Long-term results and arthropathy following the modified Bristow-Latarjet procedure

Excellent clinical and radiological mid-term outcomes of the arthroscopic "double-inlay" Eden-Hybinette procedure for bone defects exceeding 20%: a 5-year case series

BACKGROUND

Eden-Hybinette procedure can maximize the restoration of the glenoid defect by harvesting a proper size of iliac bone block. We developed an arthroscopic "double-inlay" Eden-Hybinette procedure to achieve better bone union of the graft. The aim of this study was to evaluate the clinical and radiological mid-term outcomes of the arthroscopic "double-inlay" Eden-Hybinette procedure for bone defects exceeding 20%.

METHODS

A retrospective case series was conducted. The inclusion criterion was a bone defect exceeding 20%, especially failed Bristow-Latarjet procedure or recurrent anterior shoulder instability among patients with epilepsy. An arthroscopic "double-inlay" Eden-Hybinette procedure was carried out. Recurrence and apprehension, the American Shoulder and Elbow Surgeons, University of California at Los Angeles, Subjective Shoulder Value, Rowe, and visual analog scale pain scores and rate of return to sports were obtained at final follow-up. Graft position, healing, and resorption were evaluated via 3D computerized tomography scan. Moreover, postoperative complications and the incidence of osteoarthritis were recorded.

RESULTS

The study cohort included 15 patients, with a mean age of 34.9 ± 13.2 years (range, 19-59 years) and a mean follow-up duration of 5 ± 1.7 years (range, 2.0-8.0 years). No patients experienced recurrent dislocation, and the visual analog scale pain and instability scores during shoulder range of motion decreased from a mean 6.5 ± 2.3 and 9.6 ± 0.9 preoperatively to 1.9 ± 1 and 2 ± 1.7 at the last follow-up (P < .001). The Rowe, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Subjective Shoulder Value scores of the patients increased from 18.7 ± 10.6, 71.8 ± 5, 22.9 ± 3.5, and 49.3 ± 16.2 preoperatively to 90.3 ± 6.2, 90.1 ± 4.2, 30.1 ± 2.4 (P < .001) and 81.1 ± 15.7 (P = .001) postoperatively. At the final follow-up, the bone graft healing rate was 100%, and there was no severe bone resorption. All patients returned to work, and 73.3% of patients (11 of 15) returned to sports at their preinjury or higher level.

CONCLUSIONS

The arthroscopic "double-inlay" Eden-Hybinette procedure has demonstrated reliability and efficacy, yielding excellent mid-term clinical and radiological outcomes for bone defects exceeding 20%, particularly in cases of failed Bristow-Latarjet procedures or in patients with epilepsy.

Determining optimal length of coracoid graft in the modified Bristow procedure for anterior shoulder instability: A three-dimensional finite element analysis

BACKGROUND

There is a lack of consensus concerning the coracoid graft length in the modified Bristow procedure.

OBJECTIVE

We attempted to determine the optimal graft length using the three-dimensional finite element method.

METHODS

In a shoulder model with a 25% anterior glenoid defect, a coracoid graft of varying lengths (5, 10, 15, and 20 mm) was fixed using a half-threaded screw. First, a compressive load of 500 N was applied to the screw head to determine the graft failure load during screw tightening. Next, a tensile load (200 N) was applied to the graft to determine the failure load due to biceps muscle traction.

RESULTS

In the screw compression, the failure loads in the 5-, 10-, 15-, and 20-mm models were 252, 370, 377, and 331 N, respectively. In the tensile load applied to the coracoid graft, the failure load exceeded 200 N for both the 5- and 10-mm models.

CONCLUSION

The 5-mm graft had a high risk of fracture during intraoperative screw tightening. As for the biceps muscle traction, the 5- and 10-mm-grafts had a lower failure risk than the 15- and 20-mm-grafts. Therefore, we believe that the optimal length of the coracoid graft is 10 mm in the modified Bristow procedure.

Low grade of osteoarthritis development after Latarjet procedure with a minimum 5 years of follow-up: a systematic review and pooled analysis

PURPOSE

The purpose of this systematic review and pooled analysis was to evaluate incidence and risk factors for glenohumeral osteoarthritis (OA) in patients who underwent Latarjet procedure with a minimum of 5-year follow-up.

METHODS

The PRISMA guidelines were followed to perform this systematic review. PubMed and EMBASE were searched up to February 29, 2020 for English, human in vivo studies that evaluated glenohumeral OA in patients undergoing Latarjet procedure at least 5 years after surgery. A pooled analysis on the included databases sent by authors was performed to evaluate the risk factors influencing the development or progression of dislocation arthropathy after the Latarjet procedure.

RESULTS

Four studies, including a total of 280 patients (213 males and 67 females), were analysed. In our study population, the median age at surgery was 25.0 years (range 20.8-32.6 years). and 92.1% were athletes. In 90% of the cases, the number of dislocations before surgery were fewer than 5. The recurrence of instability after Latarjet procedure was observed only in seven patients (2.5%). The position of the bone graft resulted flush to the anterior glenoid rim in 238 cases (85.3%), medial in 8 (2.9%) and overhanging in 33 (11.8%). Radiological signs of development or progression of shoulder OA were observed in 25.8% of the patients, of which 88.6% presented a grade 1 of OA according to Samilson and Prieto classification. The overhanging position of the bone graft resulted statistically significant for onset or worsening of OA. The age at surgery, the number of dislocations before surgery and the Hill-Sachs lesion were not significantly associated with joint degeneration. Instead, hyperlaxity showed a prevention role in the development of OA after open Latarjet procedure.

CONCLUSION

The Latarjet procedure is a valid and safe surgical treatment in recurrent anterior shoulder instability with a low risk of developing moderate or severe OA also at long-term follow-up. The overhanging position of the bone graft represents the principal risk factor of joint degeneration, whereas the hyperlaxity seems to be protective. Finally, age, gender, time between first dislocation and surgery, and number of dislocations do not seem to affect the onset of OA after Latarjet procedure. Therefore, an accurate execution of the Latarjet procedure can be considered a valid treatment even in young and athletes thanks to the low recurrence rates and the low development of major long-term complications.

