Level of the Subscapularis Split During Arthroscopic Latarjet

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Latarjet procedure restores range of motion at 6 months postoperatively: a prospective cohort study using motion capture analysis

BACKGROUND

There is a common concern that range of motion (ROM) is negatively affected by the Latarjet procedure. We hypothesize that the Latarjet procedure results in full recovery of ROM postoperatively and significantly improved patient-reported outcome measures.

METHODS

Patient data were prospectively collected from a randomized controlled trial to analyze outcomes after open Latarjet procedure. Inclusion criteria involved a minimum follow-up of 6 months and unilateral shoulder instability. Study outcome was assessed by postoperative ROM at 6 months postoperatively and compared to the preoperative ROM of the ipsilateral shoulder as well as the ROM of the unaffected contralateral shoulder. All ROM measurements were performed using a motion capture system to ensure consistent and reliable measurements.

RESULTS

The study included a total of 84 patients. ROM was measured in external rotation with the shoulder adducted (ER1), external rotation with the shoulder abducted 90° (ER2), internal rotation with the arm abducted 90° (IR2), and active forward elevation (AE). The mean difference in ROM between the operated arm vs. the contralateral healthy arm at 6 months postoperatively was 3.4° in ER1 (P = .19), 4.2° in ER2 (P = .086), 2.2° in IR2 (P = .36), and 2.4° in AE (P = .045). Subanalysis of patients with and without sling use revealed no significant difference in ROM between the operated shoulder and the contralateral shoulder at 6 months in either group, with the exception of ER2 in the sling group. In this latter group, ROM was 71° in the operated arm and 79° in the contralateral arm (P = .0094). Mean preoperative pain score was 25.7 (95% CI 21.4-30.1) vs. 13.0 postoperatively at 6 months (95% CI 9.50-16.5) (P < .00001). Mean preoperative Single Assessment Numeric Evaluation instability was 42.9 (95% CI 38.4-47.3) vs. 86.2 postoperatively at 6 months (95% CI 83.6-88.7) (P < .00001). Mean preoperative Rowe score was 38.5 (95% CI 34.3-42.7) vs. 84.3 at postoperative month 6 (95% CI 81.1-87.4) (P < .00001).

CONCLUSIONS

Latarjet procedure performed for anterior instability using a capsular repair results in complete ROM recovery in ER1, ER2, and IR2 at 6 months postoperatively, with only a slight discrepancy in active elevation. Sling use after the Latarjet procedure results in no benefit over postoperative recovery without the use of a sling. Sling use negatively affects the ROM in ER2, taking as reference the contralateral arm of the same patient, when compared to patients who did not use a sling postoperatively.

Splitting the subscapularis at the upper two-third and lower one-third junction or in the middle during the Latarjet-Walch procedure does not affect the external rotation range of motion

BACKGROUND

Our purpose was to investigate (1) the difference in external rotation range of motion (ROM) limitation between the two recommended subscapularis-splitting techniques (mid-split vs. upper 2/3rd -lower 1/3rd split) and (2) the differences in elevation ROM, internal rotation (IR) ROM, the functional outcomes and the IR strength between the two techniques in the Latarjet-Walch procedure.

MATERIAL AND METHODS

We conducted a prospective cohort study of patients with recurrent shoulder instability treated by the Latarjet-Walch procedure between January 2021 and January 2022. After a priori calculation of sample size, 32 patients were divided into two groups according to the type of intraoperative subscapularis split [upper 2/3rd -lower 1/3rd level split (LS group, n = 19) vs. mid-LS (MS group, n = 13)] performed in the Latarjet-Walch procedure.

RESULTS

The final external rotation with the arm adducted deficit (as compared to opposite normal shoulder) was not significantly different between the LS (9° ± 8°) and the MS (10° ± 8°, P = .8) groups. The final ER with the elbow abducted @ 90° (ER2) deficit was not significantly different between that of the LS (14° ± 12°) and the MS groups (12° ± 9°, P = .5). Only in the MS group were the final ER with the arm adducted deficit (P = .03) and the final ER with the elbow abducted @ 90° deficits (P = .05) significantly better (smaller) than the corresponding baseline values. The Rowe scores (P = .2) and the Shoulder Subjective Value (P = .7) were not significantly different between the two groups. There were no postoperative subluxations in either group. However, 3 patients tested positive in apprehension testing in the LS group compared to none in the MS group, the difference being statistically insignificant. The IR strength was 95% of the normal, unaffected shoulder in the LS group and 93% of the normal in the MS group (P = .6). Computed tomography scan evaluation showed that the transverse diameter index of subscapularis (upper subscapularis diameter/lower subscapularis diameter) was not different in the MS (0.9 ± 0.1) and the LS (0.9 ± 0.1, P = .3) groups.

