Arthroscopic Latarjet procedure: analysis of the learning curve

Management of intraoperative coracoid fractures in the arthroscopic Latarjet procedure

BACKGROUND

A marked increase in the number of Latarjet procedures performed has been observed and, with that, a rise in the number of complications, with intraoperative coracoid fracture being reported as one of the most common complications, especially in the arthroscopic approach. There is a scarcity of studies reporting on these complications; thus, the techniques and results are unclear.

METHODS

Retrospective case series of patients with intraoperative coracoid graft fractures during arthroscopic Latarjet performed between 2010 and 2023. In this report, we described a new coracoid graft fracture classification based on the location of the fracture relative to the screw's holes (type 1, through the distal hole; type 2, through the proximal hole [2A: partial, 2B: complete stable, 2C: complete unstable]; type 3, longitudinal splits through both holes [3A: symmetric fragments, 3B: asymmetric fragments]; and type 4, severely comminuted fractures) and proposed an algorithm approach to address intraoperative coracoid fractures during the arthroscopic Latarjet.

RESULTS

Twelve intraoperative coracoid graft fractures were identified, of which 3 were classified as type 3 (1 case treated with a stabilizing suture, 2 with an Eden-Hybinette procedure), 1 type 1 (treated with an interference screw), and the remaining 8 as type 2. Of those, the graft was secured with a stabilizing suture in 2 cases with a 2A fracture. In the remaining, a transporting suture was used for graft handling and fixation was obtained with 1 (4 cases) or 2 screws (2 cases). Immediate postoperative computed tomographic scan showed satisfactory position of the graft in all cases, including those revised with an Eden-Hybinette procedure. Satisfactory postoperative clinical and functional results were obtained. At 69.6 ± 40.8 months' mean follow-up, all patients had full range of movement and no instability. Postoperative scores were also satisfactory, with a median (range) Rowe, Western Ontario Shoulder Instability Index, and Subjective Shoulder Value scores of 80.8 (10-100), 571 (25-1345), and 80 (20-100), respectively. Six patients returned to sport at the same preoperative level. Eighty-three percent of patients were satisfied with their postoperative status.

CONCLUSIONS

The arthroscopic Latarjet technical difficulty and steep learning curve may lead to a high rate of intraoperative graft fractures. In the current study, we described 3 types of intraoperative coracoid graft fractures in 12 patients undergoing an arthroscopic Latarjet. We performed 6 different techniques that enabled maintaining stability with no revision surgery. Fractures with poor bone quality and instability may be better managed with an iliac crest bone grafting technique.

Multicentre randomised controlled trial comparing Bankart repair with remplissage and Latarjet procedure in shoulder instability with subcritical bone loss (STABLE): study protocol

INTRODUCTION

Recurrent shoulder dislocations often cause attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management for patients with shoulder instability with subcritical bone loss remains unknown and current clinical practice is highly varied.

METHODS AND ANALYSIS

The Shoulder instability Trial comparing Arthroscopic stabilisation Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multicentre, randomised controlled trial of 114 patients diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss (10%-20%, measured on 3D CT using circle of best fit technique). Patients are randomised either arthroscopic capsuloligamentous repair (Bankart repair+remplissage) or open or arthroscopic coracoid transfer (Latarjet procedure). The primary outcome of this trial will be the between-group difference in the change from baseline to 24 months postintervention in Western Ontario Shoulder Instability Index scores. Secondary outcomes include: (1) rates of recurrent shoulder dislocations and symptoms of instability up to 24 months' postsurgery; (2) clinical outcomes measured by American Shoulder and Elbow Society score, Shoulder Activity Scale, EQ-5D and Patient Satisfaction Scale; (3) physical examination (range of motion, stability); (4) return to previous level of activity/sport; (5) rate of shoulder-related complications and serious adverse events.

ETHICS AND DISSEMINATION

This protocol has been reviewed and approved by the Hamilton Integrated Research Ethics Board (HiREB; project number 15998) prior to commencement of the trial. Results from the study will be submitted for publication in a peer-reviewed journal regardless of whether there are statistically significant findings.

TRIAL REGISTRATION NUMBER

NCT05705479; this study was prospectively registered on clinicaltrials.gov.

DECREASED SURGICAL DURATION, LESS COMPLICATIONS, AND FASTER RETURN TO ACTIVITIES ACROSS THE LEARNING CURVE FOR THE ARTHROSCOPIC LATARJET TECHNIQUE

OBJETIVE

This study aims to analyze the learning curves in performing the arthroscopic Latarjet surgery.

METHODS

This was an observational, retrospective, single-center study. All cases of arthroscopic Latarjet performed in this institution from 2016 to 2021 were included. The data analyzed were surgical time (of the chief surgeon alone and the group of surgeons), complications, and time until the return to sports activities. Technical observations about the learning process were also reported.

RESULTS

In total, 50 consecutive cases were included (93% retention of the initial sample identified at the institution). The decrease in surgical time was presented logarithmically and showed a decrease in time both for the individualized analysis of the senior surgeon (r = -0.67, p < 0.001) and for the surgical group (r = -0.476, p < 0.001). Mean operating time (and standard deviation) dropped from 235 minutes (73) in the first 10 cases to 156 minutes (34) for the subsequent cases (p < 0.001). In the first 20 cases, five intercurrences were recorded and three reoperations were performed, whereas subsequent cases presented only one intercurrence requiring surgical intervention (p = 0.032). The median time to return to sport was nine months for the first 20 cases versus six months for subsequent cases (p = 0.001).

CONCLUSION

The learning curve for the arthroscopic Latarjet procedure showed a progressive decrease in operative time, complications, and time to return to sports activities. This suggests that the surgeon developed the necessary skills and confidence to reach a plateau of expertise to perform the surgical procedure. Level of evidence IV, Observational retrospective.

Arthroscopic Coracoid Transfer in the Lateral Decubitus Position is Safe and Effective at Short-Term Follow-Up

Purpose

To report on operative and clinical outcomes in a series of shoulders treated with arthroscopic Latarjet performed in the lateral decubitus position.

Methods

Patients with shoulders that underwent arthroscopic Latarjet in the lateral decubitus position were identified. Data were retrospectively collected, including patient demographics, operative times, intra- and postoperative complications, and clinical and functional outcomes. Descriptive statistics were performed.

Results

Eighteen shoulders in 17 patients were included in the study with a mean follow-up of 14 ± 12.1 months (range, 4-39 months). The mean operative time for all procedures was 132.2 ± 18.0 minutes, and the mean operative time for the first half of the cohort was significantly longer than that of the second half (141.6 ± 14.2 minutes vs 122.8 ± 17.0 minutes, P = .02). There were no intraoperative complications, and no patients required a conversion to open surgery. One patient experienced a recurrent dislocation after a traumatic event but was able to be treated nonoperatively. Preoperative and postoperative patient-reported outcome measures (PROMs) were able to be collected on 8 of 18 patients (44.4%). Although all PROMs demonstrated improvements postoperatively, only the Single Assessment Numeric Evaluation score and American Shoulder and Elbow Surgeons Shoulder Index displayed a statistically significant increase (P < .05). Five of 8 (62.5%) shoulders demonstrated bony fusion on postoperative computed tomography scan. Of those eligible, 100% of patients returned to sport or felt that they could return if they wanted to.

Conclusions

The arthroscopic Latarjet is an effective procedure for managing glenohumeral instability and can safely be performed in the lateral decubitus position.

Level of Evidence

Level IV, therapeutic case series.

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

Background

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

Objective

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

Materials and method

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

Results

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

Discussion

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

Conclusion

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

The arthroscopic Latarjet procedure with a posterior guided system and suture-button fixation enables more precise bone block positioning in the axial plane versus anterior screws fixation

PURPOSE

Adequate position of the bone block during arthroscopic Latarjet procedure is critical for an optimal functional outcome. However, this procedure is complex with a long learning curve. Our aim was to compare the bone block position between a dedicated glenoid posterior instrumentation and suture button fixation versus an anterior screw fixation, on a postoperative computed tomography (CT) scan.

METHOD

Seventy-nine consecutive patients operated on for an anterior shoulder instability were included in this retrospective study. The same surgeon performed arthroscopically the Latarjet procedure either with an anterior drilling and screw fixation (Group A), or with a specific posterior glenoid guide pin, a posterior drilling, and a suture cortical button fixation (Group B). Evaluations were made by two independent observers. The position was evaluated by CT scan in the axial and sagittal planes. Learning curves with operative time, complications and clinical outcomes were assessed at a minimum of 2 years of follow-up.