LEVEL OF EVIDENCE

IV.

Latarjet procedure for anterior shoulder instability: a 24-year follow-up study

INTRODUCTION

Different surgical techniques (open and arthroscopic) have been described for the treatment of post-traumatic recurrent anterior instability. The aim of the surgery is to restore when possible, normal shoulder anatomy by repairing the underlying pathology responsible for the instability. Sometimes other surgical techniques are indicated. The purpose of this retrospective study was to investigate the long-term clinical and radiographic results and complications of the open Latarjet procedure after a minimum follow-up of 24 years.

MATERIALS AND METHODS

A retrospective study was performed for 67 patients treated with an open Latarjet procedure in a single center. Forty of these 67 patients returned for follow-up evaluation and clinical/radiological examination during the year 2018, having had a minimum of 24-year follow-up. Clinical outcomes were analyzed using two functional scores, in addition to the ROM and strength assessment. Radiographic evaluation included several views (AP views in neutral, internal and external rotation and a comparative Bernageau view) RESULTS: A total of 40 patients underwent an open Latarjet procedure. All the patients were avaible for follow-up at an average of 25.6 years. Clinically, no patient reported any episode of dislocation at the time of follow-up. The mean Rowe score and the Walch-Duplay score were 84.5 (range 45-100) and 83.5 (range 55-100), respectively. Non-union/fibrous union was reported in 12.5% of cases, partial resorption of the graft was found in 7.5% of cases, while total resorption was found in 5% of cases. Osteoarthritis was identified in 52.5% (21) of the patients.

CONCLUSIONS

This long-term follow-up study demonstrated that the open Latarjet procedure is a safe and reliable technique for recurrent anterior shoulder instability. The Latarjet procedure provides good long-term stability although associated with a slight limitation in external rotation.

LEVEL OF EVIDENCE

Level III; retrospective cohort comparison; treatment study.

Surgical stabilization of pediatric anterior shoulder instability yields high recurrence rates: a systematic review

PURPOSE

The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability.

METHODS

The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non-randomized Studies (MINORS) tool was used to assess the quality of included studies.

RESULTS

Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow-up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%).

CONCLUSIONS

Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non-operative management, it may be reasonable to perform surgery at a first-time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post-operative efficacy (i.e. re-dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow-up.

LEVEL OF EVIDENCE

IV.

Clinical outcomes and radiologic assessment of a modified suture button arthroscopic Latarjet procedure

Background

As several neurologic and hardware complications have been reported with screw fixation. Suture buttons are used to serve as an alternative to screw fixation to obtain better outcome and to reduce the complication. The purpose of this study was to observe the clinical outcomes and make the radiologic assessment of a modified suture button (MSB) arthroscopic Latarjet procedure.

Methods

A total of ninty-one patients with recurrent shoulder joint dislocation who underwent MSB arthroscopic Latarjet procedure was retrospectively reviewed. Fifty cases identified from the chart review met the inclusion criteria. The clinical outcomes and position of the grafts, glenohumeral degeneration, and graft healing condition were assessed postoperatively in a follow-up with at least one and half of a year.

Results

All the fifty patients were satisfied with their clinical outcome. The overall complication rate was 4% in this study. The mean visual analog scale score, the affected shoulder active mobility in Ers(external rotation at the side), Era(external rotation in abduction) decreased significantly; the ASES score, Rowe score, Walch-Duplay score improved significantly. CT scans in the sagittal view showed that grafts in 88% of cases were in good position, grafts in 12% of cases were fixed too superiorly and inferiorly. In the axial view grafts in forty cases were flush with the glenoid rim, ten were considered as too lateral. The ten grafts became remodeled and were more flush with the glenoid rim in the follow-up.

Conclusions

The MSB arthroscopic Latarjet procedure provides excellent outcome with few complications, and no degenerative changes were observed in the follow-up. Moreover, the graft fixed too laterally presented a phenomenon of remodeling and became flush with the glenoid rim over time.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2544-x) contains supplementary material, which is available to authorized users.

Comparative Systematic Review of Fixation Methods of the Coracoid and Conjoined Tendon in the Anterior Glenoid to Treat Anterior Shoulder Instability

BACKGROUND

Coracoid process transfer for the treatment of recurrent glenohumeral dislocations is a safe and reliable procedure; however, there is no consensus as to which is the best method, the Bristow or Latarjet procedure.

PURPOSE

To analyze the results of coracoid process transfer for the treatment of recurrent glenohumeral dislocations and to compare the results of this transfer between the Bristow and Latarjet techniques.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The databases surveyed for this review included J-STAGE; Cochrane Bone, Joint and Muscle Trauma Group Specialized Register; Cochrane Controlled Register of Trials; MEDLINE; Ovid; Embase; Google Scholar; and CINAHL. Inclusion criteria consisted of (1) studies related to anterior glenohumeral dislocations treated with transfer of the coracoid process to the anterior glenoid rim and (2) studies that could provide data to perform at least 1 meta-analysis or other statistical evaluation. Titles and abstracts were reviewed for inclusion; thereafter, outcomes and the risk of bias were extracted. Statistical analyses were performed according to the nature of the data. When possible, the 95% CI was included.

RESULTS

Of the 779 studies found, 63 were able to provide data assessing 3395 shoulders. There were no randomized, blinded, or double-blinded trials. The recurrence of dislocations was assessed in 41 studies that used the Bristow technique (n = 2346 shoulders; percentage redislocations [mean ± SE], 1.00% ± 0.20%) and 18 studies that used the Latarjet technique (n = 930 shoulders; percentage redislocations, 2.13% ± 0.49%) (P = .04). The mean loss of external rotation was 12.91° for the Bristow procedure (n = 1440 shoulders) and 11.70° for the Latarjet procedure (n = 243 shoulders). The mean quality-of-life outcome scores were as follows for the Bristow and Latarjet procedures, respectively: Rowe score, 92.06 and 89.33; Western Ontario Shoulder Instability Index score, 16.44% and 19.68%; Japanese Orthopaedic Association score, 93.28 and 92.00; and American Shoulder and Elbow Surgeons score, 91.00 and 89.90.