CONCLUSION

We found no difference in final external rotation limitation between the upper 2/3rd - lower 1/3rd vs. mid-level subscapularis split techniques. The functional outcomes, the IR strength, subscapularis transverse diameter index, and fatty infiltration in the computed tomography scan were similar in both groups.

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

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

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

Arthroscopic Biceps Transfer to the Glenoid With Bankart Repair Grants Satisfactory 2-Year Results for Recurrent Anteroinferior Glenohumeral Instability in Subcritical Bone Loss

PURPOSE

To evaluate the short-term outcomes of the arthroscopic dynamic anterior stabilization (DAS), which is a transfer of the intra-articular portion of the long head biceps through the subscapularis split and fixation on the anterior glenoid, combined with a Bankart repair.

METHODS

A retrospective evaluation was performed of DAS and a minimum of 2-year follow-up. Inclusion criteria were the presence of anteroinferior instability, a positive apprehension test at 90° of abduction and external rotation, and subcritical glenoid bone loss (less than 20%). Exclusion criteria were severe (≥20%) glenoid bone loss, presence of biceps lesions or rupture (spontaneous or biceps tenotomy), pre-existing glenohumeral osteoarthritis, multidirectional or voluntary instability, previous arthroscopic stabilization procedure, and epilepsy. Outcomes included the Rowe score, range of motion (ROM), and recurrence.

RESULTS

Twenty-three patients were treated with DAS and arthroscopic Bankart repair during the study period. One person was lost to follow-up, leaving 22 patients available at last follow-up. Those 22 patients had an average age of 31.9 ± 12.3 years (range, 18-68) and were evaluated at an average follow-up of 3.2 ± 0.7 years (range, 1.2-4.2). The Rowe score increased from 36.1 ± 16.2 (range, 10-70) preoperatively to 89.8 ± 20.1 (range, 30-100) postoperatively (P < .001) with almost all patients (90.9%) improving their score beyond the minimal clinically important difference of 9.7 points. Postoperatively, ROM was maintained. Three patients (13.6%) analyzed at final follow-up demonstrated recurrence, one was successfully treated conservatively, but two revised with a Latarjet. No postoperative Popeye deformity, biceps cramping, or other complication were reported.

CONCLUSIONS

The DAS procedure may be an option for augmentation of a Bankart repair in patients with anterior shoulder instability and subcritical bone loss. ROM is maintained without evidence of postoperative Popeye deformity or biceps cramping.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Evaluation of the subscapularis split created with passive rotation during arthroscopic dynamic anterior stabilization (DAS): A cadaveric study

INTRODUCTION

The purpose of the present study was to analyze the ability to create a subscapularis split by passive rotation of the arm during dynamic anterior stabilization (DAS) and to analyze the new geometry of the long head of the biceps LHB.

HYPOTHESIS

The hypothesis was that this passive simple technique can create subscapularis split without additional dissection giving rise to new position of LHB with a new stabilization function.

MATERIAL AND METHODS

A technique of subscapularis split using the LHB was used in 12 fresh-frozen human cadaveric shoulders. A subscapularis split was created by passive rotation of the arm after the LHB is shuttled into the joint during DAS. The length of the subscapularis split, post-DAS position and length of the LHB, and the angulation of the LHB relative to bicipital groove were measured after DAS and if this new geometry can give a new dynamic effect on subscapularis muscle.

RESULTS

The mean length of the subscapular split after maximal rotation was 20.4±6.0mm (range: 10-32mm). The mean elongation of the LHB was 0.6±1.4mm (range: -1 to +3mm). The final angle of the LHB relative to the bicipital groove was 45±5 degrees (range: 41 to 55 degrees).

DISCUSSION

There is no need to create a distinct split prior to DAS. Additionally, DAS maintains the length-tension relationship of the LHB. The post-procedure medial angulation of the LHB relative to the bicipital groove may provide a lowering of the subscapularis, helping explain the anterior reinforcement of this technique.

LEVEL OF EVIDENCE

Basic science study, cadaver study.

