The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability

Latarjet procedure: open with screws or arthroscopic with cortical buttons? A retrospective cohort comparison of outcomes and complications

BACKGROUND

The original Latarjet-Patte procedure is a reliable technique to treat traumatic anterior shoulder instability. However, attempts to reduce possible complications have led to the emergence of modified techniques. More prominent among them are the arthroscopic approach and the use of cortical buttons for coracoid fixation. To date, limited research is available directly comparing the simultaneous use of these 2 modifications to the original Latarjet-Patte technique. The purpose of this article is to compare clinical and radiologic outcomes and complications between open Latarjet with screws and arthroscopic Latarjet with cortical buttons for traumatic anterior shoulder instability.

METHODS

A multicenter retrospective cohort study was performed of medical records and imaging studies of 2 groups of patients, with 2 years of follow-up, who underwent either one of 2 variations of the Latarjet procedure: open approach with screws (open-screw group) or arthroscopic approach with cortical buttons (scope-button group). Group homogenization was ensured by statistical comparison of 14 baseline independent variables as well as multiple regression analysis to assess confounding factors. The primary outcome was the Rowe score at 24 months after surgery, for which the minimal clinically important difference of 9.7 points was used. Secondary outcomes were recurrence of instability, graft positioning, the Rowe score at other points in time, and complications.

RESULTS

Thirty-eight patients were evaluated in the open-screw group and 44 in the scope-button group, with a 24-month follow-up. All but 1 patient in each group achieved the minimal clinically important difference from pre- to postoperative Rowe score. The Rowe score did not differ between groups during any of the assessment times. There was no difference regarding graft vertical (P = .620) or horizontal (P = .280) positioning. There was 1 recurrence in each group: a dislocation in the open-screw group (P = .463) and a subluxation in the scope-button group (P > .999). Other complications happened exclusively in the scope-button group: neuropraxia (n = 1; P > .999), infection (n = 2; P > .999), graft fracture (n = 1; P > .999), and graft migration (n = 2; P > .999). Multiple regression analysis did not observe influence from any of the potential confounding factors on the final results.

CONCLUSION

At early follow-up, arthroscopic Latarjet with cortical buttons yielded comparably good clinical and radiologic results to the conventional open Latarjet with screws.

Geographic Variability in the Management of Anterior Glenohumeral Instability: A Binational Analysis

Background

The Bankart and Latarjet procedures are the 2 most commonly performed procedures for stabilization of anterior glenohumeral instability around the world. The aim of this study was to describe actual trends in surgery for anterior instability in the United States and in France.

Hypothesis

Glenohumeral stabilization surgery overall is becoming more frequent in France and in the United States, with an increasing number of Latarjet procedures having been performed in each country in recent years.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A retrospective review was performed using French and American databases from 2009 to 2018. Procedure codes MEMA005 and MEMC004 were pulled from the French National Health Insurance System and Current Procedural Terminology codes 23455, 29806, and 23462 were pulled from IBM MarketScan. During this period, 73,914 patients underwent anterior shoulder stabilization surgery in France and 391,521 in the United States. For each year and the global period, the estimated number of Bankart procedures in the United States was compared with the number of French procedures. The same comparison was done for Latarjet procedures. The sex ratio was compared using chi-square testing. The mean age was compared using a Student t test.

Results

The Bankart procedure represents 98% of the shoulder stabilization procedures in the United States, but the Latarjet procedure is becoming more common in the United States, having increased by 154% during the 10-year study period. In France, the Latarjet procedure represents 75% of the surgeries, having increased by 40% during the 10-year study period. However, use of the Bankart procedure in France increased from 11.2/100,000 in 2009 to 13.4/100,000 in 2018.

Conclusion

This study demonstrated that, overall, use of the Latarjet procedure has been increasing over the last decade in both the United States and France. However, there remains a divergence in the treatment of anterior shoulder instability between the 2 countries. The Latarjet procedure remains the preferred treatment option in France for anterior shoulder instability (75% Latarjet vs 25% Bankart), whereas the Bankart procedure is dominant within the United States (98% Bankart vs 2% Latarjet). When breaking data down by age groups, more Bankart procedures are being performed on younger patients, and in both countries the incidences of women requiring these surgeries are increasing. The authors hope this study will serve as a foundation for future prospective studies establishing evidence-based algorithms to guide the treatment of anterior instability and provide a root cause analysis on why different surgeons choose a specific procedure to treat this problem.

Outcomes of arthroscopic cortical-button Latarjet procedure with minimum 5-year follow-up

BACKGROUND

The surgical treatment of anterior shoulder instability with arthroscopic cortical-button Latarjet procedure has been the subject of very few medium and long-term studies. The aim of this study was to analyze the clinical and radiologic results of arthroscopic cortical-button Latarjet procedure with minimum 5 years follow-up.

METHOD

This is a monocentric retrospective study including 40 patients who have undergone shoulder stabilization with primary arthroscopic cortical-button Latarjet procedure and been reviewed with minimum 5 years follow-up. The average age at the time of surgery was 26.6 years (16-59; ±10) and 92.5% were sporty individuals. The average Instability Severity Index score was 6 points (2-9; ±1.6). The clinical evaluation involved active range of motion measurement, apprehension test, Rowe and Walch-Duplay scores, Subjective Shoulder Value and Net Promoter Score. Radiologically, evolution of the bone graft and degenerative arthritis of the shoulder joint were analyzed at the last follow-up.

RESULTS

At an average follow-up of 71 months (60-97; ±12), 3 patients (7.5%) experienced recurrence as a dislocation or subluxation, which was responsible for revision in 1 case. Moreover, apprehension persisted in 6 (16%) patients. There were no significant restrictions in recovery of active ranges of motion, including external rotation. Return to sports was effective in 94.6% of cases. The average Rowe and Walch-Duplay scores were 87 points (15-100; ±20) and 88 points (15-100; ±19) respectively. Subjective Shoulder Value was 91% (10-100; ±16) and NET Promoter Score was 9.3 points (5-10; ±1,3). Radiologically, degenerative arthritis occurred in 18.7% of patients, mainly asymptomatic stage 1 (9.4%). Bone healing was acquired in 72% of cases and partial lysis of the bone block in 41%.

CONCLUSION

At an average follow-up of 6 years, arthroscopic cortical-button Latarjet procedure is effective, enabling return to sport in 95% of cases. Onset of asymptomatic arthritis seems similar to conventional techniques but justifies a longer-term follow-up.

The Evolution of Arthroscopic Shoulder Surgery: Current Trends and Future Perspectives

Arthroscopic shoulder surgery has undergone significant advancements over the past decades, transitioning from a primarily diagnostic tool to a comprehensive therapeutic approach. Technological innovations and refined surgical techniques have expanded the indications for arthroscopy, allowing minimally invasive management of shoulder instability and rotator cuff pathology. Methods: This narrative review explores the historical evolution, current trends, and future perspectives in arthroscopic shoulder surgery. Results: Key advancements in shoulder instability management include the evolution of the arthroscopic Bankart repair, the introduction of the remplissage technique for Hill-Sachs lesions, and the development of arthroscopic Latarjet procedures. Additionally, novel techniques such as Dynamic Anterior Stabilization (DAS) and bone block procedures have emerged as promising solutions for complex instability cases. In rotator cuff repair, innovations such as the suture-bridge double-row technique, superior capsular reconstruction (SCR), and biological augmentation strategies, including dermal allografts and bioinductive patches, have contributed to improving tendon healing and functional outcomes. The role of biologic augmentation, including biceps tendon autografts and subacromial bursa augmentation, is also gaining traction in enhancing repair durability. Conclusions: As arthroscopic techniques continue to evolve, the integration of biologic solutions and patient-specific surgical planning will likely define the future of shoulder surgery. This review provides a comprehensive assessment of current state-of-the-art techniques and discusses their clinical implications, with a focus on optimizing patient outcomes and minimizing surgical failure rates.