CONCLUSION

Transferring the coracoid to the anteroinferior border of the glenoid through the subscapularis tendon is effective, regardless of the technique. When comparing the Bristow and Latarjet techniques, the recurrence of dislocations was the only outcome that could undergo a meta-analysis, and it presented a statistically significant difference in favor of the Bristow procedure. All other outcomes presented no clinically significant differences between their effect sizes. More studies presenting better methodology are still needed to achieve more robust conclusions.

Editorial Commentary: Is It Time to Take a Stand? When Arthroscopic Bankart Repair Is No Longer a Viable Option for Anterior Shoulder Instability

Recurrent anterior instability remains a challenging pathology to treat effectively. Arthroscopic Bankart repair, with its low invasiveness and complication rates, is readily the first, as well as most commonly, used procedure. However, some outcomes studies have reported an unacceptably high failure rate. As such, the ideal candidate for an arthroscopic repair has yet to be fully defined, mainly because of the multiple risk factors for failure after arthroscopic instability repair. Among those factors, recurrence of an instability event is clearly a risk factor for worse outcomes after arthroscopic instability repair. This may be due to an association between recurrent instability and an increase in glenoid bone loss, humeral bone loss, and more extensive labral tears, as well as more capsular, ligamentous, and rotator cuff injuries. Patients who present with 2 preoperative dislocations and a duration of instability symptoms of more than 6 months, as well as off-track Hill-Sachs lesions, may not be ideal candidates for arthroscopic instability repair. There is a "cost" to waiting on surgery after a first dislocation.

Modified Bristow-Latarjet procedure for treatment of recurrent traumatic anterior glenohumeral dislocation

Objective

Retrospective case–control study of authors experience in the modified Bristow-Latarjet procedure for treatment of recurrent traumatic anterior glenohumeral dislocation with glenoid bone injury.

Methods

Sample with 102 recurrent glenohumeral dislocation cases submitted to modified Bristow-Latarjet procedure. Indications included situations of recurrent traumatic anterior glenohumeral instability with more than two dislocation episodes and with glenoid bone attritional or fragmentary injuries, without possibility of reconstruction. Mean follow-up time was 5.33 ± 2.74 years (minimum 1; range 1–13).

Results

The mean Walch-Duplay Score at the last evaluation was 91.23 ± 11.46 (range 15–100). The functional score of patients with glenoid bone loss greater than 20% did not show a significant difference in comparison with patients with glenoid bone loss lower than 20% (90 vs. 92, respectively). The functional score also did not show a significant difference between sports practice categories and between recreational and competitive practice, being excellent (greater than 90) in every category. There were no dislocation recurrences and the only complications were a case of persistent instability and a screw revision. Mild glenohumeral osteoarthrosis imaging signs were identified in 7.84% of the patients; however, their functional scores were not significantly different in comparison to other patients.

Conclusion

The modified Bristow-Latarjet procedure is a very effective procedure with few complications in the medium-term, showing very satisfactory functional outcomes in the treatment of recurrent traumatic anterior glenohumeral dislocation associated with glenoid bone injury.

Is the two-dimensional computed tomography scan analysis reliable for coracoid graft positioning in Latarjet procedures?

BACKGROUND

The aim of the study was to develop a computed tomography (CT)-based measurement protocol for coracoid graft (CG) placement in both axial and sagittal planes after a Latarjet procedure and to test its intraobserver and interobserver reliability.

METHODS

Fifteen postoperative CT scans were included to assess the intraobserver and interobserver reproducibility of a standardized protocol among 3 senior and 3 junior shoulder surgeons. The evaluation sequence included CG positioning, its contact area with the glenoid, and the angle of its screws in the axial plane. The percentage of CG positioned under the glenoid equator was also analyzed in the sagittal plane. The intraobserver and interobserver agreement was measured by the intraclass correlation coefficient (ICC), and the values were interpreted according to the Landis and Koch classification.

RESULTS

The ICC was substantial to almost perfect for intraobserver agreement and fair to almost perfect for interobserver agreement in measuring the angle of screws in the axial plane. The intraobserver agreement was slight to almost perfect and the interobserver agreement slight to substantial regarding CG positioning in the same plane. The intraobserver agreement and interobserver agreement were both fair to almost perfect concerning the contact area. The ICC was moderate to almost perfect for intraobserver agreement and slight to almost perfect for interobserver agreement in analyzing the percentage of CG under the glenoid equator.

CONCLUSION

The variability of ICC values observed implies that caution should be taken in interpreting results regarding the CG position on 2-dimensional CT scans. This discrepancy is mainly explained by the difficulty in orienting the glenoid in the sagittal plane before any other parameter is measured.

What is a Bristow-Latarjet procedure? A review of the described operative techniques and outcomes

OBJECTIVES

A variety of operative techniques have been described as under the term 'Bristow-Latarjet' procedure. This review aims to define the original procedure, and compare the variation in techniques described in the literature, assessing any effect on clinical outcomes.

MATERIALS AND METHODS

A systematic review of 24 studies was performed to compare specific steps of the technique (coracoid osteotomy site, subscapularis approach, orientation and position of coracoid graft fixation and fixation method, additional labral and capsular repair) and detect any effect this variability had on outcomes.

RESULTS

Overall recurrence rate was 5.36% (2.94% to 43%). Half of the studies performed the procedure for recurrent shoulder instability, with only five studies documenting glenoid bone loss as an indication: 12 studies used the procedure as the primary surgical intervention for recurrent instability. No change in outcome was noted when examining variation in the coracoid osteotomy site, the fixation site on the scapular neck, the fixation method or whether a capsular repair was also performed. Performing a horizontal split in subscapularis may preserve external rotation compared with performing a tenotomy.