Short-Term Bone Fusion With Arthroscopic Double-Button Latarjet Versus Open-Screw Latarjet

BACKGROUND

Recently, arthroscopic double-button Latarjet (AL) has provided an alternative to conventional open Latarjet (OL) in the treatment of anterior shoulder instability with glenoid bone loss. Therefore, theoretically, the faster fusion is obtained, the sooner return to sports under safe conditions can occur. The emerging flexible fixation of the bone block has clearly offered a new approach to achieve bone fusion. However, the period required to achieve this goal remains controversial.

PURPOSE/HYPOTHESIS

The purpose was to compare computed tomography (CT) scan results of AL and OL in the early postoperative period. It was hypothesized that the bone block fusion with AL would require a longer time than that with OL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In a retrospective 1-year study, the authors compared 17 primary double-button AL to 22 primary 2-screw OL procedures indicated for anterior shoulder instability in patients with an Index Severity Instability Score >3 points. These patients were reviewed with a CT scan at 1 day, 3 months, and 6 months postoperatively. The characteristics for the 2 groups were comparable. CT scans aimed to analyze graft position, bone contact area with the scapula, and fusion at 3 and 6 months. Clinical assessment was based on the Walch-Duplay and Rowe scores.

RESULTS

The mean preoperative Index Severity Instability Score was 5.3 ± 1.9 points, with a mean anterior glenoid bone loss of 9.1% ± 4.6%. At 3 months, the rates of fusion were 41% and 100% for the AL and OL groups, respectively (P < .001). This rate increased to 70% in the AL group at 6 months (P = .006). In the axial and sagittal planes, there was no difference in graft position between the AL group and the OL group. The bone block was longer and there was a more extensive bone contact area in the OL group (AL, 131 mm² vs OL, 223 mm²; P < .001). At 6 months of follow-up, no significant difference in clinical scores was noted between the groups: Walch-Duplay score, 93.0 ± 10.9 points versus 91.8 ± 12.5 points (P = .867); and Rowe score, 99.0 ± 2.2 points versus 95.0 ± 8.4 points (P = .307) for the AL and OL groups, respectively.

CONCLUSION

AL required more time to achieve bone block fusion than OL. This finding should be taken into account when considering this procedure for patients in a hurry to return to sports involving the shoulder.

Editorial Commentary: Augmented Bankart Could Be the Right Option for Subcritical Bone Loss

The suitable treatment for recurrent anterior shoulder instability with subcritical glenoid bone loss remains controversial. Although the Latarjet procedure is one of the most successful surgery for shoulder instability, it has been associated with potential complications in my patients with limited bone loss and poor soft-tissue conditions, which motivated me to further investigate Bankart augmentation techniques. A myriad of them have been devised and proposed for this specific group of patients; however, there are no sufficient clinical data reported in the literature to support one of them particularly or clarify in which situation they should be used. Further comparative and prospective studies are therefore needed to build an evidence-based decision tree to help us treating our patients and better match their expectations. That said, current literature and my experience have resulted in a shift in my treatment paradigm undertaken 3 years ago to augmented Bankart in case of subcritical glenoid bone loss.

A Reproducible Technique for Creation of the Subscapularis Split During Dynamic Anterior Stabilization for Shoulder Instability

The subscapularis split is a required difficult step of several instability procedures. We propose creating a subscapularis split using the shuttled long head of the biceps by simple passive external rotation of the arm during dynamic anterior stabilization. This technique simplifies one of the technically demanding steps of dynamic anterior stabilization, making the split quicker and more reproducible.

Comparison of Coracoid Graft Position and Fixation in the Open Versus Arthroscopic Latarjet Techniques: A Cadaveric Study

BACKGROUND

Since the description of the arthroscopic Latarjet technique, discussion about the superiority of the open or arthroscopic procedure has arisen. The appropriate placement of the coracoid graft (CG) on the anterior glenoid neck is reported to be the most important step of the Latarjet procedure.

PURPOSE

To verify if there are differences in the parameters that may affect the final position and fixation of CG obtained from the open and arthroscopic Latarjet techniques.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty fresh-frozen human paired cadaveric shoulder specimens were randomly distributed in 2 surgery groups (open group [OG] and arthroscopic group [AG]) with 10 specimens in each. Two surgeons, each with experience performing open and arthroscopic Latarjet techniques, executed these procedures: one surgeon performed all open techniques, and the other performed all arthroscopic techniques, respectively. After surgery, a computerized tomography scan was performed. The surgical time, the position of each CG, a series of variables that might affect the CG fixation, and the level of the subscapularis muscle split were evaluated.