RESULTS

Thirty-five patients were included in Group A and 44 in Group B. In Group A, 27 bone blocks were flush (87.1%) and 38 in Group B (92.7%) (p < 0.01). In Group A, 72% of the bone block height was below the equator and 76%, in Group B (ns). The mean operating time was 123 ± 32.5 min in Group A and 95 ± 34.1 min in Group B (p < 0.0001). At the final follow-up, the mean aggregate Rowe score was respectively 94.6 ± 10.4 and 93.1 ± 9.8 points in Groups A and B. The mean aggregate Walch-Duplay score was respectively 94.2 ± 11.6 and 93.4 ± 10.6 points in Groups A and B. There were 11 complications (31.4%) in Group A and five complications (11.3%) in Group B (ns).

CONCLUSION

The arthroscopic Latarjet procedure with a posterior drilling guided system and suture-button fixation allows more precise positioning in the axial plane than with anterior drilling and screw fixation. This posterior-guided procedure could reduce intraoperative and short-term complications.

LEVEL OF EVIDENCE

Level IV.

Bristow-Latarjet Surgery: A Current Overview in Brazil

Objective  To provide a current overview of the Bristow-Latarjet surgery in Brazil. Materials and Methods  This cross-sectional study was based on an electronic questionnaire with 26 items, which was sent to active members of the Brazilian Society of Shoulder and Elbow Surgery (Sociedade Brasileira de Cirurgia do Ombro e Cotovelo, SBCOC, in Portuguese). The questionnaire addressed training, surgical technique, complications, and postoperative management. Results  We sent the questionnaire to 845 specialists from April 20 to May 12, 2021, and 310 of them answered i in full. During their specialization, most specialists participated in up to ten Bristow-Latarjet procedures. The most frequent complication was graft fracture, while the most common technical difficulty was screw positioning. In total, 50.6% and 73.9% reported having experienced intraoperative and postoperative complications respectively; 57.1% declared performing subscapularis suture; 99.7% indicated postoperative immobilization; and 61.9% considered graft consolidation fundamental. Conclusion  Most specialists participated in up to ten Bristow-Latarjet procedures during the specialization, but 13.5% of them graduated without participating in the surgery. The most frequent complication was graft fracture. The most common technical difficulty was screw positioning. Most participants prefer postoperative immobilization since they believe graft consolidation is essential to resume the practiced of sports. The highest complication rate occurred with specialists who have obtained their titles 11 to 15 years ago. In Brazil, the Southeast region is the largest producer of specialists and has the highest concentration of these professionals.

Recurrent Anterior Shoulder Instability Treated Using the Arthroscopic Bankart-Latarjet Technique: Experience of a Peripheral Hospital

The arthroscopic Bankart-Latarjet procedure is used in the surgical management of anterior shoulder instability. This technique is mainly performed in referral centers due to its high technicity. This study aimed to evaluate surgical outcomes in a peripheral hospital center. This is a retrospective study of patients treated for recurrent anterior shoulder instability. The clinical scores (Walch-Duplay, Rowe, and Western Ontario Shoulder Instability Index (WOSI)) were assessed preoperatively and at 12 months after surgery. The consolidation and the position of the bone block were evaluated at 6 months using a CT scan. Between 2016 and 2020, 40 patients had been operated on (mean age: 28.5 ± 7.9 years). During a mean follow-up of 29.5 ± 11.6 months, we noted only one complication, a case of fracture of the callus of a consolidated bone block. No recurrence of instability was recorded. The Walch-Duplay score increased from 17.8 to 94.6, the Rowe score from 24.9 to 96.8, and the WOSI score decreased from 52.1% to 6.9%. The bone block was consolidated in 35 patients (87.5%), and a flush position with the anterior edge of the glenoid was noted for all patients. At one year, 67.0% of the patients practicing sport had returned to sports. The arthroscopic Bankart-Latarjet technique was a reliable procedure in the hands of an experienced shoulder surgeon, even in a peripheral hospital center.

Screw-Related Complications May Occur at a Greater Rate After Arthroscopic Versus Open Latarjet Procedure: A Systematic Review

Purpose

To determine the rate of complications attributable to the use of screw fixation during the Latarjet procedure and to delineate screw-related complications for open and arthroscopic Latarjet surgery.

Methods

A systematic review of the literature was performed by querying MEDLINE and EMBASE computerized databases for relevant articles that reported clinical outcomes associated with the Latarjet procedure. Clinical studies of open and/or arthroscopic Latarjet surgery that employed screw fixation of the coracoid were included in our analysis.

Results

From 692 articles identified initially, 32 studies met eligibility criteria. The study cohort comprised 2,758 shoulders, with a mean age of patients ranged from 17 to 62 years, and the mean duration of follow-up ranged from 0.3 to 25.6 years. Twenty-two studies reported outcomes of an open Latarjet technique whereas 10 studies reported on an arthroscopic Latarjet technique. Across all studies, the overall complication rate ranged from 1.4% to 36%. The rate of screw-related complications ranged from 0% to16%, and the rate of screw removal ranged from 0% to 18%. Among the subset of studies that reported specific indications for screw removal, the most common indications were pain and screw loosening. Reported rates of screw-removal among arthroscopic Latarjet procedures range from 0% to 18% and among open procedures range from 0% to 7.3%.

Conclusions

(1) Up to one-third of the overall surgical complications associated with the Latarjet procedure may be related to the use of screw fixation, (2) arthroscopic Latarjet procedure did not decrease the rate of screw related complications. The reported rate of screw-removal may be higher after the arthroscopic Latarjet procedures (up to 18%) than after open procedures (up to 7,3%), and is mainly indicated for persistent shoulder pain and/or screw loosening.

Level of Evidence

Level IV, systematic review of Level III-IV studies.

Clinical outcomes and recurrence rate of 4 procedures for recurrent anterior shoulder instability: ASA, remplissage, open, and arthroscopic Latarjet: a multicenter study

BACKGROUND

The aim of the present study was to compare the clinical outcomes of 4 surgical techniques in patients with recurrent anterior shoulder dislocation, glenoid bone loss (GBL) <15% and Instability Severity Index (ISI) score >3.

METHODS

A retrospective multicenter study was conducted on 226 patients who underwent 1 of 4 different techniques (Bankart plus arthroscopic subscapularis augmentation (ASA), Bankart plus remplissage, Latarjet, Arthro-Latarjet). The inclusion criteria were: recurrent dislocation, GBL <15%, and ISI score >3. The exclusion criteria were: GBL >15%, voluntary instability, multidirectional instability, preexisting osteoarthritis, throwing athletes' first dislocation, and ISI score<3. Follow-up ranged from 24 months to 6 years. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Clinical outcomes were assessed using the Rowe score and the Western Ontario Shoulder Instability Index (WOSI) for each technique. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. The Pico area method was used to assess the percentage of GBL. The operations were performed by 10 experienced surgeons; the functional outcomes were evaluated by 2 independent observers.

RESULTS

A total of 226 patients who met the inclusion criteria were included in the present series. A total of 89.2% of patients in the ASA group reported an excellent Rowe score at the final follow-up, and their scores on the WOSI scale, improved from 838 to 235 points. A total of 79.9% of patients in remplissage (R) group reported an excellent Rowe score at the final follow-up, and their scores on the WOSI scale improved from 1146 to 465 points. A total of 98.5% of patients in the Latarjet (L) group reported an excellent Rowe score at the final follow-up, and their scores on the WOSI scale improved from 1456 to 319 points. A total of 81.6% of patients in the Arthro-Latarjet (AL) group reported an excellent Rowe score at the final follow-up, and their scores on the WOSI scale improved from 1250 to 221 points. The recurrence rates were as follows: ASA group (7%), remplissage group (6.1%), L group (1.5%), Arthro-Latarjet group (0%). Patients in the open L group had 15.5% (10/66) more complications.

CONCLUSION

The use of ASA and remplissage to augment the Bankart repair have been demonstrated to be effective for restoring joint stability, yielding good clinical outcomes similar to the L procedure in patients affected by recurrent anterior dislocation with GBL <15% and an ISI score score >3. Soft tissues augmentations of the Bankart repair have been demonstrated to be effective for addressing anterior soft tissue deficiency dysfunction and critical Hill-Sachs lesions.

