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

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.

Distal Tibial Allograft for the Treatment of Shoulder Instability Provides Excellent Results with Low Rates of Recurrent Instability - A Systematic Review of Clinical and Biomechanical Studies

PURPOSE

The purpose of this study was to systematically review the literature to evaluate the clinical and biomechanical results of distal tibial allograft (DTA) for shoulder instability.

METHODS

A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical and biomechanical studies reporting DTA for shoulder instability were included. Qualitative and quantitative data were evaluated.

RESULTS

A total of nine clinical and seven biomechanical studies were included. A total of 341 patients with average age from 25.5 to 31 were included in the clinical analysis. Cohorts ranged from 61.9% to 100% male and average glenoid bone loss ranged from 20% to 33%. The recurrent dislocation rate following DTA ranged from 0% to 2.0%. Preoperative mean Single Assessment Numeric Evaluation (SANE) scores ranged from 32.2 to 50, while postoperative scores ranged from 85 to 91. Preoperative mean American Shoulder and Elbow Score (ASES) scores ranged from 40 to 63, while postoperative scores ranged from 90.5 to 92. Postoperative forward flexion ranged from 156.8° to 177°. Union rate on post-operative CT scan was 90.3% to 100%, with significant reportion (over 50%) ranging from 8.1-16%. Biomechanical studies demonstrated that the DTA resulted in improved contact pressures, contact areas, and stability when compared to those with simulated glenoid bone loss.

CONCLUSION

The literature on DTA for the management of anterior shoulder instability with glenoid bone-loss shows overall excellent results with low rates of recurrent instability, and high patient reported outcomes. Biomechanical studies demonstrate that glenoid reconstruction with DTA provides near anatomic reconstruction leading to increased stability, improved contact area, and decreased loading pressures.

CLINICAL RELEVANCE

The findings of the biomechanical review demonstrate that DTA provides highly congruent grafts for glenoid reconstruction. This is important for short term outcomes including re-dislocations and PRO's, as well as longer term outcomes including osteoarthritis. Our review of Level III and IV clinical studies shows the clinical implications with low rates of recurrent instability and high patient reported outcomes.

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.

Long head of biceps as an anterior dynamic sling for recurrent anterior shoulder dislocation

PURPOSE

To evaluate the functional outcomes of arthroscopic onlay dynamic anterior stabilization (DAS) using the long head of the biceps (LHB) tendon for treatment of anterior glenohumeral instability (AGI) with limited to subcritical glenoid bone loss (GBL).

METHODS

Twenty-five patients underwent arthroscopic DAS using LHB tendon between March 2022 and October 2022 for treatment of anterior glenohumeral instability (AGI) with limited to subcritical glenoid bone loss (GBL) were included in a prospective study with a minimum follow-up period of 2 years. The shoulder functional outcomes were assessed using the Rowe and the Quick Disabilities of Arm, Shoulder and Hand (Quick DASH) scores both preoperative and at 2 years follow-up. Magnetic resonance imaging (MRI) was done 6 months after surgery to evaluate LHB tendon healing to the anterior glenoid.

RESULTS

The study included 25 patients complaining of recurrent AGI. Twenty-one patients were males and four patients were females. The mean age of the patients at surgery was 22.75 ± 3.24 years. The mean duration between the first shoulder dislocation episode and surgery was 5.5 ± 2.13 months. The right shoulder was injured in 15 patients while the left shoulder was involved in 10 patients. The mean follow-up period was 24.25 ± 0.82 months. DAS using the long head of the biceps tendon resulted in a statistically significant improvement of the mean Rowe and the Quick DASH scores between preoperative and 2 years postoperative. Recurrent dislocation was reported in two (8%) patients during the follow-up period.

CONCLUSION

Arthroscopic onlay dynamic anterior stabilization using the long head of the biceps tendon is a safe and effective method for the treatment of recurrent anterior shoulder instability with GBL up to 25%.

LEVEL OF EVIDENCE

Level IV, case series study.

Assessment of Primary Stability and Micromotion of Different Fixation Techniques for Scapular Spine Bone Blocks for the Reconstruction of Critical Bone Loss of the Anterior Glenoid-A Biomechanical Study

Anteroinferior shoulder dislocations require surgical intervention when related to critical glenoid bone loss. Scapular spine bone blocks have emerged as a promising alternative to traditional bone augmentation techniques. However, limited data exist on their biomechanical stability when using different suture-based fixation techniques. This study aimed to evaluate primary stability and micromotion after glenoid augmentation using a scapular spine bone block. A total of 31 fresh-frozen human shoulder specimens underwent bone block augmentation. The specimens were randomized into three groups: double-screw fixation (DSF), single-suture bone block cerclage (SSBBC), and double-suture bone block cerclage (DSBBC). Biomechanical testing was conducted using cyclic loading (5000 cycles at 1 Hz) and micromotion was analyzed using an optical 3D measurement system. Statistical analysis showed that medial irreversible displacement was significantly greater in the SSBBC group compared to DSF (p = 0.0386), and no significant differences were found in anterior or inferior irreversible displacements. A significant difference was noted in posterior reversible displacement (p = 0.0035), while no differences were found in inferior or medial reversible displacements. Between DSF and DSBBC, no significant differences were found in irreversible or reversible displacements in any direction. DSBBC provided stability comparable to DSF while offering a viable metal-free alternative. In contrast, SSBBC displayed inferior biomechanical properties, raising concerns about its clinical reliability.

IODA-shoulder®, a 3-dimensional automated software for glenoid bone loss quantification in shoulder instability. A validation study

BACKGROUND

Glenoid bone loss (GBL) calculation in patients with shoulder instability has a wide variability in methods and their reliability. The purpose of this study was to describe and validate a new semi-automated software developed to improve GBL calculation using a 3D imaging modeling (IODA-shoulder) and to compare the method to the PICO area method.

PATIENTS AND METHODS

A semi-automated software to assess GBL was preliminarily developed and validated on 7 fresh frozen specimens (scapulae with artificially created glenoid defect), using water displacement method. Afterwards, the software was retrospectively used on CT images of 20 patients affected by recurrent shoulder dislocation. Inclusion criteria were: unilateral dislocation, minimum 2 dislocation episodes. Exclusion criteria were bone reconstruction of the glenoid, failed shoulder stabilization, bilateral dislocation, shoulder arthritis. Three-dimensional computed tomography images of bilateral shoulder were retrieved for each patient. Two methods to determine GBL were compared. The PICO surface area method and the new IODA method. We assessed the intra- and inter-rater reliability of the two methods with the Intraclass Correlation Coefficient (ICC), the Bland-Alman analysis, and Lin's concordance correlation coefficient (CCC).

RESULTS

We did not find a statistically significant difference between the mean volumes calculated with PICO and IODA methods, respectively 914 vs. 815 mm3, p=0.155. The analysis carried out by using the traditional PICO method showed a lower concordance rate among four observers than the higher concordance found using IODA method, regardless of the size and the location of the defect. The ICC agreement with PICO was significantly lower than with IODA (0.76 vs. 0.97). We found a poor CCC with PICO (from 0.65 to 0.81) and a substantial one with IODA (from 0.96 to 0.98).

DISCUSSION

The intra- and inter-rater reliability using IODA method is significantly better than PICO method. The assessment of GBL using IODA method is time saving, avoiding significant inter- and intra-observer variation, mainly due to individual skill and experience in the method.

LEVEL OF EVIDENCE

IV, experimental study.