CONCLUSIONS

This is the first review to examine various operative techniques of the Bristow-Latarjet procedure, and their effect on outcome. We found that other than the approach through subscapularis, outcome was independent of the surgical technique, and depended more on patient selection. We would commend future publications on this procedure to provide a detailed description of the surgical technique, and as a minimum present rates of recurrence as an outcome measure. Cite this article: Bone Joint J 2016;98-B:1208-14.

A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair

BACKGROUND

The Bankart repair and Latarjet procedure are both viable surgical options for recurrent traumatic anterior instability of the shoulder joint. The anatomic repair is the more popular option, with 90% of surgeons internationally choosing the Bankart repair as the initial treatment. There has been no previous review directly comparing the 2 techniques. Hence, we aimed to systematically review studies to compare the outcomes of Bankart repairs vs. the Latarjet procedure for recurrent instability of the shoulder.

METHODS

Six electronic databases were searched for original, English-language studies comparing the Bankart and Latarjet procedures. Studies were critically appraised using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Data were extracted from the text, tables, and figures of the selected studies.

RESULTS

Eight comparative studies were identified with 795 shoulders; 416 of them underwent open or arthroscopic Bankart repairs, and 379 were repaired by the open Latarjet procedure. Primary and revision procedures were studied. The Latarjet procedure conferred significantly lower risk of recurrence and redislocation. There was no significant difference in the rates of complication requiring reoperation between the two procedures. Rowe scores were higher and loss of external rotation lower in the Latarjet group compared with the Bankart repair group.

CONCLUSIONS

Our studies demonstrate that the Latarjet procedure is a viable and possibly superior alternative to the Bankart repair, offering greater stability with no significant increase in complication rate. However, the studies identified were retrospective and of limited quality, and therefore randomized controlled trials with large populations of patients or prospective assessment of national orthopedic registries should be employed to confirm our findings.

Surgical options for the young patient with glenohumeral arthritis

Young patients with glenohumeral arthritis are an ongoing treatment challenge. They typically have high demands of their shoulders, require long-term durability due to their young age, and often have altered local anatomy, through their disease process (instability arthropathy, juvenile rheumatoid arthritis, etc.) or from previous surgery (capsulorraphy arthropathy, chondrolysis, etc.). Workup to evaluate underlying causes of early arthritis, and to exclude infectious causes are necessary. When nonoperative management fails, arthroscopic debridement, hemiarthroplasty (isolated, with glenoid reaming, or with biological interposition), and total shoulder arthroplasty are treatment options available to the treating surgeon. Debridement or hemiarthroplasty can provide pain relief for a subset of patients, but results have not been reproducible across the literature and have not been durable over time. Total shoulder arthroplasty provides the most reliable pain relief, but long-term glenoid loosening and wear continue to lead to high revision rates in this patient population.

The Anatomic Basis for the Arthroscopic Latarjet Procedure: A Cadaveric Study

BACKGROUND

The Latarjet technique is a reliable treatment option for recurrent anterior shoulder instability. However, the complication rate has been reported to be as high as 30%, with 1.6% of patients suffering a nerve injury. The all-arthroscopic Latarjet procedure has been gaining popularity, even as it has introduced its own challenges. Given that the surgeon is not able to palpate the nerves, their localization and protection can be difficult. Additionally, the use of different instruments can lead to distinct nerve injury mechanisms.

PURPOSE

To describe the anatomic trajectory of the musculocutaneous, axillary, and suprascapular nerves in relation to the arthroscopic Latarjet approach. Using this information, guidance is provided for reducing nerve injuries during instrumentation and screw insertion.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A total of 50 cadaveric shoulders from 25 whole-body specimens were examined. The specimens were placed in the beach-chair position, and the deltopectoral and dorsal approaches were used to expose the relevant structures. A subscapularis muscle split was performed between the inferior and middle thirds of the tendon. Digital caliper measurements were taken between various points of the trajectories of the nerves and surrounding anatomic landmarks. The location of the nerves relative to the split was recorded.

RESULTS

The musculocutaneous nerve lay within the split in 66% of the shoulders (n = 33); it was medial to the split in 28% (n = 14); it was found lateral to split in 2% (n = 1); and it was not identified in 4% of shoulders (n = 2). The mean length of the axillary nerve was 4.0 cm (95% CI, 3.7-4.2) from the exit of the plexus to the quadrangular space. The axillary nerve was found to be within the split in 50% of the shoulders (n = 25) and medial to the split in the remaining 50% (n = 25). The suprascapular nerve at the level of the supraspinatous fossa passed 3.3 cm (95% CI, 3.1-3.5) medial to the superior rim of the posterior glenoid. The nerve curves around the root of the spine at the spinoglenoid notch level, approximating the glenoid rim to a distance of 2.1 cm (95% CI, 2.0-2.2). Finally, the nerve runs medially again before branching out into smaller fibers to innervate the infraspinatus muscle at a distance of 2.9 cm (95% CI, 2.7-3.1) from the inferior glenoid rim. Based on these findings, there is an approximately 2 cm-wide safe zone from the edge of the glenoid rim for the insertion of graft-fixing screws.

CONCLUSION

When performing a subscapularis split in the arthroscopic Latarjet procedure, the risk of injuries to the musculocutaneous and axillary nerves could be reduced by aiming the switching stick inserted through the posterior portal toward the lateral edge of the intended location of the split. Injuries to the suprascapular nerve could be prevented by aiming the graft-fixing screws laterally toward the edge of the glenoid rim.

CLINICAL RELEVANCE

This study clarifies the location of the nerves relevant to the arthroscopic Latarjet technique and provides anatomic information that could help the surgeon reduce the risk of injuries to the musculocutaneous, axillary, and suprascapular nerves.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis

PURPOSE

The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques.