Arthroscopic Latarjet for Primary Shoulder Instability With Off-Track Lesions or Revision Surgery Yields Satisfactory Clinical Results and Reliable Return to Sport and Work at Minimum 3-Year Follow-Up

PURPOSE

To retrospectively evaluate clinical and radiologic outcomes and return to sport and to work of patients after arthroscopic Latarjet stabilization for primary instability or revision surgery; factors influencing and determining results and potential predictors for clinical outcomes also were evaluated.

METHODS

This is a retrospective study including patients older than 18 years old who underwent arthroscopic Latarjet stabilization for recurrent anterior glenohumeral instability with off-track lesions, or for cases of recurrence after previous surgery, from 2011 to 2017. Patients were assessed preoperatively and at a minimum 3 years of follow-up using the Rowe score, the University of California at Los Angeles Shoulder Score and Simple Shoulder Test score; the range of motion, satisfaction rate, return to work and sport, perception of discomfort during sporting and daily activities, and complications and recurrence after surgery were also evaluated. The integration of the coracoid graft and the position of the screws were examined by computed tomography scan.

RESULTS

At a mean follow-up time of 6 ± 2 years, 93 patients (95 shoulders) showed significant improvement of all scale scores (P < .001), 97.8% of the patients had returned to the same working condition as before surgery, and all the patients who practiced sports preoperatively (85; 91.4%) returned to sport after surgery; 97.9% of patients were satisfied with surgery. The complication rate was 5.4%, and 2 cases (2.1%) of recurrence occurred, both after high-energy trauma. At an average of 17 ± 13 months postoperatively, computed tomography scans showed 4 (6.6%) stable nonunions, 9 (14.8%) superior, and 1 (1.6%) inferior lyses of the graft; a correct positioning of the graft was observed in 86.9% of the cases. Greater satisfaction, fewer complications, less pain during daily activities, and a lower number of reoperations were associated with a shorter time between the first dislocation episode and surgery (P = .019, P < .001, P = .014, and P = .005, respectively). Complications were directly associated with older patient age at operation (P = .001). A greater number of nonunions was found in patients with increased angle between the line linking the posterior and anterior glenoid rim and the screw axis (P = .040) and a medial axial position or a lower coronal position of the graft (both P = .010). A lower age at the time of surgery predicted better Rowe scores at follow-up (P < .001), and a lower age at the time of the first episode of dislocation predicted better postoperative Simple Shoulder Test scores (P = .026).

CONCLUSIONS

At a mean 6-year follow-up time, excellent clinical outcomes, and radiological results, with few complications, high rates of satisfaction and return to work and sport and low sports anxiety can be expected after arthroscopic Latarjet procedure. A shorter time between the first dislocation episode and surgery was associated with higher satisfaction, fewer complications, less pain during daily activities and lower reoperations; a lower age at the operation was associated with lower complications.

Learning Curve for Arthroscopic Shoulder Latarjet Procedure Shows Shorter Operating Time and Fewer Complications with Experience

PURPOSE

To evaluate the learning curve of the arthroscopic Latarjet procedure in a consecutive series of 103 shoulders in 102 patients by comparing the early clinical and radiologic outcomes and complications of the first 25 patients with the latter 25 patients. Our hypothesis was that the studied parameters would be enhanced over time.

METHODS

A consecutive cohort of 103 shoulders in 102 patients treated with arthroscopic Latarjet procedure was prospectively registered from December 2014 until November 2019. Patients in this cohort represent the first cases of arthroscopic Latarjet for the 2 shoulder surgeons. All patients had a double screw fixation technique. The Western Ontario Shoulder Instability Index (WOSI) score preoperatively and at 1-year follow-up and 3-dimensional computed tomography scans preoperatively, postoperatively, and at 1-year follow-up were prospectively registered. Patient demographics, intraoperative data, complications, and reoperations were all recorded. In total, 85 of 103 shoulders (83%) had complete data sets. Patient demographics, WOSI scores, operating time, complications, satisfaction rate, and radiology scores in the first and last 25 patients were compared to evaluate learning curve.

RESULTS

There was longer operating time in the early group compared with the latter (130 vs 105 minutes, P = .001) and number of complications was reduced with experience (16 vs 4, P = .0005). Serious complications requiring a reoperation were 4 (16%) in the early group compared to 1 (4%) in the latter group (P = .157). Clinical results were good with major improvement in WOSI scores and 84 % satisfaction rates in both groups.

CONCLUSIONS

Arthroscopic Latarjet was associated with a learning curve where the early group had longer operating time and greater rates of complications. This is a procedure with few serious complications, acceptable surgery time and learning curve.

LEVEL OF EVIDENCE

Level III, retrospective comparative observation trial.

Arthroscopic Subscapularis Augmentation Using the Long Head of the Biceps Tendon for Anterior Shoulder Instability

The limitations of transferring the coracoid process along with the conjoined tendon are coracoacromial arch damage, technical difficulty, and nerve injury. The long head of the biceps tendon (LHBT) proximal transposition technique has a weaker sling effect and a risk of nerve injury. The arthroscopic subscapularis augmentation technique may have risks of shoulder external rotation restriction and subscapularis transection. Herein, we introduce an arthroscopic technique for the transfer of the LHBT for subscapularis augmentation to address these risks. Indications of this technique were patients younger than 45 years of age who engage in competitive sports, require forceful external rotation and abduction, have a related capsule-ligament insufficiency, and have a glenoid bone loss <25%. The steps include detaching the LHBT at the upper edge of the pectoralis major, transecting and braiding the LHBT, establishing a scapular tunnel, placing a guide suture through the upper third of the subscapular and scapular tunnel, passing the LHBT through the established tunnels, and fixating the LHBT. This technique achieves stability of the anterior shoulder by transecting and transferring the distal end of the LHBT to press on the upper third of the subscapularis muscle.

A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol

Introduction

Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied.

Methods and analysis

The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively.

Conclusions

This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability.

Trial registration

This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&draw=2&rank=1.

Ethics and dissemination

This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV; systematic review.

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

HYPOTHESIS AND BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Decreased motion with normal strength after Latarjet procedure has minimal impact on return to activity

PURPOSE

The Latarjet procedure can affect the range of motion (ROM) and strength of the shoulder, which determine the time to return to the preinjury level of activity. This study prospectively assessed whether the Latarjet procedure leads to a decrease in range of motion and muscle strength, affecting the time to return to the previous level of activity.

METHODS

Fifty-one consecutive patients who underwent the Latarjet procedure for recurrent dislocation of the shoulder were included prospectively. The ROM, strength, Walch-Duplay score, and Rowe score were measured every 3 months for 1 year and then every 6 months for 2 years. Radiological assessments were performed to confirm the graft location, union, and the humeral head position in abduction and external rotation (ER).

RESULTS

Out of 51 patients, 49 completed all follow-ups. The median age was 27 years (17-45 years), and the dominant side was involved in 36 patients. The median number of dislocations was 11 (5-50). Twelve patients were sleep dislocators. There was a significant loss (p < 0.0001) of abduction, forward flexion (FF), ER, and internal rotation (IR) in the affected shoulder compared to the contralateral shoulder. Recovery plateaued at 12 months. There was near complete recovery of muscle strength after the Latarjet procedure, and the difference between the affected and contralateral shoulders was not significant (n.s.). The modified Rowe score was excellent in 44 (90%) patients, and the Walch-Duplay score was excellent in 43 patients (88%) at 24 months. Suboptimal results were associated with non-compliance with rehabilitation in two (4%) patients and neglected unreduced dislocation in one (2%) patient. The coracoid graft position was below the equator in 44 patients (90%). Forty-six patients (94%) could return to the previous level of activity.

CONCLUSION

The Latarjet procedure results in a restricted ROM of the shoulder, but there is no loss of muscle strength.

LEVEL OF EVIDENCE

III.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

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

CONCLUSION

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

A New Guide for the Arthroscopically Assisted Latarjet Procedure

The Latarjet procedure is a commonly used treatment for recurrent shoulder instability. However, its neurological complication rate has been reported to be as high as 10%. During the Latarjet procedure, the neurovascular structures are relocated inferiorly and medially. I hypothesized that the risk of nerve injury would be reduced by assisting the inferior-medial relocation of the neurovascular structures intraoperatively.

Methods

Seventeen consecutive patients with shoulder instability accompanied by glenoid bone loss were treated with an all-arthroscopic Latarjet procedure assisted by the novel low-profile SaSumata (SS) guide. The SS guide is inserted through a portal made above the coracoid process and is attached to the coracoid process by 2 pre-fix screws (i.e., temporary pre-fixation screws). Unlike previous techniques, the SS guide is not shuttled from 1 portal to the other to redirect the bone graft from the donor site to the recipient site; instead, it remains attached to the graft throughout the procedure. The SS guide brings the coracoid graft along an inferior-medial trajectory, pushing aside the neurovascular structures with the help of a switching stick. Owing to its semicircular pronged head, the SS guide holds the graft until the pre-fix screws are exchanged with permanent screws. All patients were clinically assessed and underwent computed tomography (CT) scans.

