Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss

To minimize glenoid bone graft resorption, bone block size must match glenoid bone loss for patients with shoulder instability

Despite having similar clinical outcomes, allograft bone blocks have higher resorption rates when compared to autograft bone block (approximately 75% versus 15%) for treating glenoid bone loss and recurrent anterior shoulder instability. The resorption of both autografts and allografts are based on Wolff's Law of bone remodeling. The physiological loading of the humeral head on the glenoid will strengthen bone blocks lying within the normal glenoid surface area. Any bone graft outside of this area will not be placed under any load and will be resorbed. Several studies have shown significant graft resorption of excess bone block over the first 6-12 months postoperatively, followed by a stable glenoid construct similar in size to that of the native glenoid. To minimize graft resorption, the size of the bone block, autograft, or allograft should be size matched to the amount of glenoid bone loss. The tendency to oversize bone blocks to maximize glenoid surface area and prevent instability should be avoided. Excess bone graft beyond the normal glenoid surface will be resorbed. Because allograft bone blocks tend to be larger than autograft, this is likely why resorption rates are so much higher for allografts. Since both grafts will eventually remodel to the native glenoid width, outcomes will be the same, and excessive graft resorption can lead to complications.

No Difference in Outcome Scores or Persistent Instability After Latarjet Procedure for Anterior Instability in Patients With Shoulder Hyperlaxity Versus Those Without Hyperlaxity

BACKGROUND

The prevalence of hyperlaxity in patients with shoulder instability is high, and its management is challenging. Shoulder hyperlaxity denotes a redundant anterior capsule with an elongated or weak glenohumeral ligament that may be associated with worse functional outcomes after procedures for instability. The functional outcomes and postoperative recurrence after a Latarjet procedure for recurrent instability in shoulders with hyperlaxity versus those without hyperlaxity has not been studied.

QUESTIONS/PURPOSES

(1) What are the differences in functional outcomes (Rowe score and shoulder subjective value [SSV]) after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity, and what proportion of shoulders achieve the patient acceptable symptom state (PASS) in both groups? (2) What is the difference in the proportion of patients who experienced a recurrence after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity? (3) What are the differences in radiologic outcomes after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity?

METHODS

Between January 2014 and January 2022, one surgeon performed the Latarjet procedure for anterior shoulder instability in 155 patients. During that time, he performed the Latarjet for all patients with recurrent instability, with or without bone loss and with or without shoulder hyperlaxity. Of those who fit the prespecified inclusion criteria, 37% (48 of 131) had shoulder hyperlaxity (defined as external rotation [elbow adducted] ≥ 85° in the opposite normal shoulder) and 63% (83 of 131) had no hyperlaxity. A total of 90% (43 of 48) of the patients with shoulder hyperlaxity and 87% (72 of 83) of patients without hyperlaxity had a minimum follow-up time of 2 years and were evaluated for the first two study questions by comparing functional outcomes (SSV, Rowe scores, ROM) and the proportion of patients who experienced recurrent instability after a Latarjet procedure. We also compared the hyperlaxity group with a subgroup of 32 patients with no hyperlaxity who had ≥ 15% glenoid loss (defined as the "critical defect, no hyperlaxity" group). In addition, 84% (36 of 43) of patients in the hyperlaxity group and 81% (58 of 72) in the no hyperlaxity group had CT scans at a median (range) 3 years (1 to 7) after surgery, and this subset of patients was analyzed for radiologic outcomes. The PASS was defined as an SSV of 82.5%, per an earlier study. Recurrent instability after the procedure was defined as any overt instability (dislocation, subluxation) or anterior apprehension noted in the postoperative period. Subluxation was evaluated clinically based on the patient's history of a subjective instability event or a dislocation of the glenohumeral joint that could be self-reduced. The patients in the hyperlaxity group were younger (mean ± SD age 23 ± 4 years) and had a smaller preoperative glenoid defect (4% ± 7%) than those in the no hyperlaxity group (age 28 ± 7 years, p < 0.001; glenoid defect 11% ± 9%, p < 0.001) and those in the critical defect, no hyperlaxity group (age 27 ± 8 years, p = 0.01; glenoid defect 19% ± 6%, p < 0.001). A priori sample size calculation showed that at a power of 90% and an alpha value of 0.05, a total of 18 patients were needed in each group to detect a difference in SSV of 12 ± 11 points.