MATERIALS AND METHODS

A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated.

RESULTS

Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis.

CONCLUSIONS

The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient.

LEVEL OF EVIDENCE

III.

Clinical Outcome and Glenoid Morphology After Arthroscopic Repair of Chronic Osseous Bankart Lesions: A Five to Eight-Year Follow-up Study

BACKGROUND

Arthroscopic osseous Bankart repair for shoulders with chronic recurrent anterior instability has been reported as an effective procedure with promising short-term outcomes. However, to date, we know of no report describing longer-term outcomes and glenoid morphologic change. The purpose of the present study was to report intermediate to long-term outcomes and glenoid morphologic change after arthroscopic osseous Bankart repair in patients with substantial glenoid bone loss.

METHODS

A consecutive series of eighty-five patients with traumatic anterior glenohumeral instability associated with a chronic osseous Bankart lesion underwent arthroscopic repair from January 2005 through December 2006. Forty-six patients with bone loss of >15% of the inferior glenoid diameter relative to the assumed inferior circle regardless of the fragment size were selected as candidates for this study. Thirty-eight patients (83%), including thirty-four male and four female patients, with a mean age of 23.4 years (range, fifteen to thirty-six years) at the time of surgery, were available for final follow-up at a mean of 6.2 years (range, 5.0 to 8.1 years) after surgery.

RESULTS

One patient had a redislocation during a traffic accident five months after surgery before obtaining an osseous union. The mean Rowe score and the mean Western Ontario Shoulder Instability Index improved significantly from 30.7 points preoperatively to 95.4 points postoperatively and from 26.5% to 81.5%, respectively. Although the mean preoperative fragment size was measured as only 4.7%, the mean glenoid bone loss improved from 20.4% preoperatively to -1.1% postoperatively.

CONCLUSIONS

Arthroscopic osseous Bankart repair is an effective primary treatment for shoulders with substantial glenoid bone loss as it provides successful outcomes without recurrence of instability once osseous union is obtained. Glenoid morphology can be normalized during the intermediate to long-term postoperative period, even in shoulders with a smaller fragment.

Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature

PURPOSE

The aim of this study was to evaluate clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures.

METHODS

A systematic review of the literature on management of anterior dislocation of the shoulder with glenoid bony procedures was performed. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "Latarjet," "Bristow," "bone loss," "Eden-Hybinette," "iliac," "bone," "block," "clinical," "outcome," and "Bankart." The following data were extracted: demographics, bone defects and other lesions, type of surgery, outcome measurement, range of motion (ROM), recurrence of instability, complications, and osteoarthritis. A quantitative synthesis of all comparative studies was performed to compare bone block procedures and Bankart repair in terms of postoperative recurrence of instability and osteoarthritis.

RESULTS

Forty-six studies were included and 3,211 shoulders were evaluated. The mean value of the Coleman Methodology Score (CMS) was 65 points. Preoperatively, the injuries detected most were glenoid bone loss and Bankart lesions. The Eden-Hybinette procedure had the highest rate of postoperative osteoarthritis and recurrence. Pooled results from comparative studies showed that the bone block procedures were associated with a lower rate of recurrence when compared with Bankart repair (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.28 to 0.74; P = .002), whereas there was no significant difference between the 2 groups in terms of postoperative osteoarthritis (P = .79).

CONCLUSIONS

The open Bristow-Latarjet procedure continues to be a valid surgical option to treat patients with anterior shoulder instability. Bone block procedures were associated with a lower rate of recurrence when compared with the Bankart repair. The Eden-Hybinette procedure has clinical outcomes very similar to the Bristow-Latarjet technique but has a higher rate of postoperative osteoarthritis and recurrence. An arthroscopic Bristow-Latarjet procedure seems to be better in terms of prevention of recurrence and rehabilitation, but randomized studies are needed to reach definitive conclusions.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Arthroscopic subscapularis bankart technique as a salvage procedure for failed anterior shoulder stabilization

BACKGROUND

Shoulder instability is a relatively common problem. Even with contemporary surgical techniques, instability can recur following both open and arthroscopic fixation. Surgical management of capsular insufficiency in anterior shoulder stabilization represents a significant challenge, particularly in young, active patients. There are a limited number of surgical treatment options. The Laterjet technique can present with a number of intraoperative challenges and postoperative complication.

DESCRIPTION OF TECHNIQUE

We report an arthroscopic subscapularis tenodesis technique as a salvage procedure for challenging glenohumeral instability cases. Sutures are passed through the subscapularis tendon and capsule before they are tied as one in the subdeltoid psace. The rotator interval is closed with superior and medial advancement of anterior and inferior tissue. This technical note carefully describes this procedure with useful technical tips, illustrations, and diagrams.

PATIENTS AND METHODS

Two clinical cases are described involving patients with recurrent instability following failed surgery who were successfully managed with this procedure.

RESULTS

Both cases described resulted in improved shoulder stability, range of motion, and function following management with this surgical technique. This arthroscopic subscapularis tenodesis procedure is proposed as a useful alternative repair technique for cases of recurrent instability after failed surgery with isolated capsular insufficiency.

CONCLUSION

It is believed that this arthroscopic subscapularis tenodesis technique can potentially provide similar outcomes to open bone block stabilization procedures, while reducing the risks associated with those procedures.

Reconstruction of a bony bankart lesion: best fit based on radius of curvature

BACKGROUND

The inferior coracoid process has traditionally been considered to be the gold standard for glenoid augmentation after anteroinferior bone loss. Other autograft sites, and more recently, osteochondral allograft sites, have been described as potential donor sources.