Results

This maneuver was performed arthroscopically in 17 patients, with no conversion to open surgery and no neurological injuries. No patient had recurrence of dislocation after follow-up for a minimum of 24 months. The mean Subjective Shoulder Value was 87.5% ± 11.7%. The mean Rowe score was 88 ± 15.7. The bone block was optimally positioned between 3 o'clock and 5 o'clock and was flush with the glenoid facet in 16 of the 17 patients. There was 1 fracture of the bone block. The mean operation time after the first 5 patients was 125 ± 23 minutes.

Conclusions

The SS guide was a useful tool for performing the arthroscopically assisted Latarjet procedure for recurrent anterior shoulder instability, with good functional results.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cuistow: Chinese Unique Inlay Bristow: A Novel Arthroscopic Surgical Procedure for Treatment of Recurrent Anterior Shoulder Instability with a Minimum 3-Year Follow-Up

BACKGROUND

The prevalence of nonunion after the Latarjet procedure remains high. The purpose of the present study was to investigate healing and clinical outcomes after a novel arthroscopic coracoid process transfer procedure.

METHODS

Sixty-three patients who underwent the arthroscopic inlay Bristow procedure combined with Bankart repair were identified, and 51 patients who met the inclusion criteria were enrolled in this study. The key feature of this technique was that the coracoid process was trimmed and fixed into a trough (5 to 10 mm deep) in the glenoid neck with a metal screw. Bone graft union and positioning accuracy were assessed with use of postoperative computed tomography (CT) imaging. Clinical examinations, return to sport, and functional scores (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) were recorded.

RESULTS

The mean duration of follow-up (and standard deviation) was 41.5 ± 7.7 months (range, 36 to 48 months). Postoperative CT scans showed that the position of coracoid graft was at 4:10 (from 3:50 to 5:00) (referencing the right shoulder) in the sagittal view. The α angle was 16.4° ± 9.5°, with 4 (7.8%) of 51 screws being over-angulated (α > 25°). On the axial view, the graft position was considered to be flush in 33 patients (64.7%), medial in 11 (21.6%), congruent in 7 (13.7%), and lateral or too medial in none. At 1 year, the coracoid graft had healed in 49 patients (96.1%) and had failed to unite in 2 patients. CT scanning, performed for 47 patients, showed grade-0 osteolysis in 9 patients, grade-1 osteolysis in 21 patients, and grade-2 osteolysis in 17 patients. At the time of the latest follow-up, there was a significant increase in the Rowe score (from 35.5 ± 8.3 to 95.7 ± 7.2) and the ASES score (from 71.2 ± 9.7 to 91.5 ± 4.4), and 87.0% of patients were able to return to sport. No arthropathy was observed in any patient.

CONCLUSIONS

After a minimum 3-year follow-up, the arthroscopic inlay Bristow procedure resulted in a high rate of graft healing, excellent clinical outcomes, and a high rate of return to sports.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Latarjet: Technique Description and Preliminary Results. Study of the First 30 Cases

Objective  Arthroscopic Latarjet has been performed with the aim to be an accurate technique with a low incidence of complications. The aim of the present study was to briefly describe the technique and to evaluate the shot-term complications following arthroscopic Latarjet procedure to correct anterior shoulder dislocation with glenoid bone loss.

Methods  Retrospective study with 30 subjects with anterior shoulder instability, submitted to arthroscopic Latarjet. Intraoperative and short-term postoperative complications were recorded, as well as the rate of revision surgery.

Results  Five cases had complication (16.7%), and in the last 10 cases no complication occurred. In 1 case (3.3%), it was required to reverse for open surgery due to a fracture of the coracoid process during fixation in the glenoid. No other intraoperative complication occurred. No infection was observed. Two cases (6.7%) evolved with temporary neuropraxia of the musculocutaneous nerve, totally reversed with physiotherapy. With a follow-up from 6 to 26 months, 2 patients (6.7%) required a new intervention for graft/screws removal and release of the joint due to excessive limitation in external rotation. There was no case of recurrence.

Conclusion  Even in an initial learning curve, arthroscopic Latarjet demonstrated a low rate of short-tem complications and was a safe procedure for treating anterior dislocation of the shoulder with glenoid bone loss.

The arthroscopic Latarjet: a multisurgeon learning curve analysis

BACKGROUND

The open Latarjet procedure is a standard surgical treatment option for anterior shoulder instability in patients with a high risk of failure following soft tissue stabilization. The arthroscopic technique has potential advantages of minimal invasiveness, reduced postoperative stiffness, and faster rehabilitation but is regarded as technically challenging with concern over surgical risk during the learning curve. The aim of this study was to undertake a multisurgeon, large-volume learning curve analysis of the arthroscopic Latarjet procedure using continuous learning curve analysis.

METHODS

Individual patient data from 12 surgeons across 5 countries were retrospectively reviewed. A total of 573 patients undergoing the arthroscopic Latarjet procedure were included. Outcome measures of learning were collected, including operative time, computed tomography (CT) bone-block positioning, complications, and patient-reported outcome measures (PROMs). A segmented linear regression modeling technique was used for learning curve analysis.

RESULTS

High-volume surgeons converged to an operative time steady state after 30-50 cases. Surgeons completing fewer procedures demonstrated a constant reduction in operative time without reaching a plateau. Low-volume surgeons completing fewer than 14 operations did not demonstrate a reduction in operative time. Accuracy of bone-block positioning on postoperative CT demonstrated constant improvement without reaching a plateau after 53 cases. There was no change in PROMs or complications with increased operative volume.

CONCLUSION

Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning. Only surgeons expecting to undertake the arthroscopic Latarjet in high volume should consider adopting this procedure.

Arthroscopic Latarjet Stabilization: Analysis of the Learning Curve in the First 90 Primary Cases: Early Clinical Results and Computed Tomography Evaluation

PURPOSE

To assess the learning curve of arthroscopic Latarjet, evaluating time of surgery, clinical outcomes, complications, revisions, and recurrence.

METHODS

Arthroscopic Latarjet procedures performed from 2011 to 2016 were reviewed. Satisfaction rate, subjective shoulder value, Walch-Duplay, Rowe scores, range of motion, and stability were evaluated on clinical examination. Graft position and fusion were analyzed using computed tomography. All patients were divided into 3 chronological groups.

RESULTS

Ninety patients (3 groups of 30) were available for clinical evaluation (96,8%). The mean follow-up was 23.7 months. Surgical time was significantly (P = .0028) longer in group I (mean 128 minutes, standard deviation [SD] 33.6) when compared with groups II (mean 102 minutes, SD 16.2) and III (mean 108 minutes, SD 21.8). A regression analysis and cumulative sum learning curve analysis showed the surgeon oscillated around mean operative time (112.7 minutes; SD 27.2) after 30 procedures. The number of intraoperative complications was significantly greater (P = .024) in Group I (5 cases; 17%) compared with zero in group II, and 3 (10%) in group III. All 3 cases (3.3%) of recurrence were reported in group I (P = .033). Significantly, 2 of 3 patients with recurrence had intraoperative graft complications (P = .0107). Overall patient satisfaction was evaluated as 92%, SSV 90%, Walch-Duplay and Rowe scores, respectively, 79 and 81 points. Nine revisions (10%) were reported. No significant differences were found between the results and revisions of the 3 chronological groups.

CONCLUSIONS

This study confirms that the arthroscopic Latarjet procedure provides good clinical and radiologic results at short-term follow-up. The surgical time, frequency of complications, and number of hardware problems significantly decreased after the first 30 cases. As such, surgeons should be aware of the elevated potential for complications and recurrence early in the learning curve-serious intraoperative complications are important risk factors for recurrence.