RESULTS

The hyperlaxity group did not differ from the no hyperlaxity group in terms of SSV (median [IQR] 85 [80 to 95] versus 90 [80 to 95], difference of medians -5; p = 0.17), Rowe score (median [IQR] 95 [90 to 100] versus 98 [88 to 100], difference of medians -3; p = 0.61), or Duplay-Walch score (median [IQR] 90 [86 to 100] versus 90 [80 to 100], difference of medians 0; p = 0.73). We found no difference between the hyperlaxity and the no hyperlaxity group in terms of the proportion of patients who achieved the PASS (56% [24 of 43] versus 71% [51 of 72], OR 0.5 [95% CI 0.23 to 1.14]; p = 0.10). The hyperlaxity group did not differ from the no hyperlaxity group in the proportion of patients who experienced postoperative instability (12% [5 of 43] versus 11% [8 of 72], OR 1.1 [95% CI 0.32 to 3.45]; p = 0.93). We found no difference between the hyperlaxity and the no hyperlaxity group in terms of bony healing (97% [35 of 36] versus 98% [57 of 58], OR 0.6 [95% CI 0.04 to 10.13]; p > 0.99). We found no difference between the hyperlaxity and the no hyperlaxity group in the proportion of patients who had major graft resorption at the superior screw level in the sagittal section (86% [31 of 36] versus 90% [52 of 58], OR 0.7 [95% CI 0.20 to 2.54]; p = 0.74), minor graft resorption at the inferior screw level in the sagittal section (100% [36 of 36] versus 97% [56 of 58], OR 3.2 [95% CI 0.15 to 69.2]; p = 0.45), and acceptable mediolateral graft positioning at the superior screw level (75% [27 of 36] versus 79% [46 of 58], OR 0.8 [95% CI 0.29 to 2.10]; p = 0.62) and the inferior screw level (75% [27 of 36] versus 86% [50 of 58], OR 0.5 [95% CI 0.17 to 1.39]; p = 0.18).

CONCLUSION

The Latarjet procedure for unidirectional shoulder instability does not result in inferior functional outcomes or higher postoperative recurrence in patients with preexisting shoulder hyperlaxity compared with patients without hyperlaxity. Therefore, our findings suggest that shoulder hyperlaxity may not necessarily be an exclusion criterion for performing the Latarjet procedure. Future studies may need to compare the functional outcomes and complications after the Latarjet procedure with those of capsular plication procedures in patients with hyperlaxity and shoulder instability.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Allograft Resorption Following Arthroscopic Anatomic Glenoid Reconstruction Is Part of Remodeling to Restore the Native Glenoid Size and Shape 6.9 Months Postoperatively

PURPOSE

To determine if the distal tibia allograft (DTA) remodels after arthroscopic anatomic glenoid reconstruction (AAGR) to restore the native glenoid size and shape postoperatively.

METHODS

This is a retrospective study on patients who underwent AAGR with DTA between 2013 and 2022 using screw fixation who have completed postoperative clinical follow-up for a minimum of 2 years and have an available postoperative computed tomography (CT) scan. Glenoid width (anterior-posterior) and height (superior-inferior) were measured using Horos and Meshmixer on an en face view. The measured glenoid width was compared to the predicted glenoid width based on height using the following equation: Width(mm) = 2.53mm + 0.71 ∗ Height(mm), and the difference between the 2 variables was calculated. Data analysis used a paired t test, Pearson correlation, and receiver operating characteristic curve at a .05 significance level.