Postoperative Variations in Shoulder Biomechanics and Kinematics in the Abduction and External Rotation Position After Remplissage With Bankart Repair for Anterior Glenohumeral Instability: A Finite Element Analysis

Background

Remplissage with Bankart repair (RMBR) is an arthroscopic procedure performed on <25% of Bankart lesions with off-track Hill-Sachs lesions (HSLs) that alters the insertion of the infraspinatus muscle into the humeral head. However, the effects of RMBR surgery on humeral head displacement due to changes in biomechanics and kinematics have not been fully elucidated.

Purpose

To evaluate how the biomechanical and kinematic effects of the post-RMBR glenohumeral joint influence humeral head displacement using the finite element analysis (FEA) method.

Study Design

Controlled laboratory study.

Methods

Biomechanical and kinematic experiments were performed on 24 established finite element (FE) models, which included 12 normal glenohumeral joint models and 12 post-RMBR glenohumeral joint models at the abduction and external rotation (ABER) position. FEA was used to compute the total displacement of the humeral head during passive anteroinferior loading and active contraction of the infraspinatus muscle.

Results

Under passive anteroinferior loading, the humeral heads showed less total anterior displacement after RMBR than did normal glenohumeral joints in the ABER position (1.94 ± 0.48 vs 5.19 ± 1.91 mm; P = .003). When the infraspinatus muscle was stimulated to contract, the humeral heads of post-RMBR glenohumeral joints exhibited greater total posterior displacement in the ABER position than did the normal glenohumeral joints (4.22 ± 0.23 vs 2.44 ± 0.56 mm; P < .001).

Conclusion

Displacement of the humeral head is influenced by changes in the insertion of the infraspinatus tendon after RMBR surgery, which consequently affects the lever arm and torque generated by the infraspinatus muscle on the humeral head.

Clinical Relevance

The FEA results confirmed that a change in the insertion of the infraspinatus tendon alters the lever arm and torque produced by the infraspinatus muscle on the humeral head. This leads to changes in the displacement of the humeral head in the ABER position after the RMBR procedure. These findings deepen the understanding of RMBR surgery in clinical practice and can assist physicians in deciding whether to choose this surgical approach in patients with combined HSL.

Outcomes of an anterior bone block technique with iliac crest allograft for the management of anteroinferior shoulder instability with subcritical glenoid defects

BACKGROUND

Glenoid bone defects play a significant role in anterior shoulder instability. Their management is controversial, and the use of anterior bone grafting is one appealing option. The purpose of this study is to assess the clinical and radiologic outcomes at a 5-year follow-up of an arthroscopic bone block procedure with iliac crest allograft for the management of subcritical glenoid bone loss in subjects with recurrent anterior shoulder instability.

METHODS

Prospective longitudinal study of a consecutive case series of subjects with anterior glenohumeral instability and subcritical (between 8% and 17%) glenoid bone defects managed with an arthroscopic bone block procedure with iliac crest allograft fixed with a double-button system associated with a Bankart repair and, when necessary, a remplissage. Preoperative computed tomographic (CT) scans were used to quantify the dimensions of the glenoid and the humeral bone defects. Postoperative CT scans 1 month after surgery and at 1-year follow-up were used to assess the graft's positioning, integration, and resorption. Clinical assessment was performed using the Constant-Murley (CS) and Rowe (RS) scores preoperatively and at a minimum 3-year follow-up.

RESULTS

Fourteen subjects were included (all male, median age 27 years, interquartile range [IQR] = 5.75), with a median of 8 (IQR = 14) dislocation episodes before surgery and a median preoperative glenoid bone defect of 13% (IQR = 14%, range: 9.3%-15.4%). A remplissage was added in 12 of 14 cases (85.7%). Graft position was excellent in all cases (100%) in the axial plane and in 12 of 14 (85.7%) in the sagittal plane. The median reconstructed glenoid surface in the postoperative CT scan was 99.4% (IQR 2.1%, range: 96.6%-100%). One-year postoperative CT scans showed bone resorption of ≥20% of volume in 13 of 14 cases (93%), with a median resorption of 80.3% (IQR = 40.8%) of the graft volume. Graft integration was observed in 6 of 14 cases (42.8%). The median reconstructed glenoid surface decreased to 93.6% (IQR = 2%, range: 87.5%-97.3%) (P < .0001). At the latest follow-up (58.9 months [IQR = 11.2]: range: 39.6-67.8), 2 subjects (14.3%) presented with recurrence of instability. There were substantial improvements in the RS (from 25 [5] to 95 [6.2], P < .0001) and in the CS (from 84 [5] to 94.5 [4.2] points, P < .0001) at the final follow-up.

CONCLUSIONS

Arthroscopic bone block procedure employing an iliac crest allograft achieves accurate graft positioning and good clinical outcomes with low recurrence rates at a mean of 5-year follow-up. However, early graft resorption and low consolidation rates are worrisome issues that must be considered.

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.

Arthroscopic shoulder instability surgery in patients under 25 years of age: the key role of soft tissue with both anterior and posterior axillary hammock tensioning

BACKGROUND

The arthroscopic treatment of shoulder instability is widely debated in the literature and includes very different surgical techniques. Imaging techniques do not allow an accurate assessment of soft tissue quality. The aim of the study is to demonstrate that correct patient selection and a surgical technique involving anterior and posterior capsular ligament repair with axillary retention may be the most crucial factors for successful arthroscopic treatment.

METHODS

Patients with recurrent shoulder instability who underwent arthroscopic stabilization between 2014 and 2015 and aged between 15 and 25 years, were included. The minimum follow-up was 5 years. Specific exclusion criteria were critical bone loss and patients with genetic connective tissue disorders. Demographics, instability characteristics, surgical procedures, recurrences, both dislocations and subluxations, and surgical revisions were evaluated. The surgical procedure, always performed by the same surgeon, involved the use of a minimum of 3 double-suture fixation devices and repair/tensioning of the axillary hammock. Statistical analysis was based on the non-parametric Kendall statistical model and proportions test, with p < 0.05.

RESULTS

The study population consisted of 44 patients. The first dislocation occurred in 61.4% of cases between the ages of 15 and 19. The number of dislocations prior to surgery was < 3 in 29.5%, between 3 and 9 episodes in 25%, and 10 or more episodes in 45.5%. Defined by patients who had no recurrent dislocations and those whose symptom of instability or subluxation did not require surgical revision, the surgical success rate was 90.9%. During the follow-up period, 4.5% of patients required surgical revision. Patients who required none or one reduction maneuver or had less than three dislocation episodes were statistically correlated with no recurrences after surgery. After the first dislocation, the 88.6% of patients had recurrency. Furthermore, if treated after only one episode, 75% of patients were affected by an isolated capsulolabral injury. Prompt stabilization surgery allows a simpler procedure, due to a reduced bone damage and associated injuries.

CONCLUSIONS

Even in a high-risk age group under 25 years, when the bone defect is subcritical, performing a standardised surgical technique including antero-posterior capsulolabral repair with axillary hammock retensioning demonstrates high success rates. Patients who correlate with the highest chance of success are those who have had less than three dislocation episodes and who have not undergone reduction manoeuvres, confirming the importance of soft tissue quality and thus of early treatment.

TRIAL REGISTRATION

Retrospectively registred.

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.

Good clinical outcomes and low recurrence rate in patients undergoing arthroscopic revision Latarjet for failed arthroscopic Bankart repair

BACKGROUND

The role of arthroscopic Latarjet stabilization after failed arthroscopic Bankart repair has yet to be definitively established and merits further investigation.

OBJECTIVE

To assess clinical and radiological outcomes after arthroscopic Latarjet stabilization as a revision procedure for failed Bankart repair, as well as the return to athletic activity and complication rates.

METHODS

Between 2009 and 2020, patients with a previous failed arthroscopic Bankart repair who were treated with an arthroscopic Latarjet were retrospectively evaluated. Clinical outcomes at a minimum of 24 months postoperatively included the Rowe score, Western Ontario Shoulder Instability Index, Constant-Murley Shoulder Outcome score, and Single Assessment Numeric Evaluation. Dislocations, subluxations, complications, pre- and postoperative levels of activity, and degree of osteoarthritis were also assessed.

RESULTS

A total of 77 patients, with a mean age at revision surgery of 31.2 ± 9.1 years and with either 1 (n = 59), 2 (n = 13), or 3 (n = 4) previous arthroscopic stabilizations, who underwent revision surgery using an arthroscopic Latarjet procedure were studied. Postoperatively, the mean Rowe and Constant-Murley Shoulder Outcome scores increased from 41.8 ± 16 to 90.7 ± 14.3 (P < .001) and from 50.5 ± 13.8 to 90.5 ± 10.3 (P < .001), respectively. Western Ontario Shoulder Instability Index decreased from 1247 ± 367.6 to 548.9 ± 363 at the final follow-up (P < .001). After a mean follow-up of 39.6 ± 23.1 months, 64 shoulders (83.1%) were subjectively graded as good to excellent using the Single Assessment Numeric Evaluation score. Grade 1, 2, and 3 osteoarthritis, according to Ogawa et al, was found in 18 (23.4%), 6 (7.8%), and 3 (3.9%) shoulders, respectively. Six (7.8%) dislocations after revision surgery were reported. In 4 failed cases, an Eden-Hybinette procedure was conducted, and in the remaining 2 patients, an arthroscopic extra-articular anterior capsular reinforcement was performed. A significantly decreased level of athletic activity was observed postoperatively (P = .01).

CONCLUSIONS

Arthroscopic Latarjet for the revision of failed arthroscopic Bankart repair provides satisfactory patient-reported subjective outcomes with a low rate of recurrences and complications. However, a decreased level of athletic activity is expected.

Additional Scapular Spine Bone Grafting Combined with Bankart and Remplissage for Off-Track Hill-Sachs Lesions with Subcritical Glenoid Bone Loss: Provides Better Stability

PURPOSE

Arthroscopic Bankart repair combined with remplissage and autologous scapular spine bone grafting have been described as a treatment for off-track Hill-Sachs lesions with subcritical glenoid bone defects in the anterior shoulder instability. However, whether these two techniques can achieve satisfactory postoperative outcomes is unclear, and there are few comparative studies between them. Therefore, this study compared the postoperative efficacy of the two techniques for off-track Hill-Sachs lesions with subcritical glenoid bone loss.

METHOD

Between June 2017 and December 2020, 62 patients with shoulder instability due to Off-Track Hill-Sachs lesions with subcritical glenoid bone loss underwent surgical treatment and were included in this regression study. Thirty-two patients underwent arthroscopic Bankart repair combined with remplissage (B + R group), and 30 patients underwent additional autologous scapular glenoid bone grafting (additional bone grafting group). The general information of the patients was recorded. The patient's activity before and after surgery was recorded. The DASH score and Constant-Murley (CM) score were used to assess the patient's functional status; the Rowe score was used to evaluate the patient's shoulder stability. The shoulder function and stability before and after surgery were analyzed and compared between the two groups.

RESULTS

The final DASH scores of the B + R group and the additional bone grafting group were significantly lower than those before surgery, with a statistically significant difference (9.76 ± 4.32 vs. 27.89 ± 6.63, 8.50 ± 3.32 vs. 28.0 ± 4.27, p = 0.000); the final CM scores of the two groups were significantly higher than those before surgery (88.71 ± 3.74 vs. 73.68 ± 3.74, 87.16 ± 2.29 vs. 71.37 ± 2.68, p = 0.000). There was no statistical difference in the final DASH score and final CM score between the two groups (p > 0.05). In terms of postoperative stability, the final Rowe scores of the two groups were significantly higher than those before surgery, with a statistically significant difference (89.06 ± 9.19 vs. 41.71 ± 4.13; 93.16 ± 4.99 vs. 42.33 ± 2.53, p = 0.000). Compared with the control group, the additional bone graft group achieved higher final Rowe scores (93.16 ± 4.99 vs. 89.06 ± 9.19, p = 0.032).

CONCLUSION

For patients with anterior shoulder instability due to off-track Hill-Sachs lesions with subcritical glenoid bone loss, although Bankart and remplissage can achieve satisfactory clinical results, additional autogenous scapular spine bone grafting can provide better stability of the shoulder, especially for patients with high sports demands.

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.

Management of bone loss in anterior shoulder instability

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Graft Position, Healing, and Resorption in Anterior Glenohumeral Instability: A Comparison of 4 Glenoid Augmentation Techniques

Background

The success of glenoid augmentation procedures depends on accurate placement and healing of the graft to the glenoid. Different glenoid augmentation techniques have been described, but no comparative studies between them exist.

Purpose

To assess the bone graft position, healing, and resorption in a group of patients treated with 1 of 4 procedures: arthroscopic anterior bone-block procedure using either (1) fresh-frozen iliac crest allograft or (2) iliac crest autograft, (3) open Latarjet, or (4) arthroscopic Latarjet.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 40 patients (87.5% men; mean age, 29.5 ± 7.9 years) were included, with 10 patients in each of the procedure groups. The graft position in the axial and sagittal planes was assessed on postoperative computed tomography (CT). Graft healing and resorption were assessed in a second CT scan performed 1 year postoperatively. Qualitative variables were compared between the 4 procedures using the chi-square test, and quantitative variables were compared with the Student t test or Mann-Whitney U test.

Results

No differences were found between the procedures in the axial or sagittal position. The healing rate was significantly lower in the allograft bone-block group (20%) compared with the autograft bone-block (80%), open Latarjet (90%), and arthroscopic Latarjet (90%) groups (P < .001). Graft resorption developed in 17 of 40 (42.5%) cases overall. Osteolysis occurred in 100% of cases in the allograft bone-block group compared with 50% in the autograft group, 20% in the open Latarjet group, and 0% in the arthroscopic Latarjet group (P < .001). The glenoid surface area on 1-year CT scan was significantly lower in the allograft bone-block group compared with the autograft bone-block, open Latarjet, and arthroscopic Latarjet groups (P < .001).

Conclusion

Arthroscopic bone-block, open Latarjet, and arthroscopic Latarjet procedures provided accurate bone graft positioning. However, very high rates of osteolysis and nonunion were observed in the iliac crest fresh-frozen allograft bone-block procedure when compared with the other procedures.

Suture Button Fixation in Latarjet Has Similar Load to Failure and Clinical Outcomes but Lower Bone Resorption Compared With Screw Fixation: A Systematic Review

PURPOSE

To compare the 2 Latarjet fixation techniques-screw fixation (SF) versus suture button (SB) -for clinical, biomechanical, and radiologic outcomes.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic and Meta-Analyses guidelines using MEDLINE and Embase databases and was prospectively registered on PROSPERO. Only comparative clinical and biomechanical studies of Latarjet with SF and SB were included. Studies were appraised using the Methodical Index for Non-Randomised Studies (MINORS) tool.

RESULTS

Eleven studies met eligible criteria: 7 clinical studies (SB, n = 279; SF, n = 845) and 4 biomechanical. In total, 80.9% (SB) and 84.2% (SF) of patients were male. Follow-up ranged from 6 to 63.6 months. The overall recurrent instability rate for SB ranged from 0 to 8.3% and for SF ranged from 0 to 2.75%. Only one study demonstrated a greater recurrent instability rate with SB (P = .02). Overall SB complication rates ranged from 0 to 12.5% and SF ranged from 0 to 27%. Two studies reported greater complications and reoperations with SF related to hardware. Summary forest plots from 4 studies showed no significant difference in Walch Duplay score (mean difference, range -5.00 to 1.20 [95% confidence interval {CI} -12.13 to 8.56], I2 inconsistency = 0%), Rowe score (mean difference, range -2.00 to 4.00 [95% CI -7.37 to 7.66], I2 inconsistency = 45%), and VAS for pain (mean difference, range -0.10 to 0.60 [95% CI -0.72 to 1.33], I2 inconsistency = 0%). There was no statistically significant difference between SB and SF in the postoperative range of motion. Radiologically, there was no significant difference in graft positioning and union at final follow-up, but graft resorption was greater in SF (range 25.2%-47.6%) compared with SB (range 10.1%-18.5%). Biomechanical studies showed no significant difference in maximum load to failure (SB, range 184-266 N vs SF, range 148-288 N).

CONCLUSIONS

Clinically, SB fixation demonstrated similar functional outcome and range of motion when compared with SF, with the potential benefit of lower rates of graft resorption and hardware-related complications. Biomechanically there was no difference in maximum load to failure.

LEVEL OF EVIDENCE

Level III, systematic review of Level III and biomechanical studies.

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.

Arthroscopic Autologous Iliac Bone Grafting With Double-Row Elastic Fixation and Double Antirotating Anchors for Recurrent Anterior Shoulder Dislocation With Massive Glenoid Bone Defect

The management of recurrent anterior shoulder dislocations with massive glenoid bone defects typically involves arthroscopic intervention. Autologous iliac bone grafting with double-row elastic fixation reportedly yields excellent outcomes. In this article, we introduce a specialized technique for iliac bone grafting that uses double-row elastic fixation and double antirotating anchors. Implementation of this technique prevents the occurrence of iliac graft rotation.

Controversies in surgical management of anterior shoulder instability. State of the Art

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

Efficacy and safety of the Latarjet procedure for the treatment of athletes with glenoid bone defects ≥ 20%: a single-arm meta-analysis

BACKGROUND

The shoulder joint is the most commonly dislocated joint in the human body, and the recurrence rate exceeds 50% after nonsurgical treatment. Although surgical treatment reduces the recurrence rate, there is controversy regarding the optimal surgical approach. Previous studies suggest that the Latarjet procedure yields favourable outcomes for specific populations at risk of recurrence, such as competitive athletes with significant glenoid defects. However, most of the existing related research consists of nonrandomized controlled trials with small sample sizes, and there is a lack of strong evidence regarding the efficacy and safety of the Latarjet procedure.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched. Athletes with ≥ 20% glenoid defects were selected for inclusion. The following data were extracted: general patient information, instability rates, return to sports (RTS) rates, imaging features (graft positioning rate and graft healing rate), functional assessments [Rowe score, Athletic Shoulder Outcome Scoring System(ASOSS), visual analogue scale (VAS), forward flexion function, and external rotation function], and complications.

RESULTS

After excluding suspected duplicate cases, a total of 5 studies were included in this meta-analysis. The studies involved a total of 255 patients, including 237 males (93%) and 18 females (7%). The average age at the time of surgery was 25.4 ± 8.5 years. All the studies had a minimum follow-up period of 2 years, with an average follow-up time of 48.7 ± 18.9 months. The pooled rate of return to sport (RTS) was 94.3% (95% CI: 87.3%, 98.8%), and 86.1% (95% CI: 78.2%, 92.5%) of patients returned to their preoperative level of activity. The pooled redislocation rate was 1.1% (95% CI: 0%, 3.8%). Regarding the imaging results, the combined graft retention rate was 92.1% (95% CI: 88.1%, 95.5%), and the graft healing rate was 92.1% (95% CI: 88%, 95.4%). Postoperative functional evaluation revealed that the combined Rowe score, ASOSS score, and VAS score were 93.7 ± 6.5 points, 88.5 ± 4.4 points, and 1.1 ± 10 points, respectively. The forward flexion and external rotation angles were 170.9 ± 6.9 degrees and 65.6 ± 4.5 degrees, respectively. After excluding one study with unclear complications, the combined complication rate was 9.4% (95% CI: 1.0%, 23.6%).

CONCLUSION

For athletes with shoulder instability and a total of ≥ 20% glenoid bone defects, the Latarjet procedure can achieve excellent functional outcomes, with the majority of patients returning to preoperative levels of sports activity. This procedure also leads to a low recurrence rate. Therefore, the Latarjet procedure has been proven to be a safe and effective treatment.

Significant Increase in Early Reoperation After Latarjet-Bristow Procedure Versus Arthroscopic Bankart Repair for Anterior Shoulder Instability: A Propensity-Score Matched Analysis

PURPOSE

To compare the 30-day outcomes, including length of stay, short-term complications, hospital readmission, all-cause reoperation, and death after arthroscopic Bankart (AB) and Latarjet.

METHODS

Patients in the National Surgical Quality Improvement Program database who had undergone either AB or Latarjet-Bristow (LB) procedures for anterior shoulder instability from 2012 to 2018 were identified using Current Procedural Terminology codes. Nearest neighbor propensity score matching was used to address any potential demographic differences. The 30-day incidence of postoperative complications were compared, and univariate and multivariate logistic regressions were used to identify risk factors associated with the incidence of post-operative complications.

RESULTS

A total of 7,519 patients were identified, with 6,990 (93.0%) undergoing AB and 529 (7.0%) LB. After propensity score matching, the baseline demographics were not significantly different (P > .05). There was no significant difference in rate of total adverse events between the AB and LB cohorts (P = .06). There was a significant difference in the rate of return to the operating room between LB (1.9%) when compared to AB (0%) (P < .001). Of reoperations, 40% were due to need for revision stabilization (0.8% of all LB cases) and 40% were for irrigation and debridement. There was also a significant difference in operative time (AB = 87 minutes, LB = 131 minutes; P < .0001).

CONCLUSIONS

Overall 30-day complication rates were low for both groups, with similar rates among AB and LB patients. However, there was a statistically significant increased rate of short-term reoperation or revision stabilization in the LB cohort.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

Bulk osteochondral allograft for massive Hill-Sachs defect combined with Latarjet procedure for bipolar bone loss in anterior instability

A proportion of patients with anterior glenohumeral instability present with bipolar bone loss comprising large Hill-Sachs lesions and substantial glenoid defect. These are surgically difficult cases to treat. We describe a novel surgical procedure of bulk size-matched osteochondral allograft reconstruction for massive Hill-Sachs lesions combined with the Latarjet procedure for these challenging cases.

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review

PURPOSE

To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up.

METHODS

A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale.

RESULTS

Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%.

CONCLUSIONS

The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

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

Characterizing the Practices of Canadian Orthopedic Surgeons in the Management of patients With Anterior Glenohumeral Instability

OBJECTIVE

To determine the practice patterns of Canadian orthopedic surgeons in the management of patients with anterior glenohumeral instability (AGHI).

DESIGN

Cross-sectional survey.

SETTING

Canada.

PATIENTS OR OTHER PARTICIPANTS

Canadian orthopedic surgeons with membership in the Canadian Orthopedic Association or Canadian Shoulder and Elbow Surgeon group who had managed at least 1 patient with AGHI in the previous year.

INTERVENTIONS

A survey including demographics and questions on the management of patients with AGHI was completed. Statistical comparisons (χ 2 ) were completed with responses stratified using the instability severity index score (ISIS) in practice, years of practice, and surgical volumes.

MAIN OUTCOME MEASURES

Summary statistics were compiled, and response frequencies were considered for consensus (75%). Case series responses were stratified on use of the ISIS in practice, years of experience, and annual procedure volumes (χ 2 , P < 0.05).

RESULTS

Eighty orthopedic surgeons responded, with consensus on areas of diagnostic workup of AGHI, nonoperative management, and operative techniques. There was no consensus on indications for soft tissue and bony augmentation or postoperative management. There was no difference in practices based on the use of ISIS, years in practice, or surgical volumes.

CONCLUSIONS

Canadian orthopedic surgeons manage AGHI consistently with consensus achieved in preoperative diagnostics and operative techniques, although debate remains as to the indications for soft tissue and bony augmentation procedures.

Assessment of micromotion at the bone-bone interface after coracoid and scapular-spine bone-block augmentation for the reconstruction of critical anterior glenoid bone loss-a biomechanical cadaver study

BACKGROUND

Glenoid bone loss is among the most important risk factors for recurrent anterior shoulder instability, and a bony reconstruction is recommended in cases of critical bone loss (> 15%). The commonly used surgical techniques, including coracoid transfer, are associated with considerable complications. The aim of this study was to assess the motion at the glenoid-bone-block interface after coracoid and spina-scapula bone-block reconstruction of the anterior glenoid.

METHODS

Twelve cadaveric shoulders were tested. A 20% bone defect of the anterior glenoid was created, and the specimens were randomly assigned for glenoid augmentation using a coracoid bone block (n = 6) or a scapular spine bone block (n = 6). The glenoid-bone interface was cyclically loaded for 5000 cycles with a force of 170 N. The micromotion was tracked using an optical measurement system (GOM ARMIS) and was evaluated with the GOM Correlate Pro software.

RESULTS

The most dominant motion component was medial irreversible displacement for the spina-scapula (1.87 mm; SD: 1.11 mm) and coracoid bone blocks (0.91 mm; SD: 0.29 mm) (n.s.). The most medial irreversible displacement took place during the first nine cycles. The inferior reversible displacement was significantly greater for spina-scapula bone blocks (0.28 mm, SD: 0.16 mm) compared to coracoid bone blocks (0.06 mm, SD: 0.10 mm) (p = 0.02).

CONCLUSIONS

The medial irreversible displacement is the dominant motion component in a bone-block reconstruction after a critical bone loss of the anterior glenoid. The spina-scapula and coracoid bone blocks are comparable in terms of primary stability and extent of motion. Thus, spina-scapula bone blocks may serve as alternatives in bony glenoid reconstruction from a biomechanical point of view.

Cadaveric Biomechanical Study of Partial Glenoid Arthroplasty Versus the Latarjet Procedure for Anterior Glenoid Bone Loss

BACKGROUND

For severe anterior glenoid bone loss due to recurrent shoulder instability, the Latarjet procedure offers a dynamic sling effect in addition to bone augmentation. Yet, it heavily alters the surrounding anatomy, while fixation and graft union issues are also common.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare a novel printed 3-dimensional (3D) partial glenoid arthroplasty (PGA) implant with the classic Latarjet procedure. It was hypothesized that by replicating the original glenoid geometry and preserving soft tissue anatomy, PGA may better reproduce normal joint kinematics. In addition, the locking screw construct may offer stronger fixation.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 14 matched cadaveric shoulders were tested. The PGA implant was 3D printed in titanium based on preoperative computed tomography. The intact, 25% anterior glenoid bone loss, and postoperative states were tested in the scapular and coronal planes. The following parameters were measured: articular surface area and stepoff, rotational range of motion and the humeral head apex position during rotation, and load and linear stiffness at 25% anterior translation and at 2-mm construct displacement.

RESULTS

The baseline dimensions of the glenoid articular surface were comparable between the groups. The articular surface area after PGA was significantly larger (P = .006) with less articular stepoff (P = .030). PGA better approximated the intact state's external (P = .006) and total (P = .019) rotational range of motion in the scapular plane. The course of the humeral head apex after PGA better followed that of the intact state (P < .001). Resistance against anterior translation after PGA was not significantly different compared with after the Latarjet procedure. Greater linear stiffness (P = .031) and loading (P = .002) at 2-mm construct displacement were demonstrated in the PGA group.

CONCLUSION

In addressing anterior glenoid bone loss, PGA better approximated intact glenohumeral joint kinematics compared with the Latarjet procedure with less articular stepoff in a cadaveric model. PGA was comparable in resisting anterior translation while being significantly stronger against loading at 2-mm construct displacement. Further clinical studies are warranted to validate this novel procedure.

CLINICAL RELEVANCE

A 3D-printed PGA implant may offer an alternative treatment option for severe glenoid bone loss due to shoulder instability, overcoming the previous drawbacks of the Latarjet procedure, including altered kinematics, fixation failure, and hardware issues.

Transglenoid Fixation Technique for Arthroscopic Subscapularis Augmentation Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

The optimal surgical management of anterior shoulder instability remains controversial. Although it has low recurrence rates and good clinical results, the Latarjet procedure has some disadvantages and is considered "overtreatment" in inactive patients with moderate glenoid bone loss. Several studies have described an arthroscopic technique called arthroscopic subscapularis augmentation. We developed a technical variation of the arthroscopic subscapularis augmentation technique involving tenodesis of the upper third of the subscapularis tendon using a graft. This technique uses a transglenoid fixation-immobilization with 2 knotless TightRope devices instead of anchors.

Recurrent Anterior Shoulder Dislocation After Trauma with Coracoid Apophysis Fracture - A Rare Association

Anterior dislocations represent about 96% of total shoulder dislocations, with recurrence/instability being more common in young patients. Injury of other shoulder structures is frequent, namely bony Bankart lesion. However, the association with coracoid apophysis fracture is very rare. The present article describes the clinical case of a 67-year-old man who presented to the emergency department with complaints of persistent omalgia, with acute episodes, beginning after a fall from his own height. The patient also presented history of shoulder trauma 3 months earlier, which was evaluated at another hospital. Shoulder anterior dislocation was observed radiographically, and the computed tomography (CT) confirmed bone erosion of the anteroinferior part of the glenoid (bone loss of about 50% of the anteroposterior diameter in the lower region of the glenoid), with almost complete resorption of the bony Bankart lesion (apparent in later analysis of the radiography of the initial traumatic episode). Connectedly, a transverse fracture of the coracoid apophysis (type II in the Ogawa classification) was diagnosed. The patient was submitted to surgical treatment, with anterior bone stop confection using the remnant of the fractured fragment of the coracoid supplemented by tricortical autologous iliac graft, fixed with cannulated screws (according to the Bristow-Latarjet and Eden-Hybinett techniques). In the postoperative follow-up, a good functional result was observed, with no new episodes of dislocation and no significant pain complaints. A rare association of shoulder lesions is described, and the challenge of their treatment is highlighted, given the late diagnosis, as in the case presented.

FIXATION METHODS IN LATARJET: BIOMECHANICAL COMPARISON OF SCREW TYPES AND PLATE FIXATION

Objective

Latarjet procedure is often preferred in recurrent shoulder dislocations accompanied by glenoid bone loss. It is observed that the superiority of bone graft fixation methods is still controversial. The aim of this study is to biomechanically compare the bone graft fixation methods in the Latarjet procedure.

Methods

15 third-generation scapula bone models were divided into 3 groups. Graft was fixated in the first group with fully-threaded cortical screws of 3.5mm diameter, in the second group two 16 mm partially-threaded cannulated screws of 4.5mm diameter, and in the third group via a mini plate and screw. The hemispherical humeral head was placed on the tip of the cyclic charge device, and thus, the charge applied to the coracoid graft was homogeneous.

Results

No statistically significant difference was found between paired comparisons (p>0.05). The forces in 5 mm displacement in total vary between 502-857N. Total stiffness measurements ranged between 105 and 625; the mean value was 258.13±53.54 with no statistically significant difference by groups (p = 0.958).

Conclusion

This biomechanical study showed that there is no difference between three coracoid fixation options in terms of fixation strength. Unlike previous assumptions, plate fixation is not biomechanically superior to screw fixation. Surgeons should consider their personal preferences and experience in choosing fixation methods.

Open Versus Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability: A Systematic Review and Meta-analysis

Background

The open Latarjet (OL) procedure and arthroscopic Latarjet (AL) procedure are able to treat recurrent anterior shoulder instability (RASI) with high success rates.

Purpose

To evaluate the clinical efficacy and postoperative revisions and complications between the OL and AL procedures in the treatment of RASI.

Study Design

Systematic review; Level of evidence, 3.

Methods

MEDLINE, Embase, and the Cochrane Library were searched to retrieve and include cohort studies comparing the OL and AL procedures for RASI. Clinical outcomes were compared, and results were reported as odds ratios (ORs) or mean differences (MDs) with 95% CIs.

Results

Eleven clinical trials with 1217 patients were included. There were no differences between the procedures in pain score, Rowe score, Walch-Duplay score, external rotation, persistent apprehension, instability, recurrence, revisions attributed to recurrent instability, overall complications, wound infection, hematoma, graft complications, screw-related complications, or osteoarthritis. When compared with the OL procedure, the AL procedure had a significantly lower nonunion rate (OR, 9.92; 95% CI, 1.71 to 57.71; P = .01); however, the AL procedure had a longer operation time (MD, -24.49; 95% CI, -48.44 to -0.54; P = .05), lower Western Ontario Shoulder Instability Index score (MD, 97.27; 95% CI, 21.91 to 172.63; P = .01), higher revision rate (OR, 0.39; 95% CI, 0.16 to 0.95; P = .04), and greater screw deviation (MD, -6.41; 95% CI, -10.25 to -2.57; P = .001).

Conclusion

For most outcome measures, no difference was seen between the OL and AL procedures. The AL procedure had a lower Western Ontario Shoulder Instability Index score and a higher revision rate and appeared to have a significant learning curve. However, the AL procedure resulted in a lower nonunion rate.

Evaluation of the inter and intraobserver reproducibility of the "defect coverage index method", a new computed tomography assessment method of sagittal graft positioning in arthroscopic bone block procedures

PURPOSE

To assess the reproducibility of a new 2-dimensional computed tomography (CT) method of assessing graft positioning in arthroscopic bone block procedure.

METHODS

This is a prospective observational study. Twenty-seven patients, (all men, mean [Standard deviation] age at surgery 30.9 [8.49] years) were included. Vertical graft position was assessed on the sagittal view by measuring the amount of glenoid bone defect covered by the graft. The length of the bone defect and the amount of graft covering the defect were measured. Positioning of the graft on the sagittal plane was classified as accurate if the graft covered at least 90% of the defect. Intraobserver and interobserver reproducibility was analyzed using intraclass correlation coefficients (ICC) and Kappa coefficient with 95% confidence.

RESULTS

Excellent intraobserver reproducibility was found, with an ICC of 0.94 (CI 95%, 0.86-0.97). Interobserver reproducibility was good, with the ICC value of 0.71, ranging from 0.45 to 0.86 (CI 95%).

CONCLUSION

This new method of assessing graft positioning in arthroscopic bone block procedures on 2-dimensional computed tomography scans is reliable, with an excellent intraobserver and good interobserver reproducibility.

LEVEL OF EVIDENCE

III.

Cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet reconstruction in anterior shoulder instability

PURPOSE

The ideal surgical treatment for anterior shoulder instability is still under debate. In the healthcare setting, both clinical and economic factors must be considered for optimal resource allocation. From the clinical perspective, the Instability Severity Index Score (ISIS) is a helpful and validated tool for surgeons, although a gray area between 4 and 6 exists. In fact, patients with an ISIS < 4 and > 6 can be treated effectively with arthroscopic Bankart repair and open Latarjet, respectively. The purpose of this study was to conduct a cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet in patients with an ISIS between 4 and 6.

METHODS

A decision-tree model was constructed to simulate the clinical scenario of an anterior shoulder dislocation patient with an ISIS between 4 and 6. Based on previously published literature, outcome probabilities and utility values in the form of Western Ontario Instability Score (WOSI) were assigned to each branch of the tree, alongside institutional cost. The primary outcome assessed was an Incremental cost-effectiveness ratio (ICER) of the two procedures. Eden-Hybbinette was also considered in the model as a salvage procedure for failed Latarjet. A two-way sensitivity analysis was performed to identify the most impactful parameters on the ICER upon their variation within a pre-determined interval.

RESULTS

Base case cost was 1245.57 € (1220.48-1270.65 €) for arthroscopic Bankart repair, 1623.10 € (1580.82-1665.39 €) for open Latarjet and 2.373.95 € (1940.81-2807.10 €) for Eden-Hybbinette. Base-case ICER was 9570.23 €/WOSI. Sensitivity analysis showed that the most impactful parameters were the utility of arthroscopic Bankart repair, the probability of success of open Latarjet, the probability of undergoing surgery after post-operative recurrence of instability and the utility of Latarjet. Of these, utility of arthroscopic Bankart repair and Latarjet had the most significant impact on the ICER.

CONCLUSION

From a hospital perspective, open Latarjet was more cost-effective than arthroscopic Bankart repair in preventing further shoulder instability in patients with an ISIS between 4 and 6. Despite its several limitations, this is the first study to analyze this subgroup of patients from a European hospital setting from both an economic and clinical perspective. This study can help surgeons and administrations in the decision-making process. Further clinical studies are needed to prospectively analyze both aspects to further delineate the best strategy.

Distal Clavicle Autograft Versus Traditional and Congruent Arc Latarjet Procedures: A Comparison of Surface Area and Glenoid Apposition With 3-Dimensional Computed Tomography and 3-Dimensional Magnetic Resonance Imaging

BACKGROUND

Limited studies have compared graft-glenoid apposition and glenoid augmentation area between the Latarjet procedure and distal clavicle graft in glenohumeral stabilization. Additionally, preoperative planning is typically performed using computed tomography (CT), and few studies have used 3-dimensional (3D) magnetic resonance imaging (MRI) reformations to assess graft dimensions.

PURPOSE

The purpose of this study was 2-fold: (1) to compare bony apposition, glenoid augmentation, and graft width among coracoid and distal clavicle bony augmentation techniques and (2) to determine the viability of 3D MRI to assess bone graft dimensions.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 24 patients with recurrent glenohumeral instability and bone loss were included in this study. 3D CT and 3D MRI reformations were utilized to measure pertinent dimensions for 5 orientations of coracoid and distal clavicle autografts: (1) standard Latarjet procedure (SLJ), (2) congruent arc Latarjet procedure (CLJ), (3) distal clavicle attached by its posterior surface (DCP), (4) distal clavicle attached by its inferior surface (DCI), and (5) distal clavicle attached by its resected end (DCR). Glenoid augmentation was defined as the graft surface area contributing to the glenoid. Bone-on-bone apposition was defined as the graft-glenoid contact area for bone healing potential, and graft width was pertinent for fixation technique. Glenoid bone loss ranged from 0% to 34%. Paired t tests were used to compare graft sizes between patients and compare 3D CT versus 3D MRI measurements.