LEVEL OF EVIDENCE

III. Therapeutic study: case-control study.

Arthroscopic Latarjet for Recurrent Shoulder Instability

Background and Objectives: The all-arthroscopic Latarjet (aL) procedure was introduced to manage recurrent shoulder instability. Our study aimed to report the outcomes of aL procedures with the Rowe, University of California-Los Angeles (UCLA), simple shoulder test (SST) scores, and range of motion (ROM) in external rotation at a minimum follow-up of 2 years. Material and Methods: A total of 44 patients presenting recurrent shoulder instability were managed with aL procedure. Clinical outcomes were assessed at a mean follow-up of 29.6 ± 6.9 months. The postoperative active ROM was measured and compared with the contralateral shoulder. The Rowe, UCLA, and SST scores were administered preoperatively and postoperatively. Results: No patients experienced infections or neuro-vascular injuries. Seven (15%) patients required revision surgery. After surgery, the external rotation was statistically lower compared to the contralateral shoulder, but it improved; clinical outcomes also improved in a statistically significant fashion. Conclusions: The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist.

Learning Curves in the Arthroscopic Latarjet Procedure: A Multicenter Analysis of the First 25 Cases of 5 International Surgeons

PURPOSE

To analyze the learning curves of 5 experienced, fellowship-trained shoulder surgeons and their respective 25 first arthroscopic Latarjet cases in regard to surgical time, graft placement, complication rates, and recurrent instability.

METHODS

The first 25 arthroscopic Latarjet procedures of 5 surgeons were retrospectively analyzed in an international multicenter setting, and thus 125 patients were included in this study. The surgical time, intraoperative and postoperative events out of the ordinary, and graft positioning were examined.

RESULTS

The 125 patients consisted of 16 women (12.8%) and 109 men (87.2%). In 81.6% (n = 102), surgery was undertaken as a first-line procedure, whereas 18.4% (n = 23) were revisions. Surgical time decreased significantly from an average of 123.8 minutes (range 70 to 210) to 92.6 minutes (range 50 to 160) from the first 5 cases to the last 5 cases of each surgeon within a period of <2 years. Overall, 22 events in 21 patients requiring additional treatment were reported (17.6%). Five (4%) were unlikely to affect final outcome and did not require revision surgery. Twelve (9.6%) required revision surgery that was not trauma related yet was prone to affect outcomes. Five events were trauma-related (4%), 4 requiring revision surgery and 1 treated conservatively. Overall, 6 patients (4.8%) had recurrent shoulder instability, 3 as a result of a traumatic event. Conventional radiology showed the bone-block in ideal positioning in 93 cases (74.4%), flush with the glenoid in a true anteroposterior view. In 3 cases (2.4%), it was considered too high, 15 too low (12%), 5 too lateral (4%), and 15 too medial (12%). Some patients had combinations of the above.

CONCLUSION

This analysis shows that surgical time in arthroscopic Latarjet can be significantly reduced after only 20 cases. However, complication rates did not decrease over this time. The authors believe that the arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Editorial Commentary: Arthroscopic Latarjet Procedure-Time Will Tell

The arthroscopic Latarjet procedure is gaining acceptance as a procedure to treat anterior glenohumeral instability. Although complications occur, it is possible to obtain clinically meaningful results. Acquiring the skills and mastering the procedure are challenging even for expert surgeons.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Early Outcomes and Perioperative Complications of the Arthroscopic Latarjet Procedure: Systematic Review and Meta-analysis

BACKGROUND

The arthroscopic Latarjet-Bristow procedure is emerging as a reliable alternative to the open procedure. The reduced soft tissue damage with potential advantages of early pain control and functional recovery is attractive. However, the operation is technically more demanding, and there are concerns regarding the potential for increased recurrence and complication rates.

PURPOSE

To evaluate the available literature focusing on the reported functional outcomes and complications of the arthroscopic Latarjet procedure and compare them with the open procedure.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive systematic review was performed with the keywords "arthroscopy," "arthroscopic," "Latarjet," and "Bristow," with no limit regarding the year of publication. The review was limited to the English-language articles, and each article was evaluated with a modified MINORS (methodological index for nonrandomized studies) scoring system.

RESULTS

Fourteen studies met the inclusion criteria and were included in the review. Overall, 813 patients met inclusion criteria, with a mean follow-up of 24.5 months. The mean Walch-Duplay and Rowe scores were 89.6 and 90.2, respectively. The overall complication rate was 16.5%; intraoperative conversion to open surgery, 2%; recurrence, 2.5%; and revision surgery, 5.6%. When only comparative studies were considered, the overall complication rates were 23.7% (arthroscopically) and 15.3% (open). The recurrence and revision surgery rates were 6.5% and 5.7% in the study group, while the corresponding values in the control group were 4% and 2.9%. The mean MINORS score was 14.5 (11.6 for noncomparative studies and 19 for comparative studies).

CONCLUSION

The arthroscopic Latarjet-Bristow procedure is reliable. Outcomes are satisfactory, with less pain and faster recovery in the first postoperative week. However, the procedure is technically demanding, and higher rates of complications and reoperations should be expected. Finally, the arthroscopic operation is much more expensive in terms of implanted materials than the open procedure.

Double-row fixation of the transferred coracoid process: a rescue technique for intraoperative coracoid fracture during the Latarjet procedure

BACKGROUND

The Latarjet procedure is the preferred method to treat recurrent anterior shoulder instability with glenoid deficiency. An iatrogenic fracture of the transferred coracoid process is one possible intraoperative complication.

METHODS

We propose a rescue technique using double-row suture bridge fixation. Double-loaded 4.5-mm suture anchors were placed medially in the scapular neck. These sutures were then brought over the top of the coracoid fragment, placed around the bony fragment, and fixated to the glenoid face with knotless suture anchors.

RESULTS

Radiologic evidence of bone graft healing was observed in the desired position.

CONCLUSIONS

We present a salvage procedure that will assist surgeons if an intraoperative fracture of the coracoid bone graft occurs during fixation when performing the Latarjet procedure.

Intraoperative graft-related complications are a risk factor for recurrence in arthroscopic Latarjet stabilisation

PURPOSE

The goal of this study was to evaluate clinical and radiological outcomes after arthroscopic Latarjet stabilisation in anterior shoulder instability.

METHODS

Ninety-three patients after primary arthroscopic Latarjet stabilisation were reviewed. Satisfaction, subjective shoulder value (SSV), Walch-Duplay and Rowe scores, and range of motion and stability were evaluated on clinical examination. Computed tomography (CT) was used to analyse graft position and fusion.

RESULTS

Ninety patients (96.8%) were available for clinical and 85 for CT evaluation. The mean follow-up was 23.7 months (13-50, SD 7.1) and age at surgery was 26.2 years (16-44, SD 5.6). Intraoperative complications were reported in eight patients (8.9%) and recurrence in three (3.3%). Significantly, two out of three patients with recurrence had intraoperative graft complications (p = 0.0107). Forty-one patients (45.6%) reported the feeling of "subjective return to sport anxiety". External rotation with arm at the side was 59° (10-90°, SD 20) with 15° (0-70°, SD 17) of loss of rotation. These two factors correlated with results the most. Patient satisfaction was evaluated as 92% (40-100, SD 14) and SSV 90% (30-100, SD12). Revision rate after primary surgery was 10%. CT showed graft healing in 81 (95.3%) patients. A graft position between 2 and 5 o'clock was found in 70 (83.4%) patients and flush to the anterior glenoid rim in 34 (40.5%). Osteolysis of the superior part of the graft was found in 55 (64.7%) patients. CT evaluation showed no correlation with clinical results.

CONCLUSION

Arthroscopic Latarjet stabilisation demonstrates satisfactory results in short-term follow-up; however, intraoperative graft-related complications are a risk factor for recurrence. "Subjective return to sport anxiety" and loss of external rotation with the arm at the side are factors worsening the results. Graft position imperfections and osteolysis of the superior part of the graft reported in CT evaluation do not influence the clinical results.

Complications After Arthroscopic Shoulder Surgery: A Review of the American Board of Orthopaedic Surgery Database

Introduction:

Shoulder arthroscopies are among the most frequently performed surgeries by orthopaedic surgeons. Little is known about complication rates among recently trained surgeons. The purpose of this study was to examine the type and frequency of complications of common arthroscopic shoulder procedures performed by candidates challenging the American Board of Orthopaedic Surgery: Part II, certification examination.

Methods:

Data were obtained from the American Board of Orthopaedic Surgery database for orthopaedic surgeons who sat for the part II examination from 2012 to 2016. In total, 27,072 procedures were reviewed. The database was queried to determine the type and frequency of complications for patients who underwent shoulder arthroscopy, including arthroscopic rotator cuff repair, labrum repair, biceps tenodesis, and bony/soft tissue débridement procedures. Complications were classified as surgical, anesthetic, or medical. Factors affecting complication rates were investigated including surgeon's fellowship training, geographic location, and patients’ age and sex.

Results:

Patients with surgical complications (n = 2,133; 7.9%) were more common than anesthetic (n = 263; 1.0%) or medical (n = 607; 2.2%) complications. There was a significant variation in the surgical complication rate among different arthroscopic shoulder procedures, ranging from 5.4% for labral repair to 10.3% for rotator cuff repair and biceps tenodesis. Stiffness/arthrofibrosis was the most commonly recorded surgical complication (2.2%). Surgical complication rates were lowest in the Northeast region (6.7%; P < 0.01) and in patients younger than 21 years (3.8%; P < 0.01). Women had significantly higher rate of complications than men (8.4% versus 7.6%; P = 0.02). Among anesthetic-related complications, 61.6% were related to regional nerve blocks. The overall revision surgery and readmission rates were 0.8% and 1.0%, respectively.

Conclusion:

The overall self-reported surgical complication rate for arthroscopic shoulder procedures was 7.9%, which is higher than the rates reported in the literature. Although the rate of anesthetic complications is low (1.0%), adverse events related to nerve blocks made up most of the overall anesthetic related complications.

Arthroscopic Anatomic Glenoid Reconstruction: Analysis of the Learning Curve

Background

Anatomic glenoid reconstruction involves the use of distal tibial allograft for bony augmentation of the glenoid surface. An all-arthroscopic approach was recently described to avoid damage to the subscapularis tendon and preserve the capsule and labrum.

Purpose

To explore and compare change in surgical time between 2 proposed methods used for the treatment of anterior shoulder instability-arthroscopic anatomic glenoid reconstruction (AAGR) and arthroscopic Latarjet (AL)-over successive procedures. We also compared graft positioning on the anterior glenoid surface between the 2 methods.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a single-surgeon retrospective review of 54 cases of surgically treated recurrent anterior shoulder instability: 27 had AAGR with distal tibial allograft, while the other 27 had AL. AAGR with the distal tibial allograft was the primary choice for the treatment of anterior shoulder instability; however, AL was performed when tibial allograft was not available from the bone bank. Thus, there was an overlapping period for those 2 procedures. Procedure start and end times were recorded, and duration was calculated. Postoperative 3-dimensional computed tomography scans were reviewed, and graft position was judged to be in the lower third (desired position), middle third, or upper third of the anterior glenoid surface. To assess learning, these data were organized in chronological order of surgery, and each surgical cohort was divided into 3 chronological clusters of 9 patients each. Learning was assessed through change in operative time over successive clusters, change in variability of operative time among clusters, and change in graft positioning among clusters. Statistical analysis comprised a 2-tailed independent-sample t test and the Levene test for equality of variance.

Results

Our study found that AAGR was significantly faster to perform than AL in the early (P = .001), middle (P = .001), and late (P = .05) clusters of each cohort. Duration of surgery did not significantly improve across clusters within each cohort (P = .15-.79). There were no significant changes in the variability of surgical time in the AAGR group (P = .09) or the AL group (P = .13). Desired positioning of the bone graft on the anterior glenoid surface (lower third) was identified more commonly in the AAGR cohort.

Conclusion

AAGR is faster to learn and perform than AL for the treatment of recurrent anterior shoulder instability with significant glenoid bone loss. The current study found higher rates of desired graft positioning for AAGR clusters.

Arthroscopy-assisted Trillat procedure for anterior shoulder instability: Surgical technique and preliminary clinical results

The Trillat procedure performed as open surgery to treat anterior shoulder instability has been proven effective in preventing recurrences and restoring range of motion. An arthroscopically assisted variant of the Trillat procedure is described here, together with the preliminary clinical results in 18 patients treated between 2011 and 2014. After a mean follow-up of 24.7±9.8 months, the clinical outcomes were very satisfactory, with a Walch-Duplay score of 81.5±18.0, a Rowe score of 83.6±16.0, and 94% of satisfied or very satisfied patients. Mean operative time was 55±13min. No recurrences were recorded. As an easily performed procedure that provides good clinical outcomes, the arthroscopically assisted Trillat procedure is a simple and reproducible alternative to arthroscopic Latarjet procedure, which is still reserved for highly experienced surgical teams.

The Learning Curve for the Latarjet Procedure: A Systematic Review

Background

Anterior shoulder instability, including recurrent instability, is a common problem, particularly in young, active patients and contact athletes. The Latarjet procedure is a common procedure to treat recurrent shoulder instability.

Purpose

To identify the reported learning curves associated with the Latarjet procedure and to determine a point on the learning curve after which a surgeon can be considered to have achieved proficiency.

Study Design

Systematic review; Level of evidence, 4.

Methods

Three online databases (Embase, MEDLINE, PubMed) were systematically searched and screened in duplicate by 2 independent reviewers. The search included results from the inception of each database to January 23, 2017. Data regarding study characteristics, patient demographics, learning curve analyses, and complications were collected. Study quality was assessed in duplicate.

Results

Two level 3 studies and 3 level 4 studies of fair methodological quality were included. Overall, 349 patients (350 shoulders) with a mean age of 25.1 years (range, 14-52 years) were included in the final data analysis. Patients were predominantly male (93.7%). After 22 open and 20 to 40 arthroscopic Latarjet procedures, surgeons achieved a level of proficiency as measured by decreased operative time. For open procedures, complication rates and lengths of hospital stay decreased significantly with increased experience (Spearman ρ = -0.3, P = .009 and Spearman ρ = -0.6, P < .0001, respectively).

Conclusion

With experience, surgeons achieved a level of proficiency in performing arthroscopic and open Latarjet procedures, as measured by decreased operative time, length of hospital stay, and complication rate. The most commonly reported difference was operative time, which was significant across all studies. Overall, the Latarjet procedure is a safe procedure with low complication rates, although further research is required to truly characterize this learning curve.

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.

Reliability of a CT reconstruction for preoperative surgical planning in the arthroscopic Latarjet procedure

PURPOSE

The arthroscopic Latarjet procedure has provided reliable results in the treatment of anterior shoulder instability. However, this procedure remains technically challenging and is related to several complications. The morphology of the coracoid and the glenoid are inconsistent. Inadequate coracoid and glenoid preparing may lead to mismatching between their surfaces. Inadequate screws lengthening and orientation are a major concern. Too long screws can lead to suprascapular nerve injuries or hardware irritation, whereas too short screws can lead to nonunions, fibrous unions or migration of the bone block. The purpose of the study was to investigate the application of virtual surgical planning and digital technology in preoperative assessment and planning of the Latarjet procedure.

METHODS

Twelve patients planned for an arthroscopic Latarjet had a CT scan evaluation with multi-two-dimensional reconstruction performed before surgery. Interobserver and intraobserver reliability were evaluated. The shape of the anterior rim of the glenoid and the undersurface of the coracoid were classified. Coracoid height was measured, respectively, at 5 mm (C1) and 10 mm (C2) from the tip of the coracoid process, corresponding to the drilling zone. Measurements of the glenoid width were then taken in the axial view at 25 % (G1) and 50 % (G2) of the glenoid height with various α angles (5°, 10°, 15°, 20°, 25°, 30°) 7 mm from the anterior glenoid rim. Shapes of the undersurface of the coracoid and the anterior rim of the glenoid were noted during the surgical procedure. Post-operative measurements included the α angle.

RESULTS

Concerning coracoid height measurements, there was an almost perfect to substantial intra- and inter-reliability, with values ranging from ICC = 0.75-0.97. For the shape of the coracoid, concordances were, respectively, perfect (ICC = 1) and almost perfect (0.87 [0.33; 1]) for the intra- and interobserver reliabilities. Concerning the glenoid, concordance was always almost perfect for 50 % height. Concordance was almost perfect for 25 % height 15° and 30° for inter- and intraobserver, for intraobserver at 0° and 25°. All the other values were still showing moderate concordance. Shape of the coracoid analysis reproducibility was perfect for both intra- and interobserver ICC = 1. There was a total agreement (ICC = 1) between the preoperative evaluation of the shape of the glenoid and the coracoid and the intraoperative assessment.

CONCLUSION

The ideal and accurate preoperative planning of screwing of the coracoid graft in the arthroscopic Latarjet can be achieved in the real surgery assisted by the virtual planning. The clinical importance of this study lies in the observation that this new preoperative planning could offer a simple, effective and reproducible tool for surgeons helping them to prepare in the best possible way a technically challenging procedure usually associated with a high rate of complications.

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

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

Editorial Commentary: The Wake of the Dragon: Will the Orthopaedic Community Adopt the Shoulder Arthroscopic Latarjet Procedure as We Adopted the Arthroscopic Rotator Cuff Repair?