RESULTS

In 109 patients included in this study, the mean ± SD age at surgery was 28.2 ± 9.6 years, mean ± SD body mass index was 26.1 ± 5.0, and mean ± SD CT follow-up was 1.0 ± 1.1 years, including 73 primary surgeries (67%), 81 men (74%), and 52 right-sided operative shoulders (48%). In all 109 patients, the predicted glenoid width (28.5 ± 2.5 mm) was significantly smaller than the measured glenoid width (30.7 ± 4.2 mm) (P < .001). A significant negative correlation was found between CT follow-up time and the difference between measured and predicted glenoid width (i.e., measured and predicted glenoid width became more similar as time passed postoperatively). A cutoff time of 6.9 months was identified for graft remodeling (area under the curve, 0.759; P < .001). In patients with ≥6.9 months between surgery and postoperative CT (n = 65), there was no difference between predicted and measured postoperative glenoid width (28.6 ± 2.6 mm, 29.4 ± 3.7 mm, respectively; P = .099). In patients with <6.9 months between surgery and postoperative CT (n = 44), the predicted glenoid width was significantly smaller than the measured glenoid width (28.4 ± 2.3 mm, 32.7 ± 3.9 mm, respectively; P < .001).

CONCLUSIONS

Predicted and measured postoperative glenoid width did not differ significantly in patients who had undergone AAGR with at least 6.9 months between surgery and postoperative CT. These findings support the hypothesis that the allograft remodels following AAGR with DTA to restore the native glenoid size and architecture.

CLINICAL RELEVANCE

These findings will help direct the size of bone blocks used in AAGR with DTA in the future to optimize surgical outcomes.

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.

Clinical and radiological evaluation of the Bristow-Latarjet procedure in patients with 30 or more years of follow-up

Background

The Bristow-Latarjet surgery is the procedure most performed for recurrent anterior shoulder dislocation. There are few studies with a follow-up of more than 20 years. Because it is a nonanatomical technique, there is interest in knowing the clinical and radiological results and the rates of complications in the long term.

Methods

We performed a retrospective case series study. Patients with recurrent anterior dislocation of the shoulder who underwent the Bristow-Latarjet procedure were included and followed-up clinically for at least 30 years. We evaluated clinical scores-the Rowe, Western Ontario Shoulder Instability, Single Assessment Numeric Evaluation, and visual analog scale-as well as clinical outcomes: the recurrency (dislocation or subluxation) and seizure. Screw and graft positioning were assessed by computed tomography, the degree of arthropathy by radiography, and subscapularis fatty degeneration as rotator cuff tears by magnetic resonance imaging. Both clinical scores and imaging were obtained at 30 years of surgery.

Results

Twenty-seven patients (30 shoulders) were evaluated, with a mean follow-up of 35 ± 4.5 years. The scores obtained were 88.28 ± 15.9 by Rowe, 208 ± 244.2 by the Western Ontario Shoulder Instability examination, 92.5% ± 10.4% by the Single Assessment Numeric Evaluation, and 0.45 ± 1.3 by the visual analog scale. The recurrence rate was 13.3%, with all patients presenting subluxations and no new dislocations. All grafts were positioned below the glenoid equator. In 82.4% of the cases, the grafts were aligned with the articular surface, 5.9% were medially deviated, and 11.8% were laterally deviated. Consolidation occurred in 76.5% of the cases. The screws presented bicortical fixation in 76.5% of the shoulders and inclination in the axial plane of less than 15° in 64.7%. A total of 58.8% of the cases presented with glenohumeral arthropathy, and 75% of the magnetic resonance imagings showed the absence of fatty degeneration.

Conclusion

Bristow-Latarjet surgery demonstrates excellent clinical results in most patients after 30 years of follow-up. The recurrence rate is low, as is the complication rate. Glenohumeral arthropathy occurs in most patients without significant clinical repercussions.

Arthroscopic Bankart repair augmented with glenoid bone dry allograft

Background

The recurrence rate of shoulder instability after arthroscopic isolated Bankart repair is up to 25% at long term, especially in case of bipolar bone loss. Bony augmentation with free bone dry allograft would be an option to reconstruct a glenoid subcritical bone defect and to minimize the failure rate.

Methods

This case series included patients with anterior shoulder instability treated by arthroscopic free bone dry allograft (Supercrit, BIOBank, Lieusaint, Ile-de-France, France), fixed with a cortical button as an augmentation of Bankart repair and reviewed with a minimum follow-up of 2 years. Clinical assessment was based on active range of motion, shoulder apprehension test, as well as Walch-Duplay Score, Rowe Score, and Subjective Shoulder Value. Radiological evaluation was based on postoperative and last follow-up computed tomography scan to assess bone block positioning, glenoid enlargement, allograft healing, and/or resorption.