How to salvage the fractured coracoid during the Latarjet Procedure? An empirical approach

The Latarjet procedure is a frequently used stabilization procedure in case of anterior shoulder instability with critical glenoid bone loss and/or off-track Hill Sachs lesions. Although uncommon, intra-operative graft fractures do occur. When confronted with this potentially challenging intra-operative complication, having a secondary solution is paramount to achieve a successful outcome. This technical note provides a treatment algorithm that may function as a useful guideline to assist surgeons that experience this potentially complex unintended event during a Latarjet procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The Biomechanical Importance of Bone Block Positioning in Glenoid Augmentation: Every Millimeter Matters

BACKGROUND

In the presence of anterior glenoid bone loss (aGBL), options for bony glenoid augmentation include Latarjet procedures and free bone block transfers. Bone graft placement is challenging, and malposition causes complications, such as recurrent instability or osteoarthritis.

HYPOTHESIS

With minimal changes in bone block positioning, osteochondral shoulder stability cannot be restored sufficiently.

STUDY DESIGN

Controlled laboratory study.

METHODS

In a robotic test setup, 14 human cadaveric scapulae were included. Soft tissue was resected, and matching artificial humeri were selected for each specimen. Testing was performed in 60° of glenohumeral abduction with 50 N of glenohumeral compression and anterior-directed translational force to the humerus. Application of 20% aGBL and screw fixation of artificial bone blocks (artBBs) with different buildup shells allowed the following testing stages: (1) intact, (2) 20% aGBL, (3) flush artBB, (4) 1-mm medialized artBB, and (5) 1-mm lateralized artBB. The stability ratio (SR) and medial-lateral humeral head starting position were assessed.

RESULTS

Specimens with 20% aGBL provided lower mean SRs than native joints (20.6% [SD, 4.7%] vs 27.8% [SD, 6.7%]; P < .0001). Flush artBB placement (mean, 35.4%; SD, 7.7%) led to an increased SR compared with both native joints (P = .002) and 20% aGBL (P < .0001). The mean SR in 1-mm medialized artBBs (21.5%; SD, 5.7%) did not differ compared with that for 20% aGBL (P = .908). One-millimeter lateralized artBBs (mean, 40.8%; SD, 5%) provided higher SR and more lateral humeral head starting positions compared with flush artBB (P = .003 and P = .003, respectively).

CONCLUSION

In the presence of aGBL, flush bone block placement restores osteochondral glenohumeral stability, while a 1-mm medialized bone block fails to increase stability. Bone block lateralization of 1 mm provides higher stability but is associated with humeral head lateralization.

CLINICAL RELEVANCE

Glenoid bone block augmentations are established in patients with glenohumeral instability and aGBL. In the case of bone block malposition, complications like recurrent instability or the development of osteoarthritis can occur. This study underlines the importance of accurate bone block placement since only minimum bone block malposition relevantly affects osteochondral shoulder biomechanics.

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.

Screw Fixation Has Better Outcomes, Lower Incidence of Redislocation, and Lower Bone Resorption Than Button Fixation for Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibia Allograft: A Matched Cohort Analysis

PURPOSE

To compare the clinical outcomes between patients who received arthroscopic anatomic glenoid reconstruction (AAGR) using distal tibia allograft with button fixation versus screw fixation.

METHODS

A retrospective chart review was conducted for all patients who underwent AAGR with button or screw fixation between 2012 and 2021. Patients were matched at a 1:1 ratio on the basis of sex, type of surgery, and time since surgery. All patients who were included had a minimum clinical follow-up of 2 years. Study outcomes compared Western Ontario Shoulder Instability (WOSI) Index scores, recurrence of instability, incidence of revision surgeries, and computed tomography readings.

RESULTS

In total, 44 patients were included with 22 patients in each group. The preoperative glenoid bone loss was 22.57 ± 8.06% in the screw group and 22.92 ± 8.84% in the button group (P = .898). Both groups demonstrated a significant improvement in WOSI from preoperative to latest follow-up; however, patients in the screw group demonstrated significantly better WOSI scores at both 2-year (P = .003) and latest follow-up (P = .019) compared with the button group. Recurrent dislocation was observed in 9 patients (40.9%), all of whom underwent button fixation (P < .001). Two patients in the screw group experienced hardware complications (P = .488). Individuals who underwent button fixation were significantly more likely to undergo a revision surgery for recurrent instability (P = .011). Individuals in the button group demonstrated a significantly smaller mean graft anteroposterior diameter postoperatively (P < .001).

CONCLUSIONS

AAGR with both screw fixation results in significantly improved WOSI scores at minimum 2-year follow-up. Button fixation has a significantly greater incidence of redislocation. Radiographic findings suggest that on average, button fixation results in greater-grade bone resorption and subsequently smaller postoperative glenoid anteroposterior width than screw fixation.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Complications and Return to Sport Between Screw Fixation and Suture Button Fixation for Arthroscopic Latarjet in a 2-year Follow-up: A Retrospective Cohort Study

Background

The Latarjet procedure may be performed arthroscopically or via an open approach, utilizing screws or suture buttons for graft fixation. There has been recent interest in suture button techniques in arthroscopic surgery, and proponents assert that these techniques may lead to fewer hardware-related complications while allowing for easier graft positioning.

Hypothesis/Purpose

This study aimed to compare the complication and return to sports (RTS) rates between screw fixation (SF) and suture button fixation (SB) for patients undergoing the arthroscopic Latarjet procedure. It was hypothesized that each group would have similar outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 112 patients underwent arthroscopic Latarjet procedures at a single center between January 2012 and December 2019. All patients had >20% glenoid bone loss, and 11.6% (n = 13) had previous arthroscopic Bankart repair. SF was utilized in 65 (58%) cases, and SB in 47 (42%) cases. Complications, reoperations, and RTS rates were analyzed. Patients were included for analysis if they had a 2-year follow-up and did not require conversion to open surgery.

Results

Total complications were similar between SF and SB and occurred in 15.4% (n = 10) and 14.9% (n = 7) of cases, respectively (P = .943). Recurrent dislocation was noted in 3.1% (n = 2) of SF cases and 4.3% (n = 2) of SB cases (P = .740). Reoperations were required in 4.6% (n = 3) of the SF group and 4.3% (n = 2) of the SB group (P = .927). There were no hardware complications in the SB group compared with 1 hardware complication in the SF group. RTS was also similar between groups, with 92.3% and 93.6% returning to sports and 75.4% and 80.9% returning to the same level of sports in the SF and SB groups, respectively.

Conclusion

Graft fixation using SF or SB yielded similar results for arthroscopic Latarjet procedures with respect to complications and RTS. The fixation method may be dictated by surgeon preference without an increased risk of complications.

Latarjet procedure versus iliac crest autograft transfer for anterior shoulder instability: a systematic review and meta-analysis of comparative studies

BACKGROUND

Anterior shoulder instability with glenoid bone loss presents a challenge in orthopedic surgery. The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are commonly employed for its management, but direct comparative evidence is insufficient.

METHODS

Following PRISMA guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Randomized controlled trials (RCTs) and cohort studies directly comparing the Latarjet and ICBGT procedures were included. Primary outcomes included postoperative recurrent instability, apprehension test, and complications, while secondary outcomes comprised Rowe score, Subjective Shoulder Value (SSV), pain level assessed by visual analogue scale (VAS), range of motion (ROM), and radiologic outcomes. Quality assessment was performed using RoB2 and MINORS tools. The weighted mean difference (WMD) for continuous variables and odds ratio (OR) for dichotomous variables were calculated, along with 95% confidence intervals (CIs). Meta-analysis was performed using RevMan 5.4.1 software.

RESULTS

A total of 6 studies with 409 patients were included. There was no significant difference in postoperative recurrent instability (OR, 1.33; 95% CI, 0.44 to 4.03; P = 0.61), positive apprehension test (OR, 0.78; 95% CI, 0.20 to 3.10; P = 0.73), revision surgery (OR, 2.06; 95% CI, 0.74 to 5.71; P = 0.16), mild complications (OR, 0.49; 95% CI, 0.23 to 1.06; 0.07), SSV (WMD, -1.94; 95% CI, -3.94 to 0.06; P = 0.06) or VAS score (WMD, 0.15; 95% CI, -0.17 to 0.47; P = 0.36) between the two procedures. The ICBGT group exhibited statistically superior Rowe scores (WMD, -3.10; 95% CI, -5.10 to -1.10; P = 0.002), as well as improved external (WMD, -5.32; 95% CI, -7.30 to -3.30; P < 0.001) and internal rotation (WMD, -5.11; 95% CI, -6.76 to -3.45; P < 0.001). However, these differences did not surpass the minimal clinically important difference (MCID). Radiological evaluations showed that the ICBGT procedure had statistically better outcomes in immediate glenoid augmentation, preservation and reduced fatty degeneration of the subscapularis (SSC) tendon, and graft remodeling at short-term follow-up.