The Latarjet procedure is a complex and difficult operation when performed both with an open approach and arthroscopically. The difficulties come from the fact that it is a combined intra- and extra-articular procedure, and that working close to the brachial plexus may be frightening for surgeons. Because of the high complication and reoperation rates reported in the literature, this procedure is, at the moment, rejected by a large part of the orthopaedic community, specifically in North America. The Chinese experience shows, after the European one, that arthroscopic Latarjet is an efficient and irreplaceable option for the treatment of recurrent anterior shoulder instability in the context of capsular and/or glenoid deficiency. A recent study shows that the arthroscopic procedure provides accurate bone block positioning and high rates of healing, excellent clinical results (no recurrence of instability at 2-year follow-up), and low rates of complications (no neurovascular injury). Although the arthroscopic Latarjet should be approached with caution, the learning curve should not be thought of as prohibitive. To learn how to perform an arthroscopic Latarjet, surgeons should visit an experienced surgeon and take a course to practice on cadavers first. Although it will take time and effort to learn and perform this operation correctly, we should command our Chinese colleagues to encourage us to follow their path. There is no reason that in the near future the orthopaedic community does not adopt the arthroscopic Latarjet procedure, as we adopted the arthroscopic rotator cuff repair and other complex surgical procedures. Among the strongest reasons to perform the Latarjet procedure arthroscopically are the accuracy of graft placement, the safety for neurovascular structures provided by direct visualization and magnification, and the excellent clinical results allowing young people to go back to sport, including high-risk (contact, overhead) sports.

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

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

Restoration of Articular Geometry Using Current Graft Options for Large Glenoid Bone Defects in Anterior Shoulder Instability

PURPOSE

The purpose of this cadaveric study was to compare standard and modified coracoid transfer procedures, bicortical and tricortical iliac crest autografts, and tibial plafond and glenoid allografts with respect to glenoid surface curvature restoration.

METHODS

Computed tomography scans of 8 cadaveric shoulders were acquired in 9 conditions: (1) intact, (2) 25% width defect, (3) classic Latarjet, (4) modified congruent-arc Latarjet, (5) tricortical iliac crest inner table, (6) outer table, (7) bicortical iliac crest, (8) distal tibia, and (9) glenoid allograft. Outcome measures included articular surface area, width, depth, axial and coronal radius of curvature, and subchondral articular step-off, analyzed in bone and soft-tissue window.

RESULTS

Reconstruction of the articular surface area was optimal with the glenoid allograft (99.4%), classic Latarjet (97.4%), and iliac crest bicortical graft (93.2%). Depth was best restored by the congruent-arc Latarjet (101.0%), tibial (98.9%), and glenoid (95.3%) allografts. Axial curvature was closely matched by the glenoid allograft (97.5%), classic Latarjet (108.7%), and iliac bicortical graft (91.2%). Coronal curvature was most accurately restored by the glenoid allograft (102.6%), the tibial allograft (115.0%), and the classic Latarjet (55.9%). The articular step-off was smallest using the glenoid allograft.

CONCLUSIONS

Overall, glenoid allografts most accurately restored articular geometry. Alternative grafts provided restoration of some parameters but not others. Classic Latarjet performed well in axial and coronal curvature on average but exhibited large variability. Tibial allograft produced the poorest results in axial curvature, despite excellent coronal curvature reconstruction. The congruent-arc Latarjet did not restore the axial curvature accurately and overcorrected coronal curvature. Graft geometry must be weighed against availability, morbidity, and the role of additional stabilizers.

CLINICAL RELEVANCE

Accurate graft morphology may help prevent postoperative osteoarthritis. Grafts differ significantly regarding geometric parameters. The findings of this study will help surgeons select the most appropriate graft for glenoid reconstruction.

Biomechanical Analysis of Latarjet Screw Fixation: Comparison of Screw Types and Fixation Methods

PURPOSE

To compare the initial fixation stability, failure strength, and mode of failure of 5 different screw types and fixation methods commonly used for the classic Latarjet procedure.

METHODS

Thirty-five fresh-frozen cadaveric shoulder specimens were allocated into 5 groups. A 25% anteroinferior glenoid defect was created, and a classic Latarjet coracoid transfer procedure was performed. All grafts were fixed with 2 screws, differing by screw type and/or fixation method. The groups included partially threaded solid 4.0-mm cancellous screws with bicortical fixation, partially threaded solid 4.0-mm cancellous screws with unicortical fixation, fully threaded solid 3.5-mm cortical screws with bicortical fixation, partially threaded cannulated 4.0-mm cancellous screws with bicortical fixation, and partially threaded cannulated 4.0-mm captured screws with bicortical fixation. All screws were stainless steel. Outcomes included cyclic creep and secant stiffness during cyclic loading, as well as load and work to failure during the failure test. Intergroup comparisons were made by a 1-way analysis of variance.

RESULTS

There were no significant differences among different screw types or fixation methods in cyclic creep or secant stiffness after cyclic loading or in load to failure or work to failure during the failure test. Post-failure radiographs showed evidence of screw bending in only 1 specimen that underwent the Latarjet procedure with partially threaded solid cancellous screws with bicortical fixation. The mode of failure for all specimens analyzed was screw cutout.

CONCLUSIONS

In this biomechanical study, screw type and fixation method did not significantly influence biomechanical performance in a classic Latarjet procedure. When performing this procedure, surgeons may continue to select the screw type and method of fixation (unicortical or bicortical) based on preference; however, further studies are required to determine the optimal method of treatment.

CLINICAL RELEVANCE

Surgeons may choose the screw type and fixation method based on preference when performing the Latarjet procedure.

Arthroscopic Bankart repair associated with subscapularis augmentation (ASA) versus open Latarjet to treat recurrent anterior shoulder instability with moderate glenoid bone loss: clinical comparison of two series

PURPOSE

The treatment of chronic anterior shoulder instability with glenoid bone loss is still debated. The purpose of this study is to compare short-term results of two techniques treating chronic shoulder instability with moderate glenoid bone loss: bone block according to open Latarjet-Patte procedure and arthroscopic Bankart repair in association with subscapularis augmentation.

METHODS

Ninety-one patients with moderate anterior glenoid bone loss underwent from 2011 to 2015. From these patients, two groups of 20 individuals each have been selected. The groups were homogeneous in terms of age, gender, dominance and glenoid bone loss. In group A, an open Latarjet procedure has been performed, and in group B, an arthroscopic Bankart repair associated with subscapularis augmentation has been performed. The mean follow-up in group A was 21 months (20-39 months), while in group B was 20 months (15-36 months). QuickDash score, Constant and Rowe shoulder scores, were used for evaluations of results.

RESULTS

The mean preoperative rate of QuickDash score was 3.6 for group A and 4.0 for group B; Rowe Score was 50.0 for group A and 50.0 for group B. Preoperative mean Constant score was 56.2 for Latarjet-Patte and 55.2 for Bankart plus ASA. Postoperative mean QuickDash score was in group A 1.8 and 1.7 in group B; Rowe Score was 89.8 and 91.6; Constant Score was 93.3 and 93.8. No complications related to surgery have been observed for both procedures. Not statistically significant difference was reported between the two groups (p > .05). Postoperatively, the mean deficit of external rotation in ER1 was -9° in group A and -8 in group B; In ER2, the mean deficit was -5° in both groups (p = .0942).

CONCLUSIONS

Arthroscopic subscapularis augmentation of Bankart repair is an effective procedure for the treatment of recurrent anterior shoulder instability with glenoid bone loss without any significant difference in comparison with the well-known open Latarjet procedure.

A Prospective Comparative Study of Arthroscopic Versus Mini-Open Latarjet Procedure With a Minimum 2-Year Follow-up

PURPOSE

To compare postoperative pain during the first postoperative week and the position of the coracoid bone block at the anterior aspect of the glenoid after the arthroscopic and the mini-open Latarjet procedure. The secondary purpose was to assess functional results and recurrence after at least 2 years of follow-up.

METHODS

This comparative prospective study included patients who underwent a Latarjet-Bristow procedure for anterior shoulder instability in 2012. The Latarjet procedure was performed by a mini-open approach (G1) in one center and by an arthroscopic approach (G2) in the other. The main evaluation criterion was average shoulder pain during the first postoperative week assessed by the patient on a standard 10-cm visual analog scale (0-10). Secondary criteria were consumption of analgesics during the first week, the position of the coracoid bone block on radiograph and computed tomography scan at the 3-month follow-up and clinical outcomes (Western Ontario Score Index and new surgery) after at least 2 years of follow-up.

RESULTS

Fifty-eight patients were included, 22 G1 and 36 G2, 13 women and 45 men, mean age 26.9 ± 7.7 years. The mean follow-up was 29.8 ± 4.4 months. There was significantly less pain in the arthroscopic Latarjet group than in the mini-open group during the first postoperative week (2.5 ± 1.4 vs 1.2 ± 1.2, P = .002) with comparable consumption of analgesics (P > .05). The arthroscopic Latarjet procedure resulted in a more lateral coracoid bone block (P = .04) and a better equatorial position than the mini-open technique (P = .02). Three patients underwent revision surgery (1 recurrence [2.8%], 1 block fracture, 1 screw ablation) in the arthroscopic group, none in the mini-open group (P = .54). At the final follow-up, the Western Ontario Score Index score was good in all patients (G1: 78.5 ± 7.5% vs G2: 82.3 ± 7%, P = .03).

CONCLUSIONS

This prospective comparative study showed that the arthroscopic Latarjet procedure was significantly less painful than the mini-open procedure during the first postoperative week. The clinical outcomes were comparable after at least 2 years of follow-up.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Comparative study of open and arthroscopic coracoid transfer for shoulder anterior instability (Latarjet)-clinical results at short term follow-up

PURPOSE AND HYPOTHESIS

The aim of this study was to compare early clinical results after open and arthroscopic Latarjet stabilisation in anterior shoulder instability. Our hypothesis was the results of arthroscopic stabilisation were comparable with the results of open procedure.

MATERIAL AND METHODS

The clinical results of the patients after primary Latarjet procedure were analysed. Patients operated on between 2006 and 2011 using an open technique composed the OPEN group and patients operated on arthroscopically between 2011 and 2013 composed the ARTHRO group; 48 out of 55 shoulders (87%) in OPEN and 62 out of 64 shoulders (97%) in ARTHRO were available to follow-up. The average age at surgery was 28 years in OPEN and 26 years in ARTHRO. The mean follow-up was 54.2 months in OPEN and 23.4 months in ARTHRO. Intra-operative data were analysed regarding time of surgery, concomitant lesions and complications. Patient results were assessed with Walch-Duplay, Rowe, VAS scores and subjective self-evaluation of satisfaction and shoulder function. Computed tomography scan evaluation was used to assess the graft healing.

RESULTS

Average time of surgery was significantly shorter in ARTHRO than OPEN: respectively 110 and 120 minutes. The number of intra-operative complications was six (12.5%) in OPEN and five (8.1%) in ARTHRO. The results were comparable in both groups, with no significant difference between OPEN and ARTHRO group: satisfaction rate - 96.8% and 91.9%, shoulder function - 92.2% and 90%, Walch-Duplay score - 83.9 and 76.7 respecively. A significant difference was reported in Rowe score: 87.8 in OPEN and 78.9 in ARTHRO. Another significant difference was found in the presence of "subjective apprehension"-a term referring to the subjective perception of instability with no signs of instability at clinical examination - 28.7% in OPEN and 50% in ARTHRO. Range of motion in both groups were comparable, however patients in OPEN had significantly lower loss of external rotation in adduction to the side comparing to the contralateral shoulder: 7° versus 14° in ARTHRO. Recurrence was reported in three cases in each group: 6.2% in OPEN and 4.8% in ARTHRO. A revision surgery was performed in four patients (9.3%) in OPEN and six (9.7%) in ARTHRO. Radiographic evaluation showed a significantly lower rate (5%) of graft healing problems (fracture, non-union and osteolysis) after arthroscopic stabilisation, however a partial osteolysis of the proximal part of the bone block was significantly more frequent (53.5%).

CONCLUSIONS

The arthroscopic Latarjet stabilisation showed satisfactory and comparable results to open procedure. We recommend further investigation and development of arthroscopic technique.

LEVEL OF EVIDENCE

III.

The learning curve associated with anteromedial portal drilling in ACL reconstruction

OBJECTIVES

The objective of the current study was to evaluate the accuracy and precision of femoral and tibial tunnel placement during anterior cruciate ligament reconstruction (ACLR) using independent anteromedial portal (AMP) drilling over a three-year observation period.

METHODS

This study was a retrospective review of 161 consecutive primary ACL reconstructions from a single surgeon over his first 36-months in practice. Femoral and tibial tunnel angulation measurements were made on anteroposterior radiographs by a single observer utilizing the assessment method described by Aglietti et al. The accuracy and precision of tunnel placement across the three-year period were assessed with comparisons made.

RESULTS

Significantly improved accuracy was demonstrated toward the cadaveric ideal femoral tunnel angle of 33.5° over time. Improved precision of tunnel placement was also demonstrated evidenced by declining standard deviations across each year. Statistically significant improvement in femoral tunnel placement was seen between the first and second cohorts of 32 cases. No significant change was seen with respect to tibial tunnel angle across the observation period.

CONCLUSIONS

A learning curve in developing accuracy and precision in ACL femoral tunnel placement using the AMP technique exists; our study indicates this to be somewhere between 32 and 64 cases. Tibial tunnel placement does not share the same learning curve using this surgical technique.

Short-term Complications of the Arthroscopic Latarjet Procedure: A North American Experience

PURPOSE

To report on the intraoperative and early postoperative (<3 months) problems and complications encountered with the arthroscopic Latarjet procedure in patients with complex anterior shoulder instability.

METHODS

Between 2010 and 2014, 83 patients underwent an arthroscopic Latarjet procedure for recurrent post-traumatic anterior instability. The group's mean age was 28 ± 10 years and consisted of 76 (92%) male patients. A "problem" was defined as an unanticipated perioperative event that was not likely to affect the patient's final outcome. A "complication" was defined as an event that was likely to negatively affect outcome.

RESULTS

At a mean follow-up of 17 months (range, 3 to 43 months), 20 (24%) patients sustained either a problem and/or a complication. The problem rate was 18% and the complication rate was 10%. The most commonly encountered adverse event was intraoperative fracture of the coracoid graft, which occurred in 6 patients (7%). In addition, 1 arthroscopic case was intraoperatively converted to open and 1 patient sustained a transient axillary nerve injury. A total of 7 cases underwent secondary operative procedures. The rate of problems and/or complications in primary cases was not significantly different than revision cases (P = .335).

CONCLUSIONS

The rate of adverse events reported in this arthroscopic series is not insignificant and is similar to that reported with the traditional open Latarjet. With appropriate training, the arthroscopic Latarjet procedure can be effective for the management of patients with complex shoulder instability.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

History of surgical intervention of anterior shoulder instability

BACKGROUND

Anterior glenohumeral instability most commonly affects younger patients and has shown high recurrence rates with nonoperative management. The treatment of anterior glenohumeral instability has undergone significant evolution over the 20th and 21 centuries.

METHODS

This article presents a retrospective comprehensive review of the history of different operative techniques for shoulder stabilization.

RESULTS

Bankart first described an anatomic suture repair of the inferior glenohumeral ligament and anteroinferior labrum in 1923. Multiple surgeons have since described anatomic and nonanatomic repairs, and many of the early principles of shoulder stabilization have remained even as the techniques have changed. Some methods, such as the Magnusson-Stack procedure, Putti-Platt procedure, arthroscopic stapling, and transosseous suture fixation, have been almost completely abandoned. Other strategies, such as the Bankart repair, capsular shift, and remplissage, have persisted for decades and have been adapted for arthroscopic use.

DISCUSSION

The future of anterior shoulder stabilization will continue to evolve with even newer practices, such as the arthroscopic Latarjet transfer. Further research and clinical experience will dictate which future innovations are ultimately embraced.

Arthroscopic Conjoint Tendon Transfer: A Technique for Revision Anterior Shoulder Stabilization

Revision anterior stabilization of the shoulder presents a challenge to the surgeon and carries a higher risk of recurrent dislocation than primary repair. The Latarjet procedure may be more reliable than revision soft-tissue repair but may not be indicated in patients without significant glenoid bone loss. We describe an arthroscopic technique of conjoint tendon transfer using a combination of suspensory and interference screw fixation for patients without significant glenoid bone loss (<15%). The arthroscopic approach to this procedure allows intra-articular visualization to assist in mobilization of the conjoint tendon, accurate bone tunnel placement, and subsequent labral repair. It avoids the additional steps of bone block preparation and the larger portals required for arthroscopic Latarjet techniques, in addition to eliminating potential complications due to coracoid bone block resorption.