Results

Five patients were included with a mean follow-up of 50 months (range 44-56). None of the patients reported a recurrence, but apprehension test was positive in one. Mean Walch-Duplay Score, Rowe Score, and Subjective Shoulder Value were 88 points (70-11), 93 points (75-100), and 89% (80-95), respectively. No surgical complications were recorded. The mean preoperative anterior glenoid bone loss was 13.8% (7-19). At last follow-up, graft resorption was observed in all patients, reaching 100% of the initial volume in 4 cases.

Conclusion

This study showed satisfactory clinical results of Bankart repair augmented with dry bone allograft in the treatment of anterior shoulder instability with glenoid subcritical bone loss. However, anatomical results were disappointing, with graft resorption that raises the question of going ahead with such a procedure.

Arthroscopic Bankart repair with remplissage yields similar outcomes to open Latarjet for primary and revision stabilization in the setting of subcritical glenoid bone loss

BACKGROUND

Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR + R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR + R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings.

METHODS

A retrospective study was conducted on patients undergoing either arthroscopic ABR + R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), <2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value, strength, and range of motion (ROM) RESULTS: One hundred eight patients (70 ABR + R, 38 Latarjet) were included with an average follow-up of 4.3 ± 2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: P = .60; Revision: P = .28) and reoperation (Primary: P = .06; Revision: P = 1.00) were observed between Latarjet and ABR + R. Primary ABR + R exhibited better subjective shoulder value, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting.

CONCLUSION

Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR + R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR + R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Bone formation of the coracoid bone graft after the Bristow procedure assessed using three-dimensional computed tomography

BACKGROUND

The Bristow procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability by compensating for glenoid bone loss and producing the sling effect. The degree of postoperative morphological change in the coracoid bone graft is speculated to influence glenohumeral joint stability; however, the details of these changes after the Bristow procedure remain unknown. This study was performed to quantify the postoperative change in the coracoid bone graft volume as assessed by three-dimensional computed tomography (3D-CT).

METHODS

The Bristow procedure was performed on 17 shoulders in 17 patients from August 2018 to January 2020. All patients were men, and their mean age at surgery was 17.9 years. The mean follow-up duration was 21.4 months. Within the first week after the operation (Time 0) and at the final follow-up, 3D-CT was used to determine the total coracoid bone graft volume. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) shoulder score, the University of California Los Angeles (UCLA) shoulder score, and the Western Ontario Shoulder Instability Index (WOSI).

RESULTS

The mean volume of the total coracoid bone graft was 1.26 ± 0.29 cm3 at Time 0 and 1.90 ± 0.36 cm3 at the final follow-up (p < 0.0001). The mean JOA score, UCLA score, and WOSI were significantly better at the final follow-up than preoperatively (p < 0.001). No postoperative infection, neurovascular injury, or recurrent instability of the glenohumeral joint occurred.

CONCLUSIONS

In the Bristow procedure, the volume of the total coracoid bone graft as shown by 3D-CT was significantly greater at the final follow-up than at Time 0, and bone formation of the coracoid bone graft was found after the Bristow procedure.

Arthroscopic Bone Block Stabilization for Anterior Shoulder Instability with Subcritical Glenohumeral Bone Loss

PURPOSE OF REVIEW

The management options for anterior shoulder instability with minimal bone loss or with critical bone loss are well established. However, there is less clear evidence to guide management for patients with subcritical bone loss, the spectrum of pathology where soft tissue repair alone is prone to higher rates of failures. In this range of bone loss, likely around 13.5% to 20%, the goal of surgery is to restore function and stability while limiting morbidity. As with many procedures in the shoulder, this decision should be tailored to patient anatomy, functional goals, and risk factors. This article provides a review of our current understanding of subcritical bone loss and treatment strategies as well as innovations in management.