PURPOSE

Potential autograft and osteochondral allograft sites were compared to identify the graft source that would provide the best fit for glenoid augmentation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Mose circles, a geometric tool found on a standard goniometer, were used to make radius of curvature measurements of 10 anatomic locations in 17 cadaveric specimens. The bony surface of the glenoid, measured from superior to inferior (G-SI) and from anterior to posterior (G-AP), was used as the standard for comparison. Autograft sites were the inferior coracoid, lateral coracoid, and inner table of the iliac crest. Potential osteochondral allograft sites were the radial head, scaphoid fossa of the distal radius (S-DR), lunate fossa of the distal radius (L-DR), medial tibial plateau, and lateral distal tibia. An acceptable match for autograft sites was based on a paired analysis and defined as a radius of curvature within 5 mm of the G-SI or the G-AP of the same cadaveric specimen. Allograft sites were evaluated using an unpaired analysis in which an ideal fit was defined as a radius of curvature of 25 to 30 mm, based on the interquartile range of the G-SI and G-AP.

RESULTS

The median (interquartile range) radii of curvature for the G-SI and G-AP were 30 mm (range, 25-30 mm) and 25 mm (range, 25-25 mm), respectively. The inferior coracoid was within 5 mm of the G-SI 59% of the time and the G-AP 94% of the time; no measurements from the lateral coracoid or iliac crest were within the range of the glenoid radius of curvature. Analysis of the allograft sites demonstrated an acceptable fit for 94% of the distal tibia, 68% of the medial tibial plateau, 12% of the S-DR, and 0% of the L-DR and the radial head specimens.

CONCLUSION

An autograft of the inferior coracoid or an osteochondral allograft of the lateral distal tibia provided the best match to re-establish the native radius of curvature of the glenoid.

CLINICAL RELEVANCE

To best re-create the native glenohumeral anatomy, surgeons should consider the use of an autograft of the inferior coracoid or an osteochondral allograft of the lateral distal tibia for the reconstruction of osseous glenoid defects.

Arthroscopic latarjet procedure: safety evaluation in cadavers

OBJECTIVE:

To evaluate the safety of arthroscopic Latarjet procedure in cadavers.

METHODS

: Twelve cadaveric shoulders underwent arthroscopic Latarjet procedure in our laboratory for arthroscopy, by four different surgeons. Following surgery, the specimens were subjected to radiographic examination and evaluated by an independent examiner. Nineteen parameters were evaluated, including the coracoid graft fixation, positioning and angulation of the screws, neurological damage and integrity of tendons.

RESULTS

: Four procedures were considered to be satisfactory, with no difference among the surgeons. The mean angulation of the screws was 27.2°. The subscapularis splitting was, on average, 17.8mm from the upper edge. The coracoid graft was properly positioned relative to equator of the glenoid in 11 cases. There was no injury to the axillary or musculocutaneous nerves. The main complications were: interposition of soft tissue, suprascapular nerve injury, articular deviation of the graft, diastasis and conjoined tendon injury.

CONCLUSION

: The arthroscopic Latarjet procedure is a complex technique in which each step must be precise to reduce the risk of complications. Our study showed a high risk of failure of the procedure. Level of Evidence IV, Case Series.

Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review

BACKGROUND

Various methods of bony stabilization, including modifications of Bristow and Latarjet procedures, are considered gold-standard treatment for recurrent anterior shoulder instability but are associated with unique complications and risk of reoperation. The purpose of this study was to identify the prevalence of these complications. We hypothesized that the Bristow-Latarjet procedure would be a successful technique for treatment of shoulder instability but associated with a risk of recurrent postoperative instability, reoperation, and other complications.

METHODS

A systematic review of multiple medical databases included studies reporting outcomes with complication and reoperation rates following original or modified versions of the Bristow or Latarjet shoulder stabilization surgeries.

RESULTS

Forty-five studies were analyzed (1,904 shoulders) (all Level IV evidence). Most subjects were male (82%). The dominant shoulder was the operative shoulder in 64% of cases. Mean subject age was 25.8 years. Mean clinical follow-up was 6.8 years. Ninety percent of surgeries were done open; 9.3% were all-arthroscopic. Total complication rate was 30%. Recurrent anterior dislocation and subluxation rates were 2.9% and 5.8%, respectively. When reported, most dislocations occurred within the first year postoperatively (73%). Nearly 7% of patients required an unplanned reoperation following surgery.

CONCLUSION

Osseous stabilization shoulder surgery using original or modified Bristow and Latarjet procedures has a 30% complication rate. Rates of recurrent dislocation and reoperation were 2.9% and 7%, respectively. Mild loss of external rotation is common. Reoperation rates were lower following all-arthroscopic techniques. There was a greater loss of postoperative external rotation with all-arthroscopic surgery.

Results of the Latarjet procedure for recurrent anterior dislocation of the shoulder in patients with epilepsy

A total of 12 epileptic patients (14 shoulders) with recurrent seizures and anterior dislocations of the shoulder underwent a Latarjet procedure and were reviewed at a mean of 8.3 years (1 to 20) post-operatively. Mean forward flexion decreased from 165° (100° to 180°) to 160° (90° to 180°) (p = 0.5) and mean external rotation from 54° (10° to 90°) to 43° (5° to 75°) (p = 0.058). The mean Rowe score was 76 (35 to 100) at the final follow-up. Radiologically, all shoulders showed a glenoid-rim defect and Hill-Sachs lesions pre-operatively. Osteo-arthritic changes of the glenohumeral joint were observed in five shoulders (36%) pre-operatively and in eight shoulders (57%) post-operatively. Re-dislocation during a seizure occurred in six shoulders (43%). Five of these patients underwent revision surgery using a bone buttress from the iliac crest and two of these patients re-dislocated due to a new seizure. Due to the unacceptably high rate of re-dislocation after surgery in these patients, the most important means of reducing the incidence of further dislocation is the medical management of the seizures. The Latarjet procedure should be reserved for the well-controlled patient with epilepsy who has recurrent anterior dislocation of the shoulder during activities of daily living.

Complications associated with open coracoid transfer procedures for shoulder instability

BACKGROUND

Interest has been maintained in the use of coracoid transfer procedures for recurrent shoulder instability despite the significant potential for serious complications. A comprehensive systematic review of the literature was performed to quantify and characterize the complication rate associated with these procedures to better inform practicing surgeons and their patients.