CONCLUSIONS

The ICBGT procedure showed statistically superior Rowe scores and range of motion, but these differences may not be clinically significant. Both procedures had comparable outcomes in recurrent instability, apprehension test results, revision surgery, mild complications, SSV, and pain levels. ICBGT appears to offer advantages in glenoid augmentation and SSC preservation at short-term follow-up.

PROSPERO REGISTRATION ID

CRD42024586157.

A comparative study of the effect of capsular repair in the Latarjet procedure

BACKGROUND

Long term studies have shown the Latarjet procedure to be successful in preventing re-dislocation in primary and recurrent anterior inferior shoulder instability. It provides stability through the sling effect of the conjoint tendon and the bone block. It is unclear whether augmentation with capsular repair provides an added benefit or leads to restricted range of external rotation. The primary aim of this study is to evaluate the effect of capsular repair in the open Latarjet procedure on rotational range of active external rotation in 90 degrees abduction (RoM-ER90). The secondary aim is to evaluate the effect on clinical outcomes including post-operative apprehension, instability, proprioception and shoulder function scores.

METHODS

This is a multi-national retrospective cohort study including patients with a minimum of 6-months follow-up post Latarjet procedure performed between 2016 and 2020 recruited from 3 units in Australia and France. Range of motion was measured using a Proteck goniometer. Clinical outcomes were assessed using the Western Ontario Shoulder Instability Index (WOSI), Oxford shoulder, Oxford instability, Walch-Duplay and Rowe scores. Shoulder proprioception was assessed by the active relocation test described by Glendon et al. RESULTS: Forty-four patients were included, median age was 29.5 years and 91% male. Three groups were assessed, open latarjet with no capsular repair (OL n = 11), open latarjet with capsular repair (OLCR n = 20), and arthroscopic Latarjet without capsular repair (AL n = 13). There was no apparent effect of capsular repair on the ROM-ER 90 in the open groups with a median (interquartile range) of 78° (72°, 90°) for OL and 84° (75°, 90°; P = 0.87) for OLCR groups. Capsular repair and arthroscopic approach did not affect the proportion of patients reporting shoulder apprehension (P = 0.52 and 0.48 respectively). There was no difference in proprioception between operative and non-operative sides for the OL group (P = 0.43). Proprioception was poorer on the operative side for the OLCR group (P = 0.04) but better on the operative side for the AL group (P = 0.08). WOSI scores for the open surgical groups were similar (OL = 78, OLCR = 80, P = 0.91) and when combined (median WOSI = 79) demonstrated greater stability than the AL group (P = 0.009). There was no evidence of an effect of capsular repair or arthroscopic approach on the Walch-Duplay, Oxford Instability, or Rowe scores.

CONCLUSIONS

There is no significant difference in ROM-ER 90 or WOSI score in patients who undergo the Latarjet procedure with and without capsular repair. The arthroscopic Latarjet may preserve proprioception but did not improve shoulder stability compared to the open Latarjet.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Modified Suture-Button Latarjet Procedure With Coracoacromial Ligament and Pectoralis Minor Preservation Achieves Good Clinical Outcomes at 2-Year Follow-Up: Case Series of Latarjet Technique

PURPOSE

To evaluate whether the modified suture-button Latarjet procedure with coracoacromial ligament (CAL) and pectoralis minor (PM) preservation could achieve excellent outcomes at the 2-year follow-up.

METHODS

During January 2019 to January 2021, the data of patients who underwent modified suture-button Latarjet with CAL and PM preservation in our department were collected. The glenoid bone loss of these patients was greater than 20% or greater than 10% with high demands for exercise. Partial coracoid osteotomy was based on the results of a preoperative 3-dimensional computed tomography evaluation of the glenoid defect area and corresponding coracoid process morphology. The preoperative and postoperative clinical results were assessed. The minimal clinically important difference (MCID) was used to compare improvement in clinical outcomes. Graft-glenoid union and remodeling were assessed using postoperative 3-dimensional computed tomography, and magnetic resonance imaging was performed to confirm the integrity of the CAL and PM postoperatively.

RESULTS

In total, 35 patients were included in this study; the mean follow-up time was 26.9 ± 1.9 months. No case of recurrent dislocation or sublaxity. Significant improvements were observed in mean visual analog scale (VAS) scores for pain during motion, American Shoulder and Elbow Surgeons (ASES) score, Rowe score, and Walch-Duplay score (P < .001). The percentage of patients achieving at least an MCID improvement in clinical outcomes was VAS 85.71%, ASES 97.14%, Rowe 100%, and Walch-Duplay 97.14%. Thirty-three patients (94.3% of all cases) were able to return to their preoperative sport levels, 34 grafts (97.1%) achieved bone union (1 soft union) in 6.3 ± 2.2 months, and the coracoid grafts restored 97.1 ± 4.0% of the perfect-fitting circle at the last follow-up. Postoperative computed tomography scan showed that 31 grafts (88.6%) were placed ideally in vertical view. In the axial view, 25 grafts (82.9%) were flushed to the glenoid, whereas 1 and 5 grafts were fixed medially and laterally, respectively. The CAL and PM were visualized postoperatively. No arthropathy was observed in any patient at the last follow-up.

CONCLUSIONS

The modified suture-button Latarjet procedure with CAL and PM preservation obtained good clinical and radiological results without recurrence or complications. A substantial number of patients (>85%) achieved the MCID for the VAS, ASES, Rowe, and Walch-Duplay scores. In addition, the malpositioned graft (17.1%) did not cause arthropathy of the joints at 2-year follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic Pectoralis Minor Release and Infraclavicular Brachial Plexus Decompression for Neurogenic Thoracic Outlet Syndrome: A Novel Treatment for an Old Problem

Background

Neurogenic thoracic outlet syndrome (nTOS) of infraclavicular etiology is a complex condition involving the compression of the brachial plexus through the interscalene triangle and costoclavicular, infraclavicular, and pectoralis minor space. New insight into nTOS of infraclavicular etiology and its association with scapular dyskinesia has enabled minimally invasive treatments: endoscopic pectoralis minor release (PMR) and infraclavicular brachial plexus neurolysis. The purpose of this study was to analyze clinical outcomes of this technique compared with historically published outcomes for open first rib resection (FRR) and/or scalenectomy.

Methods

All patients who underwent endoscopic surgical decompression for nTOS of infraclavicular etiology were retrospectively reviewed at a single institution. Surgical treatment included endoscopic PMR, subclavius release, and neurolysis of the infraclavicular brachial plexus. Patient-reported outcomes were collected prospectively and compared with prior research on FRR and scalenectomy. A subgroup analysis was performed on patients with prior open FRR or anterior cervical discectomy and fusion (ACDF).

Results

Fifty-eight shoulders among 55 patients were included, with an average follow-up of 25.8 months (range: 12-52). Patients showed significant improvement in visual analog scale pain (7.0-2.1) and single alpha-numeric evaluation scores (37% to 84%). Overall, 90% of patients experienced good or excellent outcomes according to the Derkash classification. There were no major complications and only 2 minor ones (one wound infection and one case of adhesive capsulitis). Satisfaction and Derkash scores among patients undergoing endoscopic surgery were comparable with previously published studies on open FRR and scalenectomy, with lower rates of major complications and equivalent or improved clinical outcomes. Patients with prior ACDF or open FRR had worse postoperative American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder, and Hand; and Derkash scores than the subgroup with no prior intervention.

Conclusions

Endoscopic PMR and infraclavicular brachial plexus decompression is a viable and effective treatment option for nTOS of infraclavicular etiology driven by the pectoralis minor and associated scapular girdle dyskinesia. This cohort demonstrates improvements in clinical outcomes comparable with open scalenectomy and FRR with high patient satisfaction and no major neurologic, vascular, or thoracic complications.

Level of Evidence

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

Learning curve for the open Latarjet procedure: a single-surgeon study

BACKGROUND

The popularity of the Latarjet procedure (LP) for the treatment of anterior shoulder instability continues to rise. However, LP is technically demanding and associated with complications. This study aims to determine the learning curve for the open LP (oLP) and the threshold for proficiency.

METHODS

This was a retrospective study of all oLPs performed by a single surgeon in a single institution from 2016 to 2021. Operative time, defined as time from incision to closure, was the primary outcome of this study, and 1-year postoperative complications were the secondary outcome. After listing oLP cases in chronological order, they were classified into groups of 15, and the average operative time for each group was determined. Demographics, operative duration, and postoperative complications were compared across groups.

RESULTS

Seventy-five oLPs were included in this study, and operative times decreased after the first 15 procedures. While operative times continued to decrease with increasing case number, the learning curve began to plateau after 30 procedures. After 75 procedures, there was a total decrease in average operative time of 31.5 minutes relative to that of the first 15 cases. There were no differences in complication or revision rates among procedure groups.

CONCLUSIONS

Establishing learning curves provides important insight into the complexity of surgical procedures. Our study demonstrates that the oLP has a steep learning curve with significant improvement in operative time after the first 15 cases. Operative time plateaus after 30 cases, indicating proficiency in this procedure. Level of evidence: IV.

Surgical treatment of anterior glenohumeral instability: a historical review

BACKGROUND

Glenohumeral instability is a common pathology, particularly in young, active patients.

METHODS

A narrative review was performed to describe the history of surgical treatments for anterior shoulder instability.

RESULTS

Open surgical techniques were first described by Bankart in 1923. Techniques include both anatomic soft tissue repairs and nonanatomic procedures to provide constraint to motion and dislocation. Osseous techniques to address glenoid bone loss include both autograft techniques, such as the Latarjet procedure, and the use of various allografts. Technologic advances, particularly arthroscopy, have continued to drive the evolution of treatments. The concept of the glenoid track has furthered our understanding of this pathology to guide appropriate treatment to reduce recurrence.

CONCLUSIONS

Surgical treatment for anterior shoulder instability continues to evolve in an effort to restore function and prevent additional injury.

Results of combined all-arthroscopic Latarjet with Hill-Sachs remplissage for significant bipolar glenohumeral bone loss

BACKGROUND

Arthroscopic Latarjet using suture-button fixation has shown good clinical results and low recurrent instability in patients with significant glenoid bone loss. However, the presence of an associated Hill-Sachs lesion (HSL) is a risk factor for recurrent instability after isolated Latarjet. The aim of the study was to report clinical and radiologic results following all-arthroscopic Latarjet combined with Hill-Sachs remplissage (HSR).

METHODS

Monocentric prospective study including 41 patients (mean age 28 ± 7 years) who underwent the combined procedure between 2014 and 2019 with minimum 2 years' follow-up (mean 40 ± 13 months). Indications were glenoid bone loss >10% (mean 23.9% ± 7.5%) and large, deep HSL (Calandra 3). Five (13%) patients had signs of osteoarthrosis stage I preoperatively, 4 (10%) had previous stabilization surgery (3 cases isolated Bankart and 1 case Bankart combined with HSR), and 4 (13%) were epileptic. The HSR was performed first followed by guided Latarjet procedure. Primary outcome measures included shoulder stability and function represented by Walch-Duplay and Rowe scores, and Subjective Shoulder Value (SSV) for daily life/sports. Secondary outcome measures included coracoid graft position and union, and glenohumeral osteoarthritis using radiographs and computed tomography.

RESULTS

Three patients (7%) had recurrent instability: 1 due to seizure, 1 following fall, and 1 related to graft osteolysis. Two patients were revised because of recurrence with arthroscopic distal clavicle autograft. There were no infections, neurologic complications, or hardware failures. The Walch-Duplay score was 90 (95% CI 76.8-93.2), and the Rowe score 95 (95% CI 77.2-92.2). The median SSV averaged 96% (95% CI 87.5-97.0) for daily life and 90% (95% CI 75.7-90.2) for sports. Mean external rotation with the arm at the side was 60° (95% CI 59°-70°) with a median loss 10° (95% CI 3°-17°) compared to the contralateral side. Among patients playing sport preoperatively, 36 (95%) were able to return to sport: 25 (67%) at the same level and 7 (18%) at a lower level, whereas 4 had to change sport. The coracoid graft was flush with the glenoid surface in 96% of cases and subequatorial in 89%. The graft developed nonunion in 11% and fractured in 5%. Seven patients (18%) had radiographic signs of grade I osteoarthritis.

CONCLUSION

Combined arthroscopic Latarjet and HSR is an efficient solution for dealing with significant bipolar glenohumeral bone loss. The combined procedure deserves consideration in high-risk patients including combined bone loss, recurrent anterior instability after failed stabilization procedures and/or seizure.

Utilization of a stepwise model to assess pivotal information for patient decision-making regarding open vs. arthroscopic Latarjet procedure

BACKGROUND

The popularity of arthroscopic Latarjet has increased significantly in recent years due to its perceived advantages. The latter include a smaller surgical incision, faster recovery, quicker return to sports, and ability to treat concomitant intra-articular pathology. Nevertheless, the arthroscopic technique is more technically challenging, has a more significant learning curve, longer operating time, and is less cost-effective. The study aimed to identify the various factors influencing patient decision-making between undergoing arthroscopic or open Latarjet using a stepwise questionnaire model.

METHODS

All patients with a primary, whether arthroscopic or open Latarjet procedure were subjected to a stepwise interviewing process and were asked to select between arthroscopic and open approaches at each step.

RESULTS

Fifty patients with a mean age of 28.8 ± 8.8 year old participated in the study. Twenty (40%) consistently selected an arthroscopic approach after analysis of the incision's aspect, whereas 34 (68%) had a final decision different from their initial choice. In addition, out of the 15 patients who chose arthroscopy or were undetermined after presentation of the incisional aspect, 9 (60%) changed their decision to open surgery after presentation of the pros and cons of each approach. Twenty-three (46%) patients were unable to choose and left the choice to their surgeon. The faith in their surgeon and recovery were identified as the 2 most important factors influencing patients' final decisions.

CONCLUSIONS

The minimally invasive nature of arthroscopic incisions was not considered to be more cosmetically appealing than that of a single open incision. The advantages of the arthroscopic procedure may not be as valued by patients as by surgeons. Patients were more interested in the equivalent short- and mid-term outcomes of both approaches and the shorter surgical duration of the open option. It is crucial to adequately inform patients during preoperative counseling to achieve the best consensus.

Comparing postoperative proprioception of the glenohumeral joint between the open and the arthroscopic Latarjet procedure

BACKGROUND

Shoulder proprioception, in which the anterior glenohumeral capsule plays a major role, is critical to the functioning of the shoulder. Consequently, most surgeons either do not resect or reinsert the anterior capsule in shoulder stabilization surgery. In the original open Latarjet procedure (OLP), the anterior capsule is preserved. However, in the all-arthroscopic Latarjet procedure (ALP), complete anterior capsule resection is recommended for better view and access to the coracoid. This raises the question if there is a postoperative difference in proprioception between these 2 procedures. Therefore, the aims of this study are (1) to assess the difference in postoperative proprioception between the operated and healthy sides after the OLP and ALP and (2) to compare the difference in postoperative proprioception on the operated side between the OLP and ALP.

METHODS

We conducted a retrospective analysis including all patients who underwent a proprioception test after an OLP or ALP at our center. Collected baseline characteristics included sex, age at surgery, operated side, hand dominance, presence of a Hill-Sachs lesion, and time between surgery and the proprioception test. For the test, patients were positioned 1 meter from a wall. They were blindfolded and had to point at a target with a laser pointer taped to their index finger. The laser point was marked and the errors were measured horizontally and vertically and categorized as <4 cm, 4-8 cm, 8-16 cm, and >16 cm.

RESULTS

Between April 2022 and April 2024, a total of 91 cases were identified, of which 24 underwent an OLP and 67 underwent an ALP. No significant difference was found in error distribution between the healthy and operated side after both the OLP (P = .30 horizontally, P = .67 vertically) and ALP (P = .20 horizontally, P = .34 vertically). Moreover, there was no significant difference in error distribution between the operated sides after the OLP vs. ALP (P = .52 horizontally; P = .61 vertically).