RECENT FINDINGS

While surgeons have largely understood that restoration of anatomy is important to optimize outcomes after stabilization surgery, there is increasing evidence that reconstructing bony anatomy and addressing both osseous and soft tissue structures yields better results than either alone. Even in the setting of subcritical bone loss, there is likely a benefit to combined osseous augmentation with soft tissue management. Additionally, there is new evidence to support management of even on-track humeral lesions when the distance to dislocation is sufficiently small, particularly for athletes. Surgeons must balance bony and soft tissue restoration to achieve optimal outcomes for anterior instability with subcritical bone loss. There are still significant limitations in the literature and several emerging techniques for management will require further study to prove their long-term efficacy. Beyond surgery, there should be a focus on a collaborative treatment strategy with the surgeon, patient, and therapists to achieve high-level function and minimize recurrence.

Improvement of coracoid process union rates: a comparative study of conventional open and arthroscopic-assisted Bristow procedures for treating anterior shoulder instability in rugby players

BACKGROUND

The Bristow coracoid transfer procedure is a reliable technique for treating anterior shoulder instability in patients with large glenoid bone loss or those involved in collision sports. However, its success is marred by its inferior bone union rate of the coracoid process as compared to the Latarjet procedure. This study aimed to evaluate whether arthroscopic confirmation of the secured coracoid fixation during the Bristow procedure improves the bone union rate and clinical outcomes as compared to the open procedure.

METHODS

We retrospectively reviewed 104 rugby players (n = 111 shoulders) who underwent an open (n = 66 shoulders) or arthroscopy (AS)-assisted (n = 45 shoulders) Bristow procedure at our center from 2007 to April 2019. In the AS-assisted group, the screw fixation and coracoid stability and contact were confirmed under arthroscopic visualization. Graft union was evaluated through computed tomography at 3 months, 6 months, and 1 year postoperatively. Patient-reported outcome measures were assessed based on the American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate. Recurrence, the rate of return to play (RTP), and the frequency of pain after RTP were also assessed.

RESULTS

The mean follow-up period was 73.5 (range: 45-160) months for the open group and 32.3 (range: 24-56) months for the AS-assisted group. In the former, the rates of bone union were 50%, 72.7%, and 88.9% at 3 months, 6 months, and 1 year, respectively. In contrast, the AS-assisted group had significantly greater bone union rates-88.9%, 93.3%, and 95.6% at 3 months, 6 months, and 1 year, respectively. Both groups showed significant improvement in the American Shoulder and Elbow Surgeons and Rowe scores compared to preoperative values as well as high satisfaction rates (open: 92%; AS-assisted: 95.7%). There were no statistically significant differences in the recurrence and RTP rates as well as the frequency of pain after RTP between the 2 groups.

CONCLUSION

The AS-assisted procedure allows early and high bone healing without compromising the clinical outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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.

The History and Evolution of the Open Labral Repair with Capsular Shift for Shoulder Instability

PURPOSE OF REVIEW

The purpose of this review is to describe the evolution of the open labral repair with capsular shift, including the current role of this procedure in the treatment of shoulder instability.

RECENT FINDINGS

Currently, a subset of patients - high-level collision/contact sport athletes, patients with significant inferior or multi-directional instability, and individuals with failed arthroscopic Bankart repair without bone loss - may experience benefit from undergoing open Bankart repair with capsular shift. Surgeons performing open stabilization can benefit from instrumentation and anchors developed to assist with arthroscopic techniques. Understanding the history and evolution behind the procedure not only allows the surgeon to appreciate principles behind an arthroscopic approach, but also permits the utilization of an open approach when required by patient pathology and risk factors.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

CRD42022368153 (PROSPERO).

Postoperative Radiographic Outcomes Following Primary Open Coracoid Transfer (Bristow-Latarjet) Vary in Definition, Classification, and Imaging Modality: A Systematic Review

PURPOSE

To analyze radiographic outcomes by conventional radiography, computed tomography (CT), or both and complication rates of open coracoid transfer at a minimum of 12-months follow-up.