MATERIALS AND METHODS

Medline, Excerpta Medica Database (EMBASE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for therapeutic studies published between 1985 and 2011. Data regarding complications was extracted from selected articles in a standardized manner. Complication rates were determined and expressed as percentages with 95% confidence intervals.

RESULTS

Included were 30 studies describing the results of 1658 coracoid transfer procedures. Repeat surgery was documented in 4.9% ± 1.0% of cases. Recurrent instability occurred in 6.0% ± 1.2%. Hardware complications occurred in 6.5% ± 1.3%. Collectively, the rate of graft nonunion, fibrous union, or postoperative graft migration was 10.1% ± 1.6%; graft osteolysis occurred in 1.6% ± 0.7%. There was a 1.2% ± 0.8% rate of nerve palsy. Surgical site infection occurred in 1.5% ± 0.7%. Intraoperative fractures occurred in 1.1 ± 0.6%.

CONCLUSION

Coracoid transfers for shoulder instability can improve shoulder stability with acceptable recurrence rates. They are challenging procedures associated with a broad range and significant incidence of complications. A detailed appreciation of anatomy and meticulous attention to technical detail, particularly graft placement, is key to reducing complications. These procedures may be best indicated in the setting of glenoid or humeral bony deficiency, although efficacy over open capsular procedures remains equivocal.

Arthroscopic latarjet procedure

Although soft tissue stabilization procedures in the shoulder yield good results, arthroscopy and radiological investigations have identified more complex soft tissue and bony lesions that can be successfully treated using a Latarjet procedure. The authors have advanced this technique to make it possible arthroscopically, thereby conferring all the benefits that arthroscopic surgery offers. This article describes how and why the arthroscopic Latarjet procedure is a valuable tool in the treatment of complex shoulder instability and how the procedure can be introduced into practice. This technique has shown excellent results at short- to mid-term follow-up, with minimal complications. As such, this procedure is recommended to surgeons with good anatomic knowledge, advanced arthroscopic skills, and familiarity with the instrumentation.

Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review

OBJECTIVE

The purpose is to systematically evaluate the literature regarding treatment of chronic glenoid bone defects in the setting of recurrent anterior shoulder instability to determine if, from an evidence-based outcomes approach, one technique may be recommended over the other.

METHODS

PubMed 1966-2009, Embase 1980-2009, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials databases were searched for human studies in English. Keywords were osseous glenoid defects, glenoid bone grafting, Latarjet procedure, iliac crest and glenoid defects, and glenoid rim fractures. Inclusion criteria were all articles evaluating chronic glenoid deficiency in the setting of recurrent anterior glenohumeral instability. Exclusion criteria were surgical techniques not reporting follow-up, glenoid rim fractures treated by open reduction internal fixation, and investigations not quantifying glenoid deficiency assessments.

RESULTS

Six articles met all inclusion and exclusion criteria. All articles were level IV (case series), most (5/6) were retrospective. Multiple techniques involving coracoid transfer and allograft or autograft reconstruction have been described for management of chronic glenoid deficiency. Lack of high level evidence in the form of prospective randomized trials limits our ability to recommend one technique over another. The 6 techniques reviewed here were all effective at preventing recurrent instability.

CONCLUSIONS

Chronic glenoid deficiency in the setting of recurrent anterior instability is an extremely challenging problem. There remains a lack of strong evidence guiding the surgeon in the decision-making process. Additional research is needed to optimize the preoperative glenoid defect assessment, further evaluate the reconstruction techniques, and follow the long-term effects of reconstruction on the development of glenohumeral arthrosis.

Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting

BACKGROUND

Multiple bone-grafting procedures have been described for patients with glenoid bone loss and shoulder instability. The purpose of this study was to investigate the alterations in glenohumeral contact pressure associated with the placement and orientation of Latarjet or iliac crest bone graft augmentation and to compare the amount of glenoid bone reconstruction with two coracoid face orientations.

METHODS

Twelve fresh-frozen cadaver shoulders were tested in static positions of humeral abduction (30 degrees , 60 degrees , and 60 degrees with 90 degrees of external rotation) with a 440-N compressive load. Glenohumeral contact pressure and area were determined sequentially for (1) the intact glenoid; (2) a glenoid with an anterior bone defect involving 15% or 30% of the glenoid surface area; (3) a 30% glenoid defect treated with a Latarjet or iliac crest bone graft placed 2 mm proud, placed flush, or recessed 2 mm in relation to the level of the glenoid; and (4) a Latarjet bone block placed flush and oriented with either the lateral (Latarjet-LAT) or the inferior (Latarjet-INF) surface of the coracoid as the glenoid face. The amount of glenoid bone reconstructed was compared between the Latarjet-LAT and Latarjet-INF conditions.

RESULTS

Bone grafts in the flush position restored the mean peak contact pressure to 116% of normal when the iliac crest bone graft was used (p < 0.03 compared with the pressure with the 30% defect), 120% when the Latarjet-INF bone block was used (p < 0.03), and 137% when the Latarjet-LAT bone block was used (p < 0.04). Use of the Latarjet-LAT bone block resulted in mean peak pressures that were significantly higher than those associated with the iliac crest bone graft (p < 0.02) or the Latarjet-INF bone block (p < 0.03) at 60 degrees of abduction and 90 degrees of external rotation. With the bone grafts placed in a proud position, peak contact pressure increased to 250% of normal (p < 0.01) in the anteroinferior quadrant and there was a concomitant increase in the posterosuperior glenoid pressure to 200% of normal (p < 0.02), indicating a shift posteriorly. Peak contact pressures of bone grafts placed in a recessed position revealed high edge-loading. Augmentation with the Latarjet-LAT bone block led to restoration of the glenoid articular contact surface from the 30% defect state to a 5% defect state. Augmentation of the 30% glenoid defect with the Latarjet-INF bone block resulted in complete restoration to the intact glenoid articular surface area.