CONCLUSION

Our data suggest that postoperative proprioception is not significantly different between the operated and healthy sides after both the OLP and ALP, nor between the operated sides after the OLP vs. after the ALP. This might imply that completely resecting the anterior glenohumeral capsule does not have a detrimental effect on shoulder proprioception. However, these results are multifactorial and prospective studies are needed to better understand the regeneration potential of glenohumeral capsule mechanoreceptors and the importance of the anterior capsule for shoulder proprioception.

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.

Short-Term Complications of Arthroscopic Bristow or Latarjet Procedure with Screw Versus Suture-Button Fixation: A Prospective Study of 308 Consecutive Cases by a Single Surgeon

BACKGROUND

This study aimed to investigate the short-term complications (minimum 1-year follow-up) after either an arthroscopic Bristow or Latarjet procedure for anterior shoulder instability utilizing screw or suture-button fixation.

METHODS

Patients undergoing arthroscopic Bristow or Latarjet procedures between November 2016 and April 2021 were enrolled. Data were collected at baseline, 3 months, 6 months, and every year after surgery. Risks of postoperative complications and unplanned reoperations were assessed. A multivariable regression model was used to identify risk factors for complications and to determine the association of complications with patient-reported outcomes.

RESULTS

A total of 412 patients (425 shoulders) undergoing arthroscopic Bristow or Latarjet procedures performed by a single surgeon between November 2016 and April 2021 were reviewed. Two hundred and ninety-nine patients (308 shoulders, 76.2% of 404 eligible) with a mean follow-up of 22.3 ± 4.2 months were included for analysis. Two hundred and sixty-nine shoulders (87.3%) underwent a Bristow procedure (165 with screw and 104 with suture-button fixation), while 39 (12.7%) underwent a Latarjet procedure (18 with screw and 21 with suture-button fixation). Eighty-two patients (83 shoulders) reported a total of 85 complications within 2 years after surgery, with an overall complication rate of 26.9%. The rates of recurrent dislocation or subluxation and infection were 1.9% and 0.6%, respectively, while a total of 4 (1.3%) of the shoulders had unplanned reoperations. The most common complications were graft-related (11.7%), followed by complications involving neurologic symptoms (10.7%). The overall, graft, and neurologic complication rates following Bristow or Latarjet procedures were 27.1% versus 25.6%, 12.3% versus 7.7%, and 10.0% versus 15.4%, respectively. Compared with the Bristow technique with screw fixation, Bristow with suture-button fixation yielded a lower risk of any complications (odds ratio [OR], 0.55; p = 0.04). Paying with rural insurance and poor sleep quality prior to surgery were associated with increased risk of any complications.

CONCLUSIONS

Compared with arthroscopic Bristow procedures with screw fixation, Bristow procedures with suture-button fixation resulted in a lower overall complication risk. Both patient demographic and implant-specific factors were associated with the development of a complication.

LEVEL OF EVIDENCE

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

Current Evidence and Techniques for Arthroscopic Bone Augmentation

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

Decision Making of the In-season Athlete with Anterior Shoulder Instability

In-season management of anterior shoulder instability in athletes is a complex problem. Athletes often wish to play through their current season, though recurrent instability rates are high, particularly in contact sports. Athletes are generally considered safe to return to play when they are relatively pain-free, and their strength and range of motion match the uninjured extremity. If an athlete is unable to progress toward recovering strength and range of motion, surgical management is an option, though this is often a season-ending decision.

Three-dimensional computerized tomography reconstruction-based morphologic assessment of the coracoid process in an Asian population: Clinical implications for shoulder surgery

Purpose

To assess coracoid process morphology in an Asian population using three-dimensional (3D) computed tomography (CT) reconstruction and provide reference values for surgical treatment.

Methods

Data on demographic and shoulder CT characteristics were collected from 142 patients for 3D-CT-based scapular reconstruction. Ten coracoid morphological indicators and the glenoid width were measured. The morphology of the superior pillar and its undersurface were classified into common shapes. Statistical analyses included intraclass correlation coefficient (ICC) analysis, Cohen's κ value, independent samples t test, Welch's t test, Mann-Whitney U test, Kruskal-Wallis test, Spearman and Pearson correlations, receiver operating characteristic (ROC) curves and area under the curve (AUC) values. Relationships among the measured indicators, patient demographics (i.e., sex, age, height and weight) and superior pillar morphology were ascertained.

Results

The intraobserver and interobserver ICC values were 0.924-0.980 and 0.906-0.962, respectively. For intraobserver and interobserver agreement, Cohen's κ values were 0.927-0.950 and 0.901-0.937, respectively. Significant sex differences in coracoid measurements were noted. Correlations were observed between the coracoid indicators and glenoid width, sex, height and weight (p < 0.05). ROC curve analysis identified height as a significant predictor of safe distance, with cutoff values of 160.5 and 170.5 cm (AUC = 0.82 and 0.83) for women and men, respectively. The superior pillar morphologies included violin (24.65%), long rod (21.13%), short rod (33.80%), trapezoidal (11.97%) and wedge (8.45%) shapes, with the undersurfaces categorized as straight (16.20%), arched (76.76%) and hooked (7.04%), with significant differences in pillar widths among the different morphological types (p < 0.05).

Conclusion

Coracoid morphology is crucial in the preoperative planning of given shoulder surgeries, with height and sex serving as key predictors of coracoid graft length. Consideration of variations in the superior pillar shape and undersurface of the coracoid could minimize surgical complications associated with special shoulder surgery.

Level of Evidence

Level IV case series with no comparison.

A qualitative investigation to identify return to sports criteria after shoulder stabilization surgery used by professional team physicians

Purpose: Purpose of this study is to explore currently utilized readiness to return to sports (RTS) criteria after shoulder stabilization surgery used in elite athletes to gain novel insights into the RTS decision making process of professional team physicians.Methods: 19 qualitative semi-structured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after shoulder stabilization surgery. General inductive analysis and a coding process were used to identify themes and sub-themes arising from the data. A hierarchical approach in coding helped to link themes.Results: We were able to identify five key themes that participating physicians focused on to determine RTS decision making: external influence, objective and subjective criteria, time elapsed since surgery and type of sport. The most important RTS criteria included: range of motion and muscle strength followed by clinical joint stability, time since surgery, ability of sporting movement, psychological readiness, functional testing, absence of pain and allied team support.Conclusion: This study identified several main themes and subordinate minor themes as having the most influence on RTS decision after shoulder surgery. We showed that even among specialized professional team physicians, the main criteria to RTS in these categories were inconsistent necessitating the future development of specific RTS guidelines.

Surgical Variations of the Modified Latarjet Procedure: A Literature Review and Video-Illustrated Surgical Technique

The modified Latarjet procedure, otherwise known as the Walch-Boileau procedure, is a very successful management procedure for recurrent shoulder dislocation especially in patients with glenoid bone loss of less than 30 percent. Multiple variations of the surgical technique have been proposed over the years, some of which are still controversial. These variations include arthroscopic vs open technique, traditional versus congruent arc Latarjet procedure, subscapularis split versus L-shaped tenotomy, intra-articular versus extra-articular coracoid placement, capsular repair versus no repair, and the various modalities of coracoid fixation. The current evidence is based on a group of low-evidence heterogenous studies since some of these variations lack strong clinical comparative studies that control other variables. In this literature review, we present the evidence available for each of the above major variations. Furthermore, we present a video illustration of the surgical procedure done in our tertiary care center.

Arthroscopic stabilization surgery for first-time anterior shoulder dislocations: a systematic review and meta-analysis

BACKGROUND

The optimal management of first-time anterior shoulder dislocations (FTASDs) remains controversial. Therefore, the purpose of this study was to assess the efficacy of arthroscopic stabilization surgery for FTASDs through a systematic review and meta-analysis of existing literature.

METHODS

MEDLINE, Embase, and Web of Science were searched from inception to December 18, 2022, for single-arm or comparative studies assessing FTASDs managed with arthroscopic stabilization surgery following first-time dislocation. Eligible comparative studies included studies assessing outcomes following immobilization for an FTASD, or arthroscopic stabilization following recurrent dislocations. Eligible levels of evidence were I to IV. Primary outcomes included rates of shoulder redislocations, cumulative shoulder instability, and subsequent shoulder stabilization surgery.