METHODS

A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were clinical studies reporting on open Latarjet as the primary surgical procedure(revision coracoid transfer after failed prior stabilization excluded) with postoperative radiographic outcomes at a minimum mean 1-year follow-up. Patient demographics, type of postoperative imaging modality, and radiographic outcomes and complications including graft union, osteoarthritis, and osteolysis were systematically reviewed. Data were summarized as ranges of reported values for each outcome metric. Each radiographic outcome was graphically represented in a Forest plot with point estimates of the incidence of radiographic outcomes with corresponding 95% confidence intervals and I2.

RESULTS

Thirty-three studies met inclusion criteria, with a total of 1,456 shoulders. The most common postoperative imaging modality was plain radiography only (n = 848 [58.2%]), both CT and radiography (n = 287 [19.7%]), and CT only (n = 321 [22.1%]). Overall, the reported graft union rate ranged from 75% to 100%, of which 79.8% (n = 395) were detected on plain radiography. The most common reported postoperative radiographic complications after the open coracoid transfer were osteoarthritis (range, 0%-100%, pooled mean 28%), graft osteolysis (range, 0%-100%, pooled mean 30%), nonunion (range, 0%-32%, pooled mean 5.1%), malpositioned graft (range, 0%-75%, pooled mean 14.75%), hardware issues (range, 0%-9.1%, pooled mean 5%), and bone block fracture (range, 0%-8%, pooled mean 2.1%). Graft healing was achieved in a majority of cases (range, 75%-100%).

CONCLUSION

Postoperative radiographic outcomes after open coracoid transfer vary greatly in definition, classification, and imaging modality of choice. Greater consistency in postoperative radiographic outcomes is essential to evaluate graft healing, osteolysis, and nonunion.

LEVEL OF EVIDENCE

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

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data

BACKGROUND

The Latarjet procedure is commonly performed in the treatment of recurrent shoulder instability and is also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. Although this procedure has shown success, there has been an increased awareness of complications in recent studies, especially graft osteolysis. Most relevant research has focused on the pathophysiology, incidence, or location of graft osteolysis or the risk factors for graft osteolysis; however, the data are limited to primary Latarjet procedures. This study aimed to investigate the effect of previous arthroscopic Bankart repair surgery on coracoid bone graft osteolysis in the Latarjet procedure.

METHODS

This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedures or revision Latarjet procedures following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion, the Subjective Shoulder Value, and the Rowe score. Volumetric analysis of each transferred coracoid graft was performed using early postoperative and late postoperative computed tomography scan data, and the amount of graft osteolysis was then calculated as the percentage of volume reduction of each graft.

RESULTS

A total of 32 patients who met the inclusion criteria were included in this study, with 24 patients in the primary Latarjet group (group I) and 8 patients in the revision Latarjet group (group II). The mean age of the patients was 32.5 ± 7.7 years, and the mean follow-up duration was 52.1 ± 8.9 months. Both study groups showed significant improvement in the Subjective Shoulder Value compared with baseline (P < .05). Comparison of postoperative clinical outcome measures showed no significant difference in any outcome parameter between the 2 study groups (P > .05). No recurrence was observed during the follow-up period. A positive apprehension sign was present in 6 patients (25%) in group I and 4 patients (50%) in group II (P > .05). Analysis of radiologic data revealed that all patients underwent some degree of graft osteolysis, with varying osteolysis ratios between 12% and 98%. The mean osteolysis ratio of the coracoid graft was 67.3% ± 22.6% in group I and 69.4% ± 25.6% in group II, with no significant difference between the 2 groups (P > .05).

CONCLUSION

The findings of this study suggest that a considerable amount of coracoid graft osteolysis is observed after both primary Latarjet procedures and revision Latarjet procedures following failed arthroscopic Bankart repair. Previous arthroscopic Bankart repair did not seem to have a significant influence on the amount of graft osteolysis, and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case series.

Congruent Concavity Restoration of the Reconstructed Glenoid After the Latarjet Procedure: Compensation for the Position of the Graft

BACKGROUND

Few clinical studies have addressed concavity restoration by natural remodeling after a Latarjet procedure. This study investigated the fibrous tissue and osseous remodeling of the reconstructed glenoid and concavity restoration after a Latarjet procedure using postoperative computed tomographic arthrography (CTA).

METHODS

This retrospective study included 31 patients who underwent immediate postoperative computed tomographic (CT) scanning followed by CTA at 6 months postoperatively. We investigated whether fibrous tissue was newly created over the graft, whether the created fibrous tissue restored the congruity of the articular surface and the osseous remodeling of the graft to the glenoid level (whether the osseous portion of the graft was remodeled flush to the glenoid level) and the concavity of the glenoid using the radius of a best-fit circle on the articular surface, and the relationship between the amount of created fibrous tissue and the position of the graft.

RESULTS

In all patients, the fibrous tissue on the graft yielded a smooth articular surface, as revealed by the CTA. The mean radius of the entire glenoid, including the transferred graft, was significantly smaller (p = 0.010) at 33.2 ± 8.5 mm than that of the glenoid posterior to the osseous step-off at 37.6 ± 9.4 mm, which is presumed to be the glenoid before the surgical procedure. Despite the congruity of the articular surfaces due to fibrous tissue seen in the CTA, 14 (45%) of 31 patients showed a subchondral osseous step-off on either the medial side or the lateral side in the immediate postoperative CT scans. However, through osseous remodeling, 8 of the 10 grafts with a lateral step-off and 2 of the 4 grafts with a medial step-off converted to a flush position. The position of the step-off was correlated with the thickness of the fibrous tissue, with a tendency for thicker tissue in cases of a step-off on the medial side (p = 0.014).

CONCLUSIONS

Fibrous tissue formation plus remodeling of the transferred graft resulted in the restoration of a congruent concavity after a Latarjet procedure by compensating for initially non-flush positioning of the graft. However, due to the small sample size in our study, clinical outcomes could not be correlated with radiographic findings, and our recommendation is to continue placing the graft as anatomically as possible.

LEVEL OF EVIDENCE

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

Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report

CASE

A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal.

CONCLUSION

Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.

A Systematic Review of Screw and Suture Button Glenoid Augmentation Constructs

Background

Glenohumeral dislocations often lead to glenoid bone loss and recurrent instability, warranting bony augmentation. While numerous biomechanical studies have investigated fixation methods to secure a graft to the glenoid, a review of available constructs has yet to be performed.

Purpose

To synthesize the literature and compare the biomechanics of screw and suture button constructs for anterior glenoid bony augmentation.

Study Design

Systematic review.

Methods

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. There were 2 independent reviewers who performed a literature search using the PubMed, Embase, and Google Scholar databases of studies published between 1950 and 2020. Studies were included that compared the biomechanical outcomes of fixation for the treatment of anterior shoulder instability with glenoid bone loss.

Results

Overall, 13 of the 363 studies screened met the inclusion criteria. The included studies measured the biomechanical strength of screws or suture buttons on a cadaveric or synthetic Latarjet construct. Screws and suture buttons were biomechanically similar, as both constructs exhibited comparable loads at failure and final displacement. Screw type (diameter, threading, or composition) did not significantly affect construct strength, and double-screw fixation was superior to single-screw fixation. Additionally, 2 screws augmented with a small plate had a higher load at failure than screws that were not augmented. Unicortical double-screw fixation was inferior to bicortical double-screw fixation, although construct strength did not significantly decrease if 1 of these screws was unicortical. Further, 2 screws inserted at 15° off axis experienced significantly higher graft displacement and lower ultimate failure loads than those inserted at 0° parallel to the glenoid.

Conclusion

Suture buttons provided comparable strength to screws and offer an effective alternative to reduce screw-related complications. Augmentation with a small plate may clinically enhance construct strength and decrease complications through the dispersion of force loads over a greater surface area. Differences in screw type did not appear to alter construct strength, provided that screws were placed parallel to the articular surface and were bicortical.

Association Between Preoperative Glenoid Bone Loss and Postoperative Outcomes After Coracoid Transfer Combined With Open Bankart Repair: Comparison of the Bristow and Latarjet Techniques

Background

Whether the extent of glenoid bone loss (GBL) affects clinical outcome after coracoid process transfer (CPT) is still unclear.

Purpose

To evaluate postoperative outcomes after CPT combined with open Bankart repair in young rugby players in terms of the extent of GBL and between the Bristow and Latarjet techniques.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors investigated 101 shoulders in 91 competