthroscopic and open Latarjet procedures.

Methods

The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies between database creation and 2018. Only studies directly comparing open and arthroscopic Latarjet procedures were included.

Results

There were 8 included studies, with a total of 580 patients treated arthroscopically and 362 patients treated with an open Latarjet procedure. Several papers found significantly better standardized outcome scores for either the open or arthroscopic procedure but these findings were not consistent across papers. Patients treated with arthroscopic Latarjet procedures had significantly lower initial post-operative pain, however pain scores became equivalent by one month post-operatively. Three of the five included studies found no significant difference in the coracoid graft positioning and two of three included studies found no significant difference in screw divergence angles between the two techniques. Arthroscopic procedures (112.2 min) appear to take, on average, longer than open procedures (93.3 min). However, operative times and complication rates decrease with surgeon experience with the arthroscopic procedure. Overall 3.8% of the patients treated arthroscopically and 6.4% of the patients treated with the open procedure went on to have post-operative complications.

Conclusions

Both open and arthroscopic Latarjet procedures can be used to effectively treat shoulder instability with similarly low rates of complications, recurrent instability and need for revision surgery. Arthroscopic Latarjet procedures are associated with less early post-operative pain but require increased operative time. The evidence does not support there being any significant difference in graft or screw positioning between the two techniques. At this time neither procedure shows clear superiority over the other.

Is the Latarjet procedure risky? Analysis of complications and learning curve

PURPOSE

The purpose of this study was to analyse the learning curve and complication rate of the open Latarjet procedure.

METHODS

The first 68 Latarjet procedures performed by a single surgeon for chronic anterior shoulder instability were reviewed retrospectively. The standard open surgical technique was followed faithfully during each procedure. Post-operative complications were taken from patient medical records. Post-operative evaluation consisted of clinical and radiological assessments.

RESULTS

The rate of early (<3 months) clinical complications was 7.4 % (5.9 % haematoma, 1.5 % neurological deficit), and the delayed complication rate was 7.3 %. Early complication rate, duration of surgery (mean 65 min; 35-135) and hospital stay (mean 3 days; 1-4) were significantly reduced as experience increased (respectively; P = 0.03, ρ = - 0.3; P = 0.009, ρ = - 0.3; P < 0.0001, ρ = - 0.6). On the radiographs, the bone block was healed and in perfect position in 87 % of cases, with no effect of surgical experience (P = 0.3, ρ = 0.1). The rate of complications on radiographs was 17 %: 11 % partial lysis, 2 % complete lysis and 4 % non-union. No recurrence of instability was found after an average follow-up of 21 months.

CONCLUSION

Despite a high rate of post-operative complications, the morbidity of Latarjet procedure remains low. A surgeon's experience significantly affects the surgery duration and the occurrence of early complications. The main radiological complication is partial lysis of the bone block. After a short learning curve, the clinical outcomes of the Latarjet procedure appear to be satisfactory and reproducible.

LEVEL OF EVIDENCE

IV.

Arthroscopic double-button Latarjet: two-thirds of bone block healed at 90 days

PURPOSE

The aim of this study was to evaluate the union rate and risk factors for delayed union in the early postoperative period after an arthroscopic Latarjet with double-button fixation.

METHOD

In a retrospective study, postoperative CT scans at 3 months were analysed following an arthroscopic Latarjet with double-button fixation used to treat anterior shoulder instability. Healing of the bone block, its position in the sagittal and coronal planes, and the contact area graft/scapula were analysed.

RESULTS

Ninety-eight CT scans (98 patients) were included. The rate of healing at 3 months was 63/98 (64%) and four grafts clearly migrated. The position was perfectly flush to the glenoid rim in 67% and under the equator in 96%. The mean contact graft/scapula area was 135 mm 2 (4-420). In multivariate analysis, the risk of non-union at 3 months was associated with tobacco consumption (p = 0.001, aOR = 12.17 95% CI [2.62-56.49]), absence of preoperative glenoid bone defect (p = 0.003, aOR = 8.06 95% CI [2.06-31.56]), and a contact area graft/scapula less than 120 mm 2 (p = 0.010, aOR = 5.25 95% CI [1.50-18.40]). Among 31 non-united grafts, 93% definitively healed on CT scan at 1 year, leaving an overall rate of 93% of united grafts at last follow-up.

CONCLUSIONS

The rate of union at 3 months after an arthroscopic Latarjet with double-button fixation was 64%, reaching 93% at 1 year. This procedure should be carefully indicated in case of tobacco use or instability without glenoid bone defect, especially when the shoulder is exposed to high-energy trauma in the early phase after surgery.

Bone block procedures in posterior shoulder instability

PURPOSE

Posterior shoulder dislocation is often associated with bone defects. Surgical treatment is often necessary to address these lesions. The aim of the present systematic review was to analyse the available literature concerning bone block procedures in the treatment of bone deficiencies following posterior dislocation. In addition, the methodology of the articles has been evaluated through the Coleman methodology score.

METHODS

A systematic review of the literature was performed using the keywords "posterior shoulder instability", "posterior shoulder dislocation", "bone loss", "bone defect", "bone block", and "bone graft" with no limit regarding the year of publication. All English-language articles were evaluated using the Coleman methodology score.

RESULTS

Fifty-four articles were identified, and 13 articles met inclusion criteria. The initial cohort included 208 shoulders, and 182 were reviewed at an average follow-up of 72.7 months (±55.2). The average Coleman score was 57.2 (±8.0). The most lacking domains were the size of study population, the type of study, and the procedure for assessing outcomes. All the articles showed an increase in the outcome scores. Radiographic evaluation revealed degenerative changes such as osteoarthritis and graft lysis in most of the series.

CONCLUSIONS

This review confirms the lack of studies with good methodological quality. However, bone grafting is a reliable option since significant improvement in all scores is reported. Although a low incidence of recurrence is generally described, there are concerns that the results may deteriorate over time as evidenced by graft lysis and glenohumeral osteoarthritis in up to one-third of patients.

LEVEL OF EVIDENCE

Systematic review, Level IV.

Horizontal ridge reconstruction of the anterior maxilla using customized allogeneic bone blocks with a minimally invasive technique - a case series

BACKGROUND

Different surgical procedures have been proposed to achieve horizontal ridge reconstruction of the anterior maxilla; all these procedures, however, require bone replacement materials to be adapted to the bone defect at the time of implantation, resulting in complex and time-consuming procedures. The purpose of this study was to describe how to use a 3D printed hardcopy model of the maxilla to prepare customized milled bone blocks, to be adapted on the bone defect areas using a minimally invasive subperiosteal tunneling technique.

METHODS

Cone beam computed tomography (CBCT) images of the atrophic maxilla of six patients were acquired and modified into 3D reconstruction models. Data were transferred to a 3D printer and solid models were fabricated using autoclavable nylon polyamide. Before the surgery, freeze-dried cortico-cancellous blocks were manually milled and adapted on the 3D printed hardcopy models of the maxillary bone, in order to obtain customized allogeneic bone blocks.

RESULTS

In total, eleven onlay customized allogeneic bone grafts were prepared and implanted in 6 patients, using a minimally invasive subperiosteal tunneling technique. The scaffolds closely matched the shape of the defects: this reduced the operation time and contributed to good healing. The patients did not demonstrate adverse events such as inflammation, dehiscence or flap re-opening during the recovery period; however, one patient experienced scaffold resorption, which was likely caused by uncontrolled motion of the removable provisional prosthesis. Following a 6 month healing period, CBCT was used to assess graft integration, which was followed by insertion of implants into the augmented areas. Prosthetic restorations were placed 4 months later.

CONCLUSIONS

These observations suggest that customized bone allografts can be successfully used for horizontal ridge reconstruction of the anterior maxilla: patients demonstrated reduced morbidity and decreased total surgery time. Further studies on a larger sample of patients, with histologic evaluation and longer follow-up are needed to confirm the present observations.

Outcomes are comparable using free bone block autografts versus allografts for the management of anterior shoulder instability with glenoid bone loss: a systematic review and meta-analysis of "The Non-Latarjet"

PURPOSE

Glenoid augmentation using free bone blocks for anterior shoulder instability has been proposed as an alternative to or bail-out for the Latarjet procedure. The purpose of this investigation was to systematically review and compare outcomes of patients undergoing glenoid augmentation using free bone block autografts versus allografts.

METHODS

A systematic review using PubMed, MEDLINE, Embase, and the Cochrane Library databases was performed in line with the PRISMA statement. Studies reporting outcomes of patients treated with free bone block procedures for anterior shoulder instability with minimum 2-year follow-up were included. Random effects modelling was used to compare patient-reported outcomes, return to sports, recurrent instability, non-instability related complications, and development of arthritis between free bone block autografts and allografts.

RESULTS

Eighteen studies comprising of 623 patients met the inclusion criteria for this investigation. There were six studies reporting on the use of allografts (of these, two used distal tibial, three iliac crest, and one femoral head allograft) in 173 patients and twelve studies utilizing autografts (of these, ten used iliac crest and two used free coracoid autograft) in 450 patients. Mean age was 28.7 ± 4.1 years for the allograft group and 27.8 ± 3.8 years for the autograft group (n.s). Mean follow-up was 98 months in autograft studies and 50.8 months for allograft studies (range 24-444 months, n.s). Overall mean increase in Rowe score was 56.2 with comparable increases between autografts and allografts (n.s). Pooled recurrent instability rates were 3% (95% CI, 1-7%; I² = 77%) and did not differ between the groups (n.s). Arthritic progression was evident in 11% of autografts (95% CI, 2-27%; I² = 90%) and 1% (95% CI, 0-8%; I² = 63%) of allografts (n.s). The overall incidence of non-instability related complications was 5% (95% CI, 2-10%; I² = 81%) and was similar between the groups (n.s). Pooled return to sports rate was 88% (95% CI, 76-96%; I² = 76%).

CONCLUSION

Glenoid augmentation using free bone block autograft or allograft in the setting of recurrent anterior shoulder instability with glenoid bone loss is effective and safe. Outcomes and complication incidence using autografts and allografts were comparable. Due to the high degree of heterogeneity in the data and outcomes reported in available studies, which consist primarily of retrospective case series, future prospective trials investigating long-term outcomes using free bone block autograft versus allograft for anterior shoulder instability with glenoid bone loss are warranted.

LEVEL OF EVIDENCE

IV.

Latarjet procedure: evolution of the bone block and correspondent clinical relevance-a clinical and radiological study

PURPOSE

The purpose of this study was to correlate the bone block graft position, its dimension, its reabsorption and its integration with clinical outcome in patients operated on for recurrent anterior shoulder instability.

METHODS

Twenty-four patients affected by recurrent anterior shoulder dislocation and operated on using the Latarjet procedure were enrolled in this study. At 6 and 24 months, patients were evaluated with the following scales: ROWE, WOSI, Oxford instability score, UCLA, DASH and Constant score. Patients underwent two postoperative CT scans: immediately after surgery (T0) and at 24 months post-op (T1).

RESULTS

At 24 months, none of the 24 patients reported further episodes of dislocation. Clinically at the final follow-up, we found excellent results in all the evaluation scales. Mean reduction in bone graft from T0 to T1 was 42% of the overall volume; similarly reduction in the overall surface was 29.3%; decrease in length, width and depth was, respectively, 3.4, 2.2 and 1.0 mm; all these parameters decreased significantly (p < 0.05). No correlations were found between radiological parameters and clinical and functional outcomes.

CONCLUSIONS

The results confirm that a lack of integration or a significant reabsorption of the graft is present in the Latarjet procedure, but they do not significantly affect the clinical and functional results.

Arthroscopic treatment of glenoid bone loss

Recurrent anterior instability of the glenohumeral joint has long been an arduous problem to solve surgically, owing to its difficulty to the need to restore both osseous and dynamic constraints in the unstable shoulder. Biomechanical studies have indicated that glenoid bone loss shortens the safe arc through which the glenoid can resist axial forces; in these cases, a soft tissue repair alone may be insufficient to maintain stability. Clinical studies have confirmed that major bone loss is associated with an unfavourable outcome. The benefits of using arthroscopic procedures for surgical stabilization of the shoulder include smaller incisions and less soft tissue dissection, better access for repair and, potentially, the maximum respect for the undamaged anatomical structures. The biggest disadvantage of arthroscopic procedures until recently was the inability to successfully treat a significant bone defect. Over the last 10 years, several new arthroscopic techniques have been developed, providing new surgical options for successfully treating soft tissues and bony lesions in anterior-inferior glenohumeral instability. Level of evidence V.

Quadriceps tendon autograft with or without bone block have comparable clinical outcomes, complications and revision rate for ACL reconstruction: a systematic review

PURPOSE

The purpose of this systematic review is to report complications, graft failure, fixation methods, rehabilitation protocol, clinical and patient-reported outcomes, and return to sports with the use of quadriceps tendon graft with the bone block (QT-B) and without bone block (QT-S).

METHODS

According to the PRISMA guidelines a comprehensive search was performed across PubMed/MEDLINE, Scopus, EMBASE, and Cochrane Library databases from inception until April 2022. Only prospective studies using quadriceps tendon autograft with a minimum of 20 patients were considered for inclusion. The outcome measures extracted from the studies were the KT-1000, Lysholm score, Subjective and Objective IKDC, Tegner, Marx Score, complications, failures and/or revision surgery, and rate of return to sports. Cochrane risk of bias and MINORS tool were used for the risk of bias assessment of all included studies.

RESULTS

A total of 13 studies were included, consisting of 5 randomized controlled trials, 6 cohort studies, 1 case-control and 1 case series. A total of 484 patients received QT-S in 6 studies of which 224 (46.2%) were males and 212 (43.8%) females with a mean age of 21.5 ± 7.5 (range 14-58). While 243 patients received QT-B in 7 studies of which 167 (68.7%) were males and 76 (31.3%) females with a mean age of 28.9 ± 4.5 (range: 18-49). The studies analyzed had a mean MINORS score of 14.6 (range, 12-19). Both QT-B and QT-S for ACL reconstruction reported satisfactory results in terms of patient-reported outcome measures. Although, a slightly higher anterior laxity was found with the QT-S than with the QT-B.

CONCLUSION

Quadriceps tendon with a bone block (QT-B) or without bone block (QT-S) for ACL reconstruction is supported by current literature. Both grafts are safe and viable options for ACL reconstruction with comparable clinical outcomes, complications and revision rates.

LEVEL OF EVIDENCE

Level IV.

REGISTRATION

PROSPERO-CRD42022347134; https://www.crd.york.ac.uk/prospero/.

Mechanical behavior of screw versus Endobutton for coracoid bone-block fixation

INTRODUCTION

Arthroscopic coracoid bone-block fixation by Endobutton was developed to avoid the complications associated with screwing. However, few studies have assessed the mechanical characteristics of the two. The aim of the present study was to assess and compare fixation rigidity by screw versus Endobutton. The study hypothesis was that rigidity is lower with Endobutton than with screws.

MATERIAL AND METHOD

3D print-outs of a glenoid and a coracoid process were obtained from CT scans of a patient showing anterior shoulder instability with significant bone defect. Four types of coracoid fixation were implemented: 1 or 2 4.5mm malleolar screws, and 1 or 2 Endobuttons. Three specimens per assembly were placed on a specific test bench. Lateromedial bone-block compression was exerted at 0.1mm/sec at 3 points: superior, central, inferior. The resultant force and bone-block displacement were recorded.

RESULTS

Mean fixation rigidity with 1 screw, 2 screws, 1 Endobutton and 2 Endobuttons was respectively 158N/mm (range, 133-179), 249N/mm (241-259), 10N/mm (5-13) and 14N/mm (13-15), with significant difference between the screw and Endobutton groups (p<0.001). Displacement was greater with 1 than 2 Endobuttons under superior or inferior force, while the difference was non-significant under central force (7.45 vs 6.93mm; p=0.53) CONCLUSIONS: Screw fixation showed greater rigidity, while the Endobutton assembly showed less tension, leading to greater bone-block mobilization. The interest of using two Endobuttons is to reduce displacement under polar pressure. the present biomechanical study confirmed the mechanical vulnerability of bone-blocks fixed by endobutton until consolidation is achieved.

LEVEL OF EVIDENCE

Biomechanical study.

Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety

BACKGROUND

Some surgical procedures are rarely done on an outpatient basis. The primary objective of this study was to assess the safety of outpatient surgical shoulder stabilisation using the Latarjet procedure.

HYPOTHESIS

The Latarjet procedure is safe when performed on an outpatient basis provided the patients are managed according to a specifically designed programme starting at the decision to undergo surgery and ending at the end of the early postoperative period.

PATIENTS AND METHODS

Consecutive patients with unidirectional anterior shoulder instability managed in 2013-2014 by primary open, minimally invasive surgery involving coracoid process transfer as described by Latarjet was included prospectively. One of the surgeons routinely offered outpatient surgery to patients who met none of the usual exclusion criteria (age>60years, ASA 3-4, and long distance from home to hospital). Standardised protocols were applied for anaesthesia and analgesia. The primary evaluation criterion was failure of the admission modality, defined as inpatient admission of a patient after outpatient surgery either without prior discharge or within 1week after discharge. Secondary evaluation criteria were early postoperative symptoms and functional outcomes after at least 1year. All self-reported criteria were entered online by the patients.

RESULTS

Of 46 included patients, 17 had outpatient surgery and 29 inpatient surgery. There were 41 males and 5 females, with a mean age of 25.3±6.4years. No significant baseline differences were found between the two groups. None of the outpatients required inpatient admission or readmission. No postoperative complications were recorded. After a mean follow-up of 18.5±5.2months, the two groups showed no significant differences for return to sports, apprehension, avoidance behaviours, or functional outcomes. Most patients were satisfied with their management and outcomes.

CONCLUSION

No serious adverse events were recorded in this first French prospective evaluation of the safety of open, minimally invasive shoulder stabilisation by the Latarjet procedure performed on an outpatient basis. Thus, in selected patients, the risks of outpatient surgery are similar to those of inpatient surgery.

LEVEL OF EVIDENCE

III, prospective, comparative, non-randomised study.

Results of the Latarjet coracoid bone block procedure performed by mini invasive approach

INTRODUCTION

The coracoid block technique described by Latarjet was modified by Patte and Walch in order to increase the glenoid surface. Saragaglia further modified this technique and described a minimally invasive approach which allows faster post-operative recovery. The aim of this study was to evaluate the medium-term functional and radiological results of this technique.