RESULTS

Thirty-four studies with 2222 shoulder dislocations were included. Of these, 5 studies (n = 408 shoulders) were randomized trials comparing immobilization to arthroscopic Bankart repair (ABR) after a first dislocation. Another 16 studies were nonrandomized comparative studies assessing arthroscopic Bankart repair following first-time dislocation (ABR-F) to either immobilization (studies = 8, n = 399 shoulders) or arthroscopic Bankart repair following recurrent dislocations (ABR-R) (studies = 8, n = 943 shoulder). Mean follow-up was 59.4 ± 39.2 months across all studies. Cumulative loss to follow-up was 4.7% (range, 0%-32.7%). A composite rate of pooled redislocation, cumulative instability, and reoperations across ABR-F studies was 6.8%, 11.2%, and 6.1%, respectively. Meta-analysis found statistically significant reductions in rates of redislocation (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.04-0.3, P < .001), cumulative instability (OR 0.05, 95% CI 0.03-0.08, P < .001), and subsequent surgery (OR 0.08, 95% CI 0.04-0.15, P < .001) when comparing ABR-F to immobilization. Rates of cumulative instability (OR 0.32, 95% CI 0.22-0.47, P < .001) and subsequent surgery rates (OR 0.27, 95% CI 0.09-0.76, P = .01) were significantly reduced with ABR-F relative to ABR-R, with point estimate of effect favoring ABR-F for shoulder redislocation rates (OR 0.59, 95% CI 0.19-1.83, P = .36). Return to sport rates to preoperative levels or higher were 3.87 times higher following ABR-F compared to immobilization (95% CI 1.57-9.52, P < .001), with limited ABR-R studies reporting this outcome. The median fragility index of the 5 included randomized controlled trials (RCTs) was 2, meaning reversing only 2 outcome events rendered the trials' findings no longer statistically significant.

CONCLUSION

Arthroscopic stabilization surgery for FTASDs leads to lower rates of redislocations, cumulative instability, and subsequent stabilization surgery relative to immobilization or arthroscopic stabilization surgery following recurrence. Although a limited number of RCTs have been published on the subject matter to date, the strength of their conclusions is limited by a small sample size and statistically fragile results.

Screw Fixation for the Latarjet Procedure May Reduce Risk of Recurrent Instability but Increases Reoperation Rate Compared to Suture-Button Fixation: A Systematic Review

PURPOSE

To perform a systematic review to compare clinical outcomes, complications, and reoperation rates of patients undergoing the Latarjet procedure with screw vs suture-button fixation.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies directly comparing screw vs suture-button fixation for the Latarjet procedure. The search terms used were shoulder screw suture button. Patients were evaluated based on reoperation rate, complication rate, recurrent instability, radiologic outcomes, and patient-reported outcomes. Graft and screw position were assessed via computed tomography.

RESULTS

Seven studies (1 Level II, 6 Level III) met inclusion criteria, with 845 patients undergoing the Latarjet procedure with screw fixation (screw group) and 279 patients with suture-button fixation (suture-button group). Mean patient age ranged from 21.2 to 29.6 years. Mean follow-up time ranged from 6.0 to 40.8 months. The recurrent instability rate ranged from 0% to 2.5% in the screw group and 0% to 8.3% in the suture-button group. The reoperation rate ranged from 0% to 7.7% in the screw group compared to 0% to 1.9% in the suture-button group. One study reported significantly lower visual analog scale pain scores in the suture-button group compared with the screw group (1.5 vs 1.2, P = .003). No other studies reported significant differences in any patient-reported outcomes. There was no significant difference in horizontal or vertical graft position, graft union rate, or complication rate between groups in any study.

CONCLUSIONS

The Latarjet procedure with screw fixation may result in a lower risk of recurrent instability compared to suture-button fixation, although screw fixation may also have a higher reoperation rate due to hardware-related complications.

LEVEL OF EVIDENCE

Level III, systematic review of Level II to III studies.

Arthroscopic Latarjet Versus Arthroscopic Free Bone Block Procedures for Anterior Shoulder Instability: A Proportional Meta-analysis Comparing Recurrence, Complication, and Reoperation Rates

BACKGROUND

Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet.

PURPOSE

To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: "Arthroscopic" AND "Bone Block" OR "Bone Graft," and "Arthroscopic" AND "Glenoid Augmentation" OR "Glenoid Reconstruction," and "Arthroscopic" AND "Latarjet" OR "Coracoid Graft" OR "Coracoid Transfer." Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias.

RESULTS

Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age (P = .07), sex (P = .14), glenoid bone loss (P = .14), number of preoperative dislocations (P = .62), proportion of primary and revision procedures (P = .95), length of follow-up (P = .81), modified Coleman Methodology Score (P = .21), and level of evidence (P = .49). There was no difference in the recurrence (P = .88), reoperation (P = .79), and complication (P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation (P = .01).

CONCLUSION

The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation.

REGISTRATION

CRD42022368153 (PROSPERO).

Current Trends and Outcomes for Open vs. Arthroscopic Latarjet

PURPOSE OF REVIEW

This paper aims to analyze and compare the existing research on open and arthroscopic Latarjet procedures for treating anterior shoulder instability. The review will assess different factors such as graft positioning, functional outcomes, complications, and return-to-play rates for both approaches. The study's primary goal is to establish which technique yields superior outcomes.

RECENT FINDINGS

Recent studies have suggested that arthroscopic Latarjet surgery can produce outcomes similar to open surgery regarding functional scores and patient satisfaction. Some research indicates that arthroscopy may even provide slightly better results. Both techniques have similar complication rates, but arthroscopy requires a longer learning curve and operating time. It is crucial to ensure the proper placement of the graft, and some studies suggest that arthroscopy may be better at achieving accurate positioning. Both open and arthroscopic Latarjet procedures are equally effective in treating shoulder instability. While arthroscopy offers a faster recovery time and causes less soft tissue damage, it requires surgeons to undergo a steeper learning curve. The optimal graft position for both techniques is still debated. More long-term data is needed to establish superiority. Future research should compare approaches in larger cohorts and identify outcome-affecting factors to improve the treatment of shoulder instability. Both techniques are promising, but arthroscopy may be a better option as the procedure evolves into a less invasive reconstruction.

Faster strength recovery and better strength ratio with arthroscopic Latarjet compared to the open technique: An observational study

INTRODUCTION

The arthroscopic bone block has shown reliability and reproducibility regarding functional scores and shoulder mobility compared to the open bone block technique. The recovery of muscle strength, especially the strength ratio external rotator/internal rotator (ER/IR), is crucial to recovering satisfactory function. This ratio should be as near to 1 as possible, meaning a good strength balance. Little is known about the difference in strength recovery between the open and arthroscopic techniques.

HYPOTHESIS

Arthroscopic Latarjet reduces surgical stress and improves the strength recovery and strength ratio.

OBJECTIVES

To compare arthroscopic and open Latarjet procedures for shoulder muscle strength and functional outcomes.

MATERIAL AND METHODS

It was an observational longitudinal and prospective cohort follow-up. Two groups of patients were accessible for comparison: 35 in an arthroscopy group and 38 in an open group. The main outcome was the muscle strength of shoulder muscles measured with a dynamometer and expressed in Newton (N) at day 21 (D21), D45, D90, D180, and D365 in the operated and contralateral shoulders. The measurements were made for the pectoralis major, the three deltoid fascicles, and the subscapularis. The shoulder ER/IR strength ratio was calculated. Other variables were the range of motion (ROM), the Walch-Duplay (WD), the Western Ontario Shoulder Instability score (WOSI), and the Visual Analogic Scale for pain assessment. The strength, ROM, and functional scores were compared between open and arthroscopy with linear mixed models.