RESULTS

The CLJ had the largest graft surface area (mean, 318.41 ± 74.44 mm²), while the SLJ displayed the most bone-on-bone apposition (mean, 318.41 ± 74.44 mm²). The DCI had the largest graft width (mean, 20.62 ± 3.93 mm). Paired t tests revealed no significant differences between the Latarjet techniques, whereas distal clavicle grafts varied significantly with orientation. All 3D CT and 3D MRI measurements were within 1 mm of each other, and only 2 demonstrated a statistically significant difference (coracoid width: 13.03 vs 13.98 mm, respectively [P = .010]; distal clavicle thickness: 9.69 vs 10.77 mm, respectively [P = .002]). 3D CT and 3D MRI measurements demonstrated a strong positive correlation (r > 0.6 and P < .001 for all dimensions).

CONCLUSION

Glenoid augmentation, bony apposition, and graft width varied with coracoid or distal clavicle graft type and orientation. Differences between 3D CT and 3D MRI were small and likely not clinically significant.

CLINICAL RELEVANCE

3D MRI is a viable method for preoperative planning and graft selection in glenoid bone loss.

Quality of life following an open Latarjet-Bristow procedure in a general population with recurrent anterior shoulder instability

BACKGROUND

Despite the extensive literature on anterior glenohumeral instability, to date, there are no studies that report on the quality of life following a Latarjet-Bristow procedure with recurrent anterior shoulder instability. The purpose of this study was to evaluate the quality of life in patients who had a Latarjet-Bristow procedure.

METHODS

A single-center retrospective review with a prospective recall of patients who underwent a Latarjet-Bristow technique for recurrent anterior glenohumeral instability between January 2017 and March 2020. Outcomes measures included health-related quality of life using the Short Form-36 (SF-36) questionnaire and patient-related outcome measures using the Western Ontario Shoulder Instability Index and Rowe scores.

RESULTS

A total of 66 patients were identified to participate in the study; 40 (60.6%) responded and were included in the analysis. There were nine females and 31 males, with a median age of 32 years (27.5‒41 years). Three cases had bilateral anterior shoulder instability with a single joint being operated and three patients were epileptic. Physical and mental components summary of the SF-36 showed a better health-related quality of life in the general population. There was a significant strong correlation between SF-36 and Western Ontario Shoulder Instability Index. However, SF-36 and Rowe score showed a fair correlation.

CONCLUSION

The Latarjet-Bristow procedure improves the quality of life in a general population similarly to an athletic population. The number of episodes of dislocation before surgery and the delayed surgical intervention did not increase the recurrent anterior shoulder instability rates postoperatively.

TREATMENT OF RECURRENT ANTERIOR SHOULDER DISLOCATION USING THE LATARJET TECHNIQUE

Objective

To describe the functional results, recurrence rate, postoperative radiographic appearance, and complications of patients undergoing the Latarjet procedure over 24 months.

Methods

Retrospective case series, including adult patients with recurrent traumatic anterior glenohumeral dislocation undergoing the Latarjet procedure. We clinically evaluated patients preoperatively by the Rowe score and at six, 12, and 24 months after the procedure. The positioning, consolidation, and resorption of the graft were analyzed by plain radiography. The recurrence rates and other complications were also described.

Results

We analyzed 40 patients (41 shoulders). The Rowe score median increased from 25 before surgery to 95 at 24 months after surgery (p < 0.001). We observed graft resorption in three cases (7.3%) and consolidation in 39 (95.1%). Most grafts presented adequate placement. We observed two recurrences (4.8%), one case of dislocation and one of subluxation. Seven patients (17.1%) had a positive apprehension test. The study had no cases of infection, neuropraxia, or graft breakage.

Conclusion

Latarjet surgery is a safe and effective procedure in the treatment of recurrent anterior dislocation of the shoulder. This surgery enables a statistically significant improvement according to the Rowe score, with a low number of recurrences. Level of Evidence IV, Case Series.

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes

BACKGROUND

In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications.

METHODS

We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis.

RESULTS

Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications.

CONCLUSION

The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

A Comprehensive Radiologic Review of Shoulder Girdle Trauma

Radiologic knowledge of different fracture patterns involving the shoulder girdle is an important tool to generate clinically relevant reports, identify concomitant injuries, guide management decisions, and predict and minimize complications, such as nonunion, osteoarthritis, osteonecrosis, and hardware failure. Complex unstable injuries like scapulothoracic dissociation can also occur because of shoulder girdle trauma. Management options may vary from conservative to surgical, depending on the fracture type and patient factors. Injuries around the shoulder girdle can involve the glenohumeral articulation, scapula, superior shoulder suspensory complex, acromioclavicular joints, and scapulothoracic articulation.

Glenoid bone augmentation: a contemporary and comprehensive systematic review of open procedures

Introduction

There is a trend towards arthroscopically treating shoulder instability with glenoid deficiency. Despite this, there remains the option for treatment through an open technique. Multiple bone augmentation options are available for recurrent anterior shoulder instability.

Objective

To provide a systematic review of recent studies for recurrent anterior shoulder instability necessitating glenoid bone augmentation specifically through open procedures using coracoid bone or free bone blocks [iliac crest bone autograft/allograft or distal tibia allograft (DTA)].

Methods

PubMed, Cochrane, EMBASE, and Google Scholar were searched for studies reporting open glenoid bone augmentation procedures with iliac crest, tibia, or coracoid bones within 10 years. Extracted data included study/patient characteristics, techniques, prior surgeries, prior dislocations, radiographic findings, range of motion (ROM), recurrent instability, patient-reported outcomes, and complications.

Results

92 met inclusion criteria (5693 total patients). Six were studies of iliac crest bone, four of DTA, and 84 using the coracoid bone. 29 studies measured postoperative arthritis showing no development or mild arthritis. 26 studies reported postoperative graft position. 62 studies reported ROM noting decline in internal/external rotation. 87 studies measured postoperative instability with low rates. Rowe Scores with noted improvement across 31/59 (52.5%) studies were seen. Common post operative complications included infection, hematoma, graft fracture, nerve injury, pain, and screw-related irritation.

Conclusion

Despite a trend towards arthroscopic management of recurrent anterior shoulder instability with glenoid deficiency, open procedures continue to provide satisfactory outcomes. Additionally, studies have demonstrated safe and efficacious use of free bone block graft options in the primary and revision setting.

Suspension fixation of iliac bone grafts under arthroscopy is an effective method for the treatment of unstable bony Bankart disease of the shoulder joint in patients with joint relaxation

PURPOSE

To evaluate the results of arthroscopic autologous iliac bone graft suspension fixation combined with the Remplissage procedure in the treatment of recurrent shoulder dislocation with bony Bankart lesions and joint hyperlaxity.

METHODS

From 2018 to 2020, 22 patients with joint laxity underwent arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure due to recurrent shoulder dislocation. Clinical assessment included range of motion (forward flexion, abduction, 90° external rotation, conventional external rotation, adduction, and internal rotation), visual analog scale (VAS) score, Rowe score, University of California Los Angeles (UCLA) score, and Western Ontario Shoulder Instability Index (WOSI) score. Post-operatively, the healing of the bone graft was evaluated with computed tomography (CT) scanning.

RESULTS

All 22 patients were followed up for a mean of 19.3 ± 4.1 months. CT imaging showed that the healing time of the bone graft was 6-8 weeks. The patient satisfaction rate was 100%, there were no cases of redislocation, all patients returned to their preinjury training state, and the fear test was negative. At the final follow-up, the UCLA, VAS, Rowe, and WOSI scores were 29.8 ± 2.1, 2.2 ± 0.8, 89.4 ± 4.2, and 482.3 ± 46.2, respectively (p < 0.001).