CONCLUSIONS

Glenohumeral contact pressure is optimally restored with a flush iliac crest bone graft or with a flush Latarjet bone block with the inferior aspect of the coracoid becoming the glenoid surface. Bone grafts placed in a proud position not only increase the peak pressure anteroinferiorly, but also shift the articular contact pressure to the posterosuperior quadrant. Glenoid bone augmentation with a Latarjet bone block with the inferior aspect of the coracoid as the glenoid surface resulted in complete restoration of the 30% anterior glenoid defect to the intact state. These findings indicate the clinical utility of a flush iliac crest bone graft and utilization of the inferior surface of the coracoid as the glenoid face for glenoid bone augmentation with a Latarjet graft.

Arthroscopic Latarjet procedure

HYPOTHESIS

Arthroscopy reveals many previously unrecognized soft tissue and bony lesions underlying recurrent anterior shoulder instability. Certain stabilising procedures however fail to adequately address the underlying pathology. The open Latarjet procedure has shown to have excellent and reproducible results in recurrent instability. We believe that this success can be transferred using an all arthroscopic technique and gain the advantages of minimally invasive surgery.

MATERIALS AND METHODS

Since December 2003, we performed over 180 arthroscopic Latarjet procedures. The technique and instruments have been refined and modified during this time. We prospectively collected the results for the first 100 shoulders.

RESULTS

The average patient age was 27.5 with 88% actively involved in sports. Mean return to work was 2 months (7 days-4 months) and return to sport at 10 weeks (21 days-6 months). At 26 months, patient-reported outcomes revealed 91% excellent scores and 9% good. Range of motion showed an average loss of external rotation of 18 degrees . Perioperative complications included 2 hematomas, 1 graft fracture, and 1 transient musculocutaneous nerve palsy. Late complications included 4 cases of graft non-union and 3 of graft lysis. Graft position was flush with the glenoid in 80%, vertical positioning was excellent in 78% (3-5 o'clock).

DISCUSSION

The all-arthroscopic Latarjet is a reliable but difficult technique, with a steep learning curve. Our technique has shown excellent results through midterm follow-up, with minimal complications and good graft positioning.

CONCLUSIONS

We recommend this procedure to those surgeons with good anatomic knowledge, advanced arthroscopic skills, and familiarity with the instrumentation.

Glenohumeral arthropathy following stabilization for recurrent instability

Little attention has been focused on the most common risk factors for post-operative glenohumeral arthropathy in patients undergoing open and arthroscopic stabilization. We performed a literature search using Medline, Cochrane and Google Scholar using the keywords: 'Shoulder instability surgery' in combination with 'glenohumeral osteoarthrosis', 'recurrent shoulder dislocation' in combination with 'surgery' and 'complications'. We identified 33 published studies. There is evidence of long-term postoperative glenohumeral arthropathy in patients undergoing surgical management for shoulder instability. The Coleman methodology score showed great heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment and generally low methodological quality. Follow-up length, age at first dislocation episode and limited external rotation have been shown to be strongly associated with shoulder arthropathy. There is no univocal outcome assessment available. To define the risk factors responsible for development of postoperative glenohumeral arthropathy, controversial findings have been detected. A common validated scale for clinical and imaging measurements for shoulder arthropathy is needed, so as to allow easier and more reliable comparison of outcomes in different studies. Patients should receive controlled imaging assessment (MR and radiographs) in addition to clinical examination. There is a need to perform appropriately powered randomized clinical trials comparing clinical and imaging related outcomes in patients undergoing open, arthroscopic and conservative management for shoulder instability. Standard diagnostic assessment, common and validated clinical and imaging scoring systems are needed.

Bristow-Latarjet procedure with specific instrumentation: study of 34 cases

A Bristow-Latarjet procedure with specific instrumentation was performed for recurrent dislocation or subluxation of the glenohumeral joint in 34 patients. The procedure was performed through a subscapularis splitting approach with three specific instruments and a special screw. The clinical outcome was assessed by the Duplay and the Constant scores. Radiographic study was conducted on 23 patients and CT scan in 11 patients. Of the 27 patients interviewed 92% were satisfied. Of the 23 patients examined, 15 had an excellent Duplay score, four a good score, three a medium score, and only one had a bad score. One patient had subluxation episodes, and one patient was revised after a redislocation following violent trauma. On the standard radiographs, all bone blocks were in the correct position. A pseudarthrosis was diagnosed in the patient with subluxation episodes. This device simplifies the surgical technique and provides reproducibility to the procedure.

Comparison of outcomes of two different surgeries in regarding to complications for chronic anterior shoulder instability

INTRODUCTION

The purpose of this study is to compare the early clinical results of two techniques in regarding to complications in the patients who suffered from chronic anterior traumatic isolated shoulder instability.

METHOD

Eighty-five patients underwent reconstructive procedures due to chronic isolated traumatic shoulder instability in our clinic between 1990 and 2002. Sixty-four patients in whom preoperatively Bankart lesion were detected with MRI and who participated in the regular follow-up were included in the study. Thirty-four patients were treated with Bankart repair (Group I) and 30 patients were treated with Modified Bristow procedure (Group II). Mean follow-up period was 25 (24-39) months for group I and 28 (24-96) months for group II. All cases were evaluated preoperatively and postoperatively according to Rowe scoring system.

RESULTS

Mean Rowe scores were 90 and 88.1 for group I and II, respectively. Due to recurrent dislocation, four revision surgeries (one in group I, three in group II) were performed. Surgical complications were encountered in group II, just as fracture at the bone block in four cases, nonunion in five cases and removal of loose screw in one case.

DISCUSSION

According to clinical outcomes, both the techniques are useful and feasible for the treatment of the chronic traumatic isolated anterior shoulder instability; however, complication rate is higher in the Modified Bristow technique and, Bankart repair is directed to the anatomic repair of the original pathology.