RESULTS

The mean surgical time was significantly longer in the AG (mean, 26 minutes for OG and 57 minutes for AG). Three intraoperative complications (30%) were identified in the AG, consisting of graft fractures. The CG was determined to be in an optimal cranial-caudal position in 90% of specimens of the OG and 44% of the AG (Fisher, P = .057). In both groups, the CG was placed in an optimal medial-lateral position in all specimens. In the OG, the degree of parallelism between the major axes of the glenoid surface and CG was significantly greater than in the AG (mean, 3.8º for OG and 15.1º for AG). No significant differences were observed in superior and inferior screw orientation between the groups. In the longitudinal and transverse directions, significant differences were found in the centering of the superior screw, being closer to the ideal point in the OG than in the AG. The location where the longitudinal subscapularis muscle split was performed was significantly higher in the AG.

CONCLUSION

The open Latarjet technique required less surgical time; presented a lower number of intraoperative complications; and allowed more adequate placement of the CG, better centering of the screws, and a subscapularis muscle split closer to the ideal position.

CLINICAL RELEVANCE

The reported benefits of the arthroscopic Latarjet technique seem less clear if we take into account the added surgery time and complications.

The arthroscopic Latarjet: a multisurgeon learning curve analysis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III. Therapeutic study: case-control study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Dynamic Anterior Stabilization Using the Long Head of the Biceps for Anteroinferior Glenohumeral Instability

Anteroinferior glenohumeral instability can be treated by variants of the Bankart repair, remplissage, and the Latarjet procedure, although all options remain associated with complications, including recurrence, stiffness, persistent pain, apprehension, and dislocation arthropathy. The authors therefore thought of a concept of dynamic anterior stabilization to treat anteroinferior glenohumeral instability by transferring the long head of the biceps within a subscapularis split to the anterior glenoid margin, thereby creating a "sling effect" by using a conservative technique. A standard Bankart repair is then to re-establish the labral damper effect. The main benefit of the dynamic anterior stabilization procedure is that it grants the "sling effect," but is easier and safer than arthroscopic Latarjet. It does not require screws nor traction of the coracoid process, and should therefore reduce the risks of neurologic damage. Furthermore, the procedure can be performed with only 3 small incisions, because it does not require coracoid transfer, which eliminates risks of nerve dissection, graft overhang, and cortical resorption, hence reducing the probability for dislocation arthroplasty. Lastly, the pectoralis minor remains intact, which would avoid scapular dyskinesis.

Editorial Commentary: Healthy Skepticism: An Invaluable Trait

Using a switching stick from the posterior portal is a frequently employed method of identifying the location for the subscapularis split for a shoulder arthroscopic Latarjet. However, in a recent cadaveric study, in none of the 20 specimens studied did this technique result in the split being placed in the preferred position-the junction of the superior two-thirds and the inferior one-third of the subscapularis. As a result, if the position of the coracoid graft is too superior, the anteroinferior extension of the glenoid arc and the vector of the conjoined sling may be suboptimal and fail to restrain humeral head translation. There is thus a need for a more reliable method for establishing the subscapularis split in patients with shoulder instability and significant glenoid bone loss. Moreover, in comparison to the open Latarjet surgical technique, an arthroscopic Latarjet procedure is notably more complex, technically challenging, and involves a demanding learning curve. For any procedure, the morbidity curve is inversely related to the learning curve-the lower one is on the learning curve, the greater the expected complications. The area beneath the morbidity curve is related to increased costs to manage complications and suboptimal outcomes. Study, practice, acquisition, and refinement of the necessary skills needed to perform a complex procedure should be done primarily in the cadaver lab. It is imperative that each of us critically evaluate our own experience and clinical practice to determine if we have or expect to generate the critical volume necessary to successfully master the arthroscopic Latarjet techniques and to retain the expertise needed for optimal patient outcomes.

Editorial Commentary: Arthroscopic Latarjet Shoulder Stabilization: Where Are We? Where Are We Going?

Arthroscopic Latarjet procedure has shown satisfactory clinical outcomes in the treatment of anteroinferior shoulder instability. Although as of today there is no proven advantage of the arthroscopic procedure over an open one, it is too early to give up. At the same time, crucial to understand the causes of failure, to find the solutions to every single difficulty to simplify this surgery and to make it as accessible as possible.