CONCLUSION

Arthroscopic autologous iliac bone graft suspension fixation and Bankart repair combined with the Remplissage procedure are effective in preventing recurrent instability with joint hyperlaxity. Furthermore, no patient had redislocation.

LEVEL OF EVIDENCE

IV.

Postoperative recovery comparisons of arthroscopic Bankart to open Latarjet for the treatment of anterior glenohumeral instability

BACKGROUND

Recurrent anterior glenohumeral instability is a disabling pathology that can be successfully treated by arthroscopic Bankart repair or open Latarjet. However, there is a paucity of studies comparing the postoperative recovery. The purpose of this study is to evaluate the postoperative pain and functional recovery following arthroscopic Bankart versus open Latarjet.

METHODS

This is a retrospective analysis of a multicenter prospective outcomes registry database. Postoperative recovery outcomes of either a primary or revision arthroscopic Bankart and open Latarjet procedures were compared. A minimum of 1-year follow-up was required. Outcomes measures included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) function score, ASES index score, and single assessment numeric evaluation (SANE) score. Overall, 787 patients underwent primary arthroscopic Bankart, 36 underwent revision arthroscopic Bankart and 75 underwent an open Latarjet procedure.

RESULTS

When compared to primary arthroscopic Bankart, open Latarjet demonstrated significantly lower VAS scores at 6 weeks (p = 0.03), 3 months (p = 0.01), and 2 years (p < 0.05). Medium-term outcomes for ASES scores and SANE score, at 1 and 2 years showed no difference. Latarjet demonstrated significantly lower (p < 0.05) preoperative early postoperative VAS pain scores with no difference at 1 year or 2 years when compared to primary Bankart. There was no difference in ASES function or index between Bankart and Latarjet. Revision Bankart provided inferior outcomes for VAS, ASES function, and ASES index when compared to primary Bankart and Latarjet at 1 year and 2 years.

CONCLUSIONS

Primary arthroscopic Bankart repair and open Latarjet provided nearly equivalent improvements in pain (VAS) and functional outcomes (ASES, SANE, VR-12) during the early recovery phase (2 years). This study supports the use of either procedure in the primary treatment of anterior glenohumeral instability. Revision arthroscopic Bankart repair demonstrated deteriorating outcomes at 1 and 2 years postoperatively.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019

BACKGROUND

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR).

METHODS

We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR).

RESULTS

Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men.

CONCLUSION

ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Long head of biceps transfer to augment Bankart repair in chronic anterior shoulder instability with and without subcritical bone loss: a biomechanical study

BACKGROUND

Treating recurrent anterior shoulder instability in participants in collision sports, patients with capsulolabral defects, and patients with bipolar bone loss remains challenging. The study purpose was to investigate the effect of long head of the biceps transfer (LHBT) on load-to-dislocation biomechanics in a repetitive serial shoulder dislocation cadaveric model comparing LHBT with the Latarjet and Bankart procedures-the first-line treatment methods for chronic traumatic anterior shoulder instability with and without anterior glenoid bone loss, respectively.

METHODS

In this controlled laboratory study, 8 fresh-frozen cadaveric shoulders with different conditions were dislocated in sequence using a custom test frame. The muscle loading configuration simulated the arm in the apprehension position, and biceps loads of 20 N and 40 N were used for the static glenohumeral position analysis to evaluate the sling effect. Sequential experimental conditions consisted of the intact state, second and third dislocations, chronic instability, Bankart repair, first LHBT, subcritical glenoid bone loss, second LHBT, and Latarjet procedure.

RESULTS

The pectoralis major and joint reaction loads to dislocation sequentially decreased with serial dislocations in all specimens, with the lowest value in the subcritical glenoid bone defect condition. In the setting of chronic instability, the pectoralis load to dislocation was significantly higher with the Bankart repair (P = .031) and LHBT (P < .001), at 71% and 85% of the intact value, respectively. Direct comparison of the pectoralis load to dislocation favored LHBT over Bankart repair (P = .015). In the subcritical defect scenario, LHBT did not significantly increase the load to dislocate, and the Latarjet procedure demonstrated a higher load to dislocate than LHBT (P < .001). All 3 surgical procedures tested significantly increased the angle of horizontal abduction at the time of dislocation and restored the glenohumeral position to closer to the intact state. Doubling the biceps load leveraged the sling effect, pulling the humeral head farther posterior-superiorly, but this was not enough to overcome the effect of a 20% subcritical glenoid bone defect.

CONCLUSIONS

In a serial dislocation model, LHBT effectively stabilized the glenohumeral joint in a simulated chronic instability scenario, increasing the pectoralis major load-to-dislocate and glenohumeral joint reaction force components at the time of dislocation and restoring relative glenohumeral positioning to close to the intact state. The Latarjet procedure outperformed LHBT in stabilizing shoulders in the 20% subcritical glenoid bone defect condition.

Biomechanical Testing of Scapular Spine Autograft for Anterior Glenoid Bone Augmentation

Background:

Augmentation of anterior glenoid defects with bone graft can improve shoulder stability and reduce the risk of redislocation. Several characteristics of the scapular spine may make it a suitable harvest site, avoiding the disadvantages associated with other glenoid augmentation procedures.

Purpose:

To evaluate the capacity of scapular spine autograft to restore the stabilizing joint-reaction forces of the shoulder in simulated scenarios of bony anterior shoulder instability.

Study Design:

Controlled laboratory study.

Methods:

We obtained 6 matched pairs of fresh-frozen cadaveric shoulders. Skin, subcutaneous tissues, and non–rotator cuff muscles were removed from the specimens, leaving intact the rotator cuff musculature and shoulder capsule. A customized testing device was used to translate the humerus 1 cm anteriorly on the glenoid under 25 N of axial compression force. The peak joint-reaction force of the glenohumeral joint was then measured under 3 conditions: (1) specimen with intact glenoid, (2) specimen after a bone defect measuring 25% of the maximal width of the glenoid was made in the anteroinferior glenoid, and (3) specimen after size-matched glenoid augmentation with a scapular spine tricortical autograft. The primary outcome was the change in peak joint-reaction forces between the defect state and augmented state.

Results:

One matched pair was removed from final analysis secondary to anatomic concerns that undermined the accuracy of test results. Among the 10 remaining specimens, all showed a significant decrease in peak joint-reaction force after the glenoid defect was created compared with the intact state (P < .001). All remaining specimens showed an increase in peak joint-reaction force in the augmented state compared with the defect state (P < .001). On average, the augmented state restored 81% of the peak reaction force of the glenohumeral joint compared with the intact state, a nonsignificant difference (P = .07).

Conclusion:

The study findings indicated that autograft harvested from the scapular spine increased the bony restraint to anterior shoulder dislocation in shoulders with glenoid bone loss.

Clinical Relevance:

The scapular spine is an alternative for bony augmentation of glenoid defects in shoulder instability.

The "Not" Good, the Bad and the Ugly: Prevention and Management of Common Intraoperative and Delayed Complications in Orthopedic Sports Medicine Surgical Procedures

Despite advances in techniques designed to make arthroscopic sports medicine procedures simple, complications still arise in the operating room; even in the most trained hands. However, what marks a skilled surgeon is not just the ability to steer the ship amidst smooth seas, but a knack for getting out of trouble once things deviate from the set course. Each surgical case presents a unique challenge, and no 2 are the same. For this reason, a true expert surgeon must know how to deal with "complications" ranging from a mild swell to a raging storm. In this review we present strategies to prevent and navigate some of the most common, and fearsome complications a sports medicine surgeon may face during surgery. A great surgeon is one that acknowledges that throughout their career it is not a question of "if" these situations will arise, but "when"; and preparation is the key to success.