METHODS

This is a single surgeon cohort of 40 shoulders in 38 patients (32 men, 6 women) with an average age of 34.5 years operated on between January and December 2014. The skin incision was 3 to 6 cm long allowing the bony block to be passed under the subscapularis tendon without sectioning it and to be placed in lying position. The bone block was fixed with a 6.5 cancellous screw or a 7.0 cannulated screw.

RESULTS

At an average follow-up of 48 months, there were no recurrent dislocations. The average WOSI score was 42, the average Constant score was 95 corrected to 97% and the average SSV was 97. Visual analogue scores were 0 at rest and 0.6 with activity. The bone block healed in 92.5% of cases. It was flush with the edge of the glenoid in 84% of cases, lateralised in 10% and medialised in 6% of cases. Mean internal rotation power was 12 kg in the operated shoulder compared with 9 kg in the non-operated shoulder.

CONCLUSION

The treatment of recurrent anterior shoulder instability by mini invasive Latarjet gives excellent medium-term functional results. The rate of recurrent dislocation in this series was zero and internal rotation power was well preserved. This is an excellent alternative to arthroscopic procedures which are yet to demonstrate their superiority over open surgery.

Complications associated with vertical bone augmentation techniques in implant dentistry: A systematic review of clinical studies published in the last ten years

Vertical bone augmentation procedures are increasingly necessary in daily practice. However, it has been reported that vertical ridge augmentation is one of the least predictable techniques in terms of complications. The aim of this systematic review was to evaluate and compare complications in relation to the different procedures used for vertical bone augmentation prior to implant placement. This review was conducted according to PRISMA guidelines. An electronic search was carried out in four databases: The National Library of Medicine (MEDLINE/PubMed); Web of Science; SCOPUS; and Cochrane Central Register of Controlled Trials (CENTRAL). The Newcastle-Ottawa Quality Assessment Scale, the Cochrane Collaboration tool for assessing risk of bias, and The Joanna Briggs Institute Critical Appraisal tool were used to assess the quality of evidence in the studies reviewed. Twenty-five studies with a total of 749 vertically augmented sites were included in the review. Complication rates varied among the different procedures: 51.02% for distraction osteogenesis, 38.01% for bone blocks, and 16.80% for guided bone regeneration. Vertical bone augmentation procedures prior to implant placement are associated with frequent surgical complications and should be approached with caution due to their possible impact on clinical treatment success.

The dowel technique for first metatarso-phalangeal joint arthrodesis in revision surgery with bone loss

BACKGROUND

The operative management of failed first metatarso-phalangeal joint (MTPJ) surgery is often complicated by bone loss and shortening of the hallux. Restoration of first ray length and alignment often cannot be achieved with in situ fusion and reconstruction techniques with bone graft are therefore required. We present a novel technique of longitudinal (proximo-distal) bone dowel arthrodesis for first MTPJ arthrodesis with bone loss.

METHODS

Between August 2007 and February 2015, eight patients have been treated by the senior author with this technique. The mean age at surgery was 60.5 years (range 45-80) with seven females and one male. Index surgery was MTPJ arthrodesis (three patients), Keller excision arthroplasty (two patients), MTPJ hemiarthroplasty (two patients) and silastic arthroplasty (one patient). Clinical and radiological fusion was assessed and other radiological measurements included hallux valgus angle (HVA) and length of the hallux (LOH).

RESULTS

All patients achieved fusion at a mean of 9.3 weeks (range 6-12) from surgery and only one patient required removal of metalwork. There were no major complications. The HVA improved in all cases from 21.4±2.8 pre-operatively to 11.6±3.5 post-operatively (p>0.05). The LOH also increased in all cases from 82.1±8.3mm to 86.7±8.2mm (p>0.05). The subgroup of patients who were revised from an arthroplasty, where maintenance of length rather than increase in length was desirable (hemiarthroplasty, silastic) had significantly lower increase in LOH than those revised from a non-arthroplasty index surgery (arthrodesis, Keller) (p=0.029).

CONCLUSION

The dowel technique is successful for first MTPJ arthrodesis revision surgery with optimal union rates and satisfactory radiographic and clinical outcomes. It is an effective and versatile option for managing bone loss and deformity of the hallux.

Management of Calcaneal Fracture Malunion with Bone Block Distraction Arthrodesis: A Systematic Review and Meta-Analysis

One of the most severe complications in calcaneal fractures is a malunion. When a malunion occurs, subtalar bone block distraction arthrodesis provides restoration of calcaneal height, length, correction of varus deformity, and elimination of subtalar joint arthritis. A systematic review showed the union rate for all procedures was 95.78%. The overall complication rate was 38% for all procedures. This is the first study to categorically break down complications with statistical analysis. The data presented indicate the level of difficulty of the subtalar distraction bone block arthrodesis for calcaneal malunions and may even suggest the need for newer techniques.

Arthroscopic bone block metal-free fixation for anterior shoulder instability. Short-term functional and radiological outcomes

INTRODUCTION

Anterior glenohumeral bone loss reconstruction reduces failure rates after soft tissue surgery in patients with large glenoid bone defects. Multiple bone block techniques have been described, most with metal hardware fixation. The objective of this study is to evaluate the safety, as well as the short-term functional and radiological results of an arthroscopic bone block metal-free fixation or bone block cerclage.

MATERIAL AND METHODS

Retrospective study of patients with glenohumeral instability and>15% glenoid bone loss operated during 2019 with follow-up of at least 12 months. Radiography and computerized tomography studies were performed. Functional outcomes were evaluated before and after surgery with the Western Ontario Shoulder Instability Index and Rowe score.

RESULTS

A total of 21 patients with a median age of 30.6 (SD 7.1) were included. All showed radiographic consolidation at 3 months follow-up. A percentage of 90.4 of bone grafts presented osteolysis at peripherical areas and 95.2% revealed consolidation in the areas with contact to the glenoid. The median glenoid estimated surface went from 79.3% before surgery to 98.4% at 12 months. Functional scores were statically significant (P<.001) for Western Ontario Shoulder Instability Index (35.6-86.9) and Rowe score (25.2 to 96.4). No serious complications were reported.

CONCLUSION

The bone block cerclage is a safe, metal-free technique that achieves total consolidation of the bone graft and favorable functional and radiological outcomes at 12 months follow-up.

Specially designed and CAD/CAM manufactured allogeneic bone blocks using for augmentation of a highly atrophic maxilla show a stable base for an all-on-six treatment concept: a case report

Background

In terms of a highly atrophic maxilla, bone augmentation still remains very challenging. With the introduction of computer-aided design/computer-aided manufacturing (CAD/CAM) for allogeneic bone blocks, a new method for the treatment of bone deficiencies was created. This case report demonstrates the successful use of two specially designed and CAD/CAM manufactured allogeneic bone blocks for a full arch reconstruction of a highly atrophic maxilla with an all-on-six concept.

Case presentation

We report the case of a 55-year-old male patient with a highly atrophic maxilla and severe bone volume deficiencies in horizontal and vertical lines. In order to treat the defects, the surgeon decided to use a combination of two allogeneic bone blocks and two sinus floor augmentations. The bone blocks were fabricated from the data of a cone beam computed tomography (CBCT) using CAD/CAM technology. After the insertion of the two bone blocks and a healing period of 7 months, six dental implants were placed in terms of an all-on-six concept. The loading of the implants took place after an additional healing time of 7 months with a screw-retained prosthetic construction and with a milled titanium framework with acrylic veneers.

Conclusion

The presented procedure shows the importance of the precise design of CAD/CAM manufactured allogeneic bone blocks for the successful treatment of a highly atrophic maxilla. Proper soft-tissue management is one of the key factors to apply this method successfully.

Open and arthroscopic posterior bone block with iliac crest autograft for posterior shoulder instability - systematic review of clinical and radiological outcomes

INTRODUCTION

Posterior shoulder instability (PSI) is a rare and challenging pathology to manage. The aim of this review was to assess and compare whether open and arthroscopic iliac crest bone graft (ICBG) bone block procedures succeeded in improving functional and clinical outcomes as well as radiological outcomes of union and graft resorption.

HYPOTHESIS

We hypothesised that there will be no difference in recurrence rate and functional outcome between open and arthroscopic procedures but there will be a higher complication rate with open bone block procedures.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines using the online databases MEDLINE and Embase. The review was registered on the PROSPERO database. Studies of open or arthroscopic ICBG bone block procedures reporting patient reported outcome measures, recurrence, complications and progression to osteoarthritis and radiological outcomes of graft union and resorption were selected. Studies were appraised using the Methodical index for non-randomised studies (MINORS) tool.

RESULTS

14 studies satisfied the inclusion criteria; five studies were arthroscopic and nine used open techniques. A total of 183 patients and 201 shoulders were included, mean age was 25 years range (14-75 years). Recurrent instability ranged from 0% to 12.5% for arthroscopic and 0% to 36.4% for open studies. Arthroscopic studies had statistically significant increases in numerous functional outcome scores but there was no evidence for similar improvements in open studies. Osteoarthritis at follow-up ranged from 12.5% to 47% in arthroscopic and 0% to 81.8% for open studies. Arthroscopic complication rate ranged from 6.7% to 75% compared to 0% to 80% for open studies. Majority of complications were metalware related requiring surgical intervention. Partial graft resorption ranged from 7.7-100% after arthroscopic and 4.8-100% after open procedures. High union rates were seen with both open and arthroscopic techniques.

CONCLUSION

This study highlights a lack of high-level evidence for arthroscopic and open posterior bone block procedures using ICBG to manage PSI. Functional and instability outcome scores showed significant improvement with arthroscopic ICBG bone block procedures however limited evidence was available for open studies. Metalwork related complications requiring revision and radiographic progression to osteoarthritis was high in both arthroscopic and open studies.

LEVEL OF EVIDENCE

IV, systematic review.

Description and Clinical Assessment of the Bone Block Tendon Interposition Technique for the Management of Thumb Carpometacarpal Joint Osteoarthritis

BACKGROUND

Pellegrini's surgical technique is the most useful for thumb carpometacarpal joint osteoarthritis. The purpose of this paper is to describe the technique of a modified version using a bone block in the tunnel through which the flexor carpi radialis tendon is passed (BBTI).

METHODS

Case series of patients diagnosed with osteoarthritis of the thumb carpometacarpal joint, in stage II or higher based on Eaton's classification, that were intervened using the BBTI technique for a 2-year period. Grip and pinch strength, range of motion, and 1-2 metacarpal angle were evaluated. Pain and function were measured using the visual analogue scale and the Disabilities of the Arm, Shoulder and Hand (DASH) scale.

RESULTS

The study included 16 cases in 14 patients (11 women and 3 men), with an average age of 55.7 ± 7.1 years. Encouraging results were obtained, with an average DASH score of 24.3 ± 17.9 and a minimum VAS pain score. A total of 58% showed a grip strength of over 80% and the postoperative movement was equivalent to the contralateral limb. No cases of infection were reported, and only two minor complications were observed.

CONCLUSIONS

The BBTI technique is a surgical option that incorporates an interference screw, offering good functional results for managing osteoarthritis of the thumb carpometacarpal joint, with a similar complication rate to that of the original technique.

Arthroscopic Allograft Bone Block Procedure with Remplissage for Bipolar Lesions

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankart repair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performed in conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that include reduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complications while preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromised outcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of "sling effect" with free bone graft reconstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

An assessment of the clinical relevance of coracoid graft osteolysis following the Latarjet procedure: a clinical and radiological review

Background

The Latarjet procedure was developed for the treatment of anterior shoulder instability in young, high-demand patients with attritional glenoid bone loss, whose risk of redislocation following primary dislocation may exceed 90%. Coracoid graft osteolysis and prominent screws are commonly observed in late computed tomography (CT) scans of patients who re-present following the procedure, but the clinical relevance of osteolysis in the overall Latarjet cohort is undetermined. We aimed to evaluate clinical and radiological outcomes in patients who underwent the Latarjet procedure, and to determine if severe coracoid graft osteolysis compromised clinical outcomes.

Methods

This was a retrospective analysis of patients who underwent the open Latarjet procedure. Patients were invited via an e-questionnaire that contained a Western Ontario Shoulder Instability Index (WOSI), and queried about redislocation and reoperation since index surgery. Preoperative glenoid bone loss was calculated on CT using the best-fit circle method. Osteolysis was graded (0, screw head buried in graft; 1, screw head exposed; 2, threads exposed; 3, complete resorption/severe osteolysis) at the level of the proximal and distal screws respectively, on axial CT scans performed ≥ 12 months postoperatively.

Results

Between 2011 and 2022, a single surgeon performed 442 Latarjet procedures. One hundred fifty eight patients responded to the questionnaire at median (interquartile range [IQR]) 44 (27-70) months postoperatively, among whom the median (IQR) WOSI score was 352 (142-666) points (0 = best, 2100 = worst). Recurrent anterior instability occurred in 3/158 (2%) patients. One patient required reoperation for this indication. Among patients who had CT scans ≥ 12 months postoperatively (median [IQR] 40 [29-69] months), 1 patient developed severe osteolysis around both screws (WOSI = 90), 17/62 (27%) patients developed severe osteolysis around 1 screw, all of which were proximal (median [IQR] WOSI = 235 [135-644]), and 44/62 (71%) patients did not develop severe osteolysis around either screw (median [IQR] WOSI = 487 [177-815]). There were no statistically significant differences in WOSI scores between groups based on the presence of severe osteolysis.

Conclusion

The Latarjet is reliable procedure that has a low rate of redislocation and reoperation. Severe coracoid graft osteolysis occurs with time, and always affects the proximal graft first. The presence of severe osteolysis did not compromise clinical outcomes.

Arthroscopic Bankart repair augmented with glenoid bone dry allograft

Background

The recurrence rate of shoulder instability after arthroscopic isolated Bankart repair is up to 25% at long term, especially in case of bipolar bone loss. Bony augmentation with free bone dry allograft would be an option to reconstruct a glenoid subcritical bone defect and to minimize the failure rate.

Methods

This case series included patients with anterior shoulder instability treated by arthroscopic free bone dry allograft (Supercrit, BIOBank, Lieusaint, Ile-de-France, France), fixed with a cortical button as an augmentation of Bankart repair and reviewed with a minimum follow-up of 2 years. Clinical assessment was based on active range of motion, shoulder apprehension test, as well as Walch-Duplay Score, Rowe Score, and Subjective Shoulder Value. Radiological evaluation was based on postoperative and last follow-up computed tomography scan to assess bone block positioning, glenoid enlargement, allograft healing, and/or resorption.

Results

Five patients were included with a mean follow-up of 50 months (range 44-56). None of the patients reported a recurrence, but apprehension test was positive in one. Mean Walch-Duplay Score, Rowe Score, and Subjective Shoulder Value were 88 points (70-11), 93 points (75-100), and 89% (80-95), respectively. No surgical complications were recorded. The mean preoperative anterior glenoid bone loss was 13.8% (7-19). At last follow-up, graft resorption was observed in all patients, reaching 100% of the initial volume in 4 cases.

Conclusion

This study showed satisfactory clinical results of Bankart repair augmented with dry bone allograft in the treatment of anterior shoulder instability with glenoid subcritical bone loss. However, anatomical results were disappointing, with graft resorption that raises the question of going ahead with such a procedure.

"Bankart Repair and Beyond. Anticipating difficulties and managing complications. Current concepts"

Anterior shoulder instability is a frequent complaint among young athletes. The Arthroscopic Bankart Repair (ABR) is a highly successful technique for restoring the native anatomy after a capsular and labrum avulsion lesion from the glenoid. The procedure has a low complication rate, and a large proportion of patients return to sports at the same pre-injury level. As a reliable surgical technique, ABR is rarely associated with intraoperative complications, but surgical details are critical to avoid struggling during the procedure. Postoperative complications, such as neurovascular injuries, infections, and stiffness, are significant concerns. In the long term, ABR's most common complications are the recurrence of instability and shoulder arthritis after the procedure. This article focuses on 1) the complications of ABR and the critical measures to prevent them, 2) additional techniques that can enhance primary ABR outcomes or address recurrences and failures, and 3) best practices to prevent shoulder arthritis after ABR.

CT-scan Evaluation of Osteointegration and Osteolysis in Different Graft Types and Surgical Techniques for the Treatment of Shoulder Instability

Background

Bone graft is often needed in treating anterior shoulder instability in glenoid bone loss and graft integration is crucial in achieving good results. This study aimed to evaluate bone graft remodeling in different techniques for shoulder anterior-inferior instability.

Methods

Graft osteointegration and osteolysis were retrospectively evaluated with CT-scan imaging performed 6 to 12 months after surgery to compare the outcome of three procedures: Latarjet, bone block with allograft, and bone block with xenograft. Screw fixation and double endobuttons fixation were also compared.

Results

CT scans of 130 patients were analyzed. Of these, 30 (23%) were performed after the bone block procedure with xenograft and endobuttons fixation, 55 (42%) after the bone block procedure with allograft and endobuttons fixation, 13 (10%) Latarjet with screw fixation and 32 (25%) Latarjet with endobuttons fixation. The prevalence of osteolysis was significantly inferior (P<.01) in the bone block procedure compared to the Latarjet procedure (11.7 % vs. 28.8 %). Bone integration was higher in bone block procedures (90.5%) than in Latarjet (84.4%), but the difference was not statistically significant. Among the Latarjet procedures, endobuttons fixation resulted in a higher integration rate (87.5% vs. 73.6%) and lower osteolysis rate than screw fixation (24.6% vs. 38.5%), despite these differences did not reach a statistical significance. Among the bone block procedures, using a xenograft resulted in a lower osteolysis rate (6.7%) than an allograft (14.5%), but the result was not statistically significant.

Conclusion

This study shows a significantly lower rate of graft osteolysis after bone block procedures compared to Latarjet procedure between 6 and 12 months postoperatively. Moreover, our findings suggest good results in osteolysis and graft integration with xenograft compared to allograft and double endobuttons fixation compared to screw fixation, despite these differences being not-significant. Further studies on this topic are needed to confirm our results at a longer follow-up and thoroughly investigate the clinical relevance of these findings.