RESULTS

The median strengths at 52 weeks were significantly higher than at 3 weeks (P<10-4): anterior deltoid (AD) 8N (Q1:7, Q3: 9) versus 4N (Q1:2, Q3: 5), lateral deltoid (LD) 9N (Q1:9, Q3: 11) versus 6N (Q1:4, Q3: 7), posterior deltoid (PD) 14N (Q1:12, Q3: 15) versus 9N (Q1:8, Q3: 10), subscapularis 10N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 8), and pectoralis major (PM) 11N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 10). The overall strengths were lower in the open group compared to the arthroscopy group: AD -2.1N (CI95%[-3.1--1.2], p=0.0005), LD -1.3N (CI95% [-2.4--0.15], p=0.03), PD -0.35N (CI95% [-1-0.9], p=0.52), subscapularis -2.1N (CI95% [-3.3--0.7], p=0.006), and PM -1.4N (CI95% [-2.2--0.02], p=0.03). The ER/IR ratio was stable throughout the follow-up for both the operated and contralateral shoulders (p>0.5). The overall mean ratio was 1.3 (median 1.2, Q1: 1, Q3:1.45) for the operated shoulder and 1.1 (median 1, Q1: 0.9, Q3:1.3) for the contralateral shoulder (p=0.0004). The average ER/IR ratio was 0.27 points higher in the open group (CI95% [0.1-0.46], p=0.003). The ROM was similar between the two groups, and there was no correlation between the ER/IR ratio and the ROM (p>0.5). The VAS < 3 weeks and WD > 12 weeks were significantly poorer in the open group: +0.61 (CI95% [0.03-1.16] p=0.02), and -7.3 points (CI95% [-13--0.01], p=0.05), on average, respectively.

CONCLUSION

The patients in the arthroscopy group had a better ER/IR strength ratio (closer to 1) and better WOSI after 12 weeks. The strength and the ROM were not correlated with each other.

LEVEL OF EVIDENCE

III.

The Subscapularis-Sparing "Flipped Latarjet" Procedure

The Latarjet procedure is a proven and effective operation to treat anterior shoulder instability. Especially in cases with anterior glenoid bone loss, the Latarjet operation is the most popular procedure to restore glenoid anatomy and avoid further dislocations. Next to the re-creation of the missing glenoid bone, the sling effect of the conjoint tendon transferred between a split in the subscapularis muscle is an important "soft tissue stabilizer" of the humeral head. However, it has been shown that the inferior part of the subscapularis muscle tends to degenerate, leading to fatty infiltration of the muscle itself. Also, exposure through the subscapularis split is technically demanding, and there is a risk of nerve damage due to the pulling forces of the retractors during open surgery. When performing the procedure arthroscopically, extremely low and medial portals are necessary to find a correct angle for the glenoid drilling when approaching from anterior. Neurovascular structures may be at risk during these surgical steps. The aim of the flipped Latarjet procedure is to facilitate a safe and reliable arthroscopic operation to anteriorly stabilize the shoulder by transferring the coracoid to the deficient glenoid without splitting the subscapularis muscle while keeping the benefits of a sling effect of the conjoined tendon.

Primary bone graft stability after Latarjet surgery: biomechanical evaluation of a fixation technique with metal-free all-suture cerclage vs. cortical screws

BACKGROUND

To reduce hardware-related complications in coracoid graft fixation to the anterior aspect of the glenoid, a metal-free Latarjet technique was recently introduced. The aim of this study was to compare the primary stability of a classic Latarjet procedure with 2 metal screws to a novel metal-free, all-suture cerclage method. It is hypothesized that fixation of the coracoid graft with 2 malleolar screws will provide higher primary stability compared with an all-suture cerclage technique.

METHODS

This biomechanical in vitro study was conducted on 12 fresh-frozen cadaveric shoulders (6 matched pairs) with a mean donor age of 80 years (range, 67-89 years). Coracoid graft fixation was performed using a recently introduced all-suture cerclage technique (group A) or a classic Latarjet technique with two 4.5-mm malleolar screws (group B). The conjoint tendon was loaded with a static force of 10 N to simulate the sling effect. Graft loading with a probe head consisted of 6 ascending load levels (10-50 N, 10-100 N, 10-150 N, 10-200 N, 10-250 N, and 10-300 N) with 100 cycles each at 1 Hz. Relative motion of the bone graft to the glenoid was measured using an optic 3-dimensional system.

RESULTS

While loading the conjoint tendon with 10 N, no difference in mean displacement of the bone-graft was found between both groups (P = .144). During cyclic loading, a significant difference in relative displacement for both groups was already detected in load level 1 (group A: 2398.8 μm vs. group B: 125.7 μm; P = .024), and this trend continued with the following load levels (P < .05).

DISCUSSION AND CONCLUSION

The study demonstrated that the innovative metal-free, all-suture cerclage fixation technique results in higher micromotion than the classic coracoid graft fixation with 2 malleolar screws. According to the present biomechanical investigation, shoulders treated with a metal-free all-suture cerclage technique might need adapted rehabilitation protocols to protect the construct and allow for graft healing.

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.

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.

Arthroscopic Distal Clavicle Bone Bock Combined With Hill-Sachs Remplissage for Primary Anterior Shoulder Instability Treatment

Arthroscopic distal clavicle transfer is an effective option to treat anterior shoulder instability with glenoid bone loss. The use of this free bone graft in an all-inside procedure, with a cortical button fixation makes the construct simpler to perform and allows to be combined with a Hill-Sachs Remplissage to address humeral bone defect. The morbidity of the donor site is low and provide the biologic capacity of an autograft. We report a step-by-step procedure, and the rationale are discussed.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up

BACKGROUND

Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management.

METHODS

Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed.

RESULTS

This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030).

CONCLUSION

At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

What keeps a shoulder stable - Is there an ideal method for anterior stabilisation?

The gleno-humeral joint is by far the most mobile in the human body but also afflicted by dislocations, predominantly anterior. Surgical stabilisation is often successful but failures not uncommon. The following review describes potential causes of failure and highlights the need of adapting surgical methods to pathomorphology.

Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review

PURPOSE

To systematically review the current evidence in the literature to compare return to play following arthroscopic Bankart repair versus open Latarjet procedure for the treatment of anterior shoulder instability.

METHODS

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies reporting return to play following arthroscopic Bankart repair versus open Latarjet procedure were included. Return to play was compared, with all statistical analysis performed using Review Manager, Version 5.3.

RESULTS

Nine studies with 1,242 patients (mean age: 15-30 years) were included. The rate of return to play was 61% to 94.1% among those undergoing arthroscopic Bankart repair and 72% to 96.8% in those undergoing an open Latarjet procedure. Two studies (Bessiere et al. and Zimmerman et al.) found a significant difference in favor of the Latarjet procedure (P < .05 for both, I2 = 37%). The rate of return to play at preinjury level was 9% to 83.8% among those undergoing arthroscopic Bankart repair and 19.4% to 80.6% in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 0%). The mean time of return to play was 5.4 to 7.3 months among those undergoing arthroscopic Bankart repair and 5.5 to 6.2 months in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 39%).

CONCLUSIONS

Overall, the majority of studies showed no significant difference in rates of return to play or timing following arthroscopic Bankart repair or open Latarjet procedure. Furthermore, no study has found a significant difference in rate of return to play at pre-injury level, or rate of return to play among collision athletes.

LEVEL OF EVIDENCE

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

Outcomes of Arthroscopic Latarjet as a Revision Surgery After Failed Arthroscopic Bankart Repair

BACKGROUND

The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established.

PURPOSE

To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure.

DESIGN

Cohort study; Level of evidence, 3.

METHODS

This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed.

RESULTS

A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group (P = .14). Patients in the revision group had a lower return to the previous level of sports participation (P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group (P = .000).

CONCLUSION

Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected.

Editorial Commentary: Both Bristow and Latarjet Procedures Result in Low Rates of Recurrent Shoulder Instability Despite Potential for Bone Resorption and Lack of Graft Healing

Anterior shoulder instability surgery has evolved over the decades, including both anatomic and nonanatomic repairs and reconstructions. Surgeons are continually advancing their skills and performing more of these procedures using arthroscopic as opposed to open techniques in patients with and without glenoid bone loss. However, there is a steep learning curve and increased technical demands when performing these procedures arthroscopically. Despite high success rates, bone graft resorption or lack of healing after Latarjet and Bristow procedures is well documented, and it is possible that patients develop enough scarring that their shoulders remain stable. Osteoarthritis after these nonanatomic procedures can occur making shoulder arthroplasty and reconstruction technically more challenging because of scarring and the altered anatomy. It remains to be seen whether these arthroscopic techniques as opposed to open surgery lessen the scarring and thus the technical demands of shoulder reconstruction in the small subset of patients who unfortunately develop symptomatic shoulder osteoarthritis. Therefore, in my practice, these techniques are carefully chosen for select patients. My indications for use of the Bristow procedure as a primary procedure for anterior shoulder instability are in patients who perform mixed martial arts fighting and high-level wrestlers without significant glenoid or humeral bone loss. My indications for the Latarjet procedure are in patients with chronic anterior instability and associated anterior glenoid bone loss 15% to 30%, off-track Hill-Sachs lesions, and revision surgery, particularly in high-demand contact and collision athletes. These 2 arthroscopic procedures, despite being nonanatomic, provide surgeons with excellent treatment options for those difficult patients with anterior shoulder instability. Despite high success rates with these arthroscopic procedures, patients should be counseled on the risks of graft resorption, graft nonunion, and possible shoulder osteoarthritis. The appropriate indications for these arthroscopic procedures can enhance the successful outcomes for high-risk patients with shoulder instability while also considering the possible long-term impacts of altering shoulder anatomy and scarring in the rare patient who develops shoulder osteoarthritis.

Clinical Outcomes, Union Rates, and Complications of Screw Versus Button Fixation in the Bristow-Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review and Meta-Analysis

Background

The Latarjet procedure is a common procedure for treating critical glenoid bone loss in anterior shoulder instability. Implants such as the screw and cortical button are widely used. The aim of this study was to compare studies on screw versus button fixation techniques in the Bristow-Latarjet procedure for anterior shoulder instability in terms of clinical outcomes, union rates, and complications.

Methods

The PubMed, Scopus, and Embase databases were searched to find comparative studies that reported outcomes of using screw versus button fixation in the Bristow-Latarjet procedure following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies that directly compared the screw and button fixation techniques and provided postoperative patient-reported outcomes, union rates, or complications were included. The Methodology Index for Non-Randomized Research (MINORS) criteria were used to assess the quality of the included studies. Odds ratios (ORs) were calculated for dichotomous outcomes whereas mean differences were calculated for continuous outcomes.

Results

Five articles included a total of 877 shoulders. All five studies had level 3 evidence. There was no statistically significant difference between the two techniques using the Walch-Duplay score, visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, range of motion, and graft union rates. However, the button fixation technique had statistically significantly higher recurrence rates than the screw fixation technique (OR, 0.24; 95% confidence interval, 0.10-0.58; p = 0.001).

Conclusions

The screw fixation technique had statistically significantly lower recurrence rates than the button fixation technique. However, there was no significant difference between screw and button fixation techniques regarding postoperative patient-reported outcomes, range of motion, graft union rates, nerve injury rates, infection rates, and reoperation rates.

Evaluation of Screws Positioning in Latarjet Surgery: Is There a Correlation between Parallelism to Glenoid and Radiographic Complications?

Objective  To evaluate whether the parallelism of screws with glenoid in Latarjet surgery interferes in the positioning of the graft and to verify the reproducibility of a method of measuring screws positioning. Methods  Retrospective, multicenter study, of patients with anterior shoulder instability submitted to modified Latarjet surgery and at least one year of postoperative follow-up. Two radiologists analyzed the postoperative tomographic images, acquired in a database, to evaluate the positioning of screws and radiographic complications. Results  We evaluated 34 patients, aged between 21 and 60 years, one of them with bilateral shoulder involvement, totaling 35 shoulders evaluated. The tomographic evaluation of the inclination angles of the screws showed no difference between the observers. There was intra- and interobserver agreement to evaluate the following surgical parameters: graft position, presence or not of radiographic complications. Conclusion  The technique described for measuring the parallelism of screws in Latarjet surgery presented a very good and excellent intra-observer agreement, respectively. Screw parallelism with glenoid is recommended; however, it is not a mandatory and unique condition to avoid radiographic complications.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

PURPOSE

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure.

METHODS

Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up.

RESULTS

No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P = .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P = .030 and P = .034, respectively).

CONCLUSIONS

Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Arthroscopic Latarjet procedure: current concepts and surgical techniques

The Latarjet procedure is a surgical procedure that can effectively restore glenohumeral stability, especially in patients with anterior shoulder instability and glenoid bone loss. Many studies have shown comparable clinical outcomes between patients undergoing the arthroscopic Latarjet procedure and those undergoing traditional open methods or other glenohumeral joint stabilization procedures. However, the arthroscopic Latarjet procedure is a challenging technique due to the unfamiliar portal placements, proximity of neurovascular structures, and serious postoperative complications. The arthroscopic Latarjet procedure has not yet been widely applied, and a clear understanding of the anatomical structure and the precise methods is required prior to operation performance. Satisfactory clinical outcomes can be achieved by thorough preoperative planning and proper implant fixation methods.

Modified Dynamic Anterior Stabilization and Labroplasty for Anterior Shoulder Instability With Concomitant SLAP Lesion

Several arthroscopic techniques to treat anterior shoulder instability have been described. Bankart repair may be insufficient in cases with some degree of bone loss, and arthroscopic Latarjet is technically challenging. It is not rare to find at the time of surgery a more extensive labral tear (SLAP lesion) or an insufficient anterior capsulolabral tissue. We describe for those cases a dynamic anterior stabilization where using the long head of the biceps we are treating the SLAP lesion and at the same time it provides the "sling effect" of a Latarjet procedure for the anterior instability.

Global variations in treatment and outcomes reported for anterior shoulder instability: a systematic review of the literature

Background

Anterior shoulder instability is a common problem around the world, with a high risk for recurrence following the index dislocation. Surgical stabilization is commonly indicated for persistent instability, particularly in patients at high risk for recurrence, to minimize the risk of further labral injury and glenoid bone loss. However, there is little known about global geographic differences in the surgical management of anterior shoulder instability. As such, the purpose of this study was to evaluate and systematically review regional differences in the surgical treatment of anterior shoulder instability, particularly the indications for and outcomes from bony stabilization procedures compared to soft tissue procedures.

Methods

A systematic review, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was performed. Inclusion criteria consisted of level I and II evidence studies evaluating indications, techniques, and outcomes following operative management of anterior shoulder instability published from January 2000 to September 2021. Studies meeting inclusion criteria were grouped into four global regions (Asia, Europe, North America, South America) based on primary study location. Patient demographics, procedural details, patient reported outcomes, and complications (recurrence and reoperation rates) were compared between regions.

Results

Sixty (n = 60) studies (5480 patients) were identified. Eighty-six percent of all patients were male, with a mean age of 26.7 years. There was no difference in mean patient age, though patients undergoing bony stabilization procedures were older than those undergoing soft-tissue stabilization procedures (P = .0002) in all regions. The proportion of bony versus soft-tissue procedure groups did not differ significantly among regions. The indications for bony stabilization procedures varied significantly. Mean final follow-up was 3.5 years. Recurrent instability was 5.0% and did not vary across regions. However, recurrent instability occurred more frequently following soft-tissue compared to bony stabilization procedures (P = .017). South American studies utilized fewer anchors during soft tissue stabilization (P < .0001) and reported a higher reoperation rate compared to other regions (P = .009).

Conclusion

There is global variation in the reporting of outcomes following surgery for anterior shoulder instability. The proportion of bony and soft-tissue procedures is similar, irrespective of geographic region. Recurrent instability does not vary by region but occurs more frequently following soft-tissue compared to bony stabilization procedures. There are a number of potential medical and nonmedical factors that may affect global variation in the surgical treatment of anterior shoulder instability.

Fully Arthroscopic Pectoralis Minor Tendon Transfer with Bone Fragment for Irreparable Subscapularis Tears

Several techniques to treat irreparable subscapularis (SSC) tendon tear have been described. We introduce a fully arthroscopic technique for pectoralis minor tendon with bone fragment transfer. This procedure starts with glenohumeral exploration and evaluation of the remaining SSC mobility. Then we detach and release the pectoralis minor (PMi) tendon with bone fragment from the coracoid, protecting the plexus structures. Next, the PMi tendon with bone fragment is fixed on the lesser tuberosity passing under the coracoid. This procedure is technically demanding and could be performed safely with low invasiveness and high reproducibility by understanding the regional anatomy and the well-described technique.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer

PURPOSE

Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts.

METHODS

A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded.

RESULTS

177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.).

CONCLUSION

The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates.

LEVEL OF EVIDENCE

Level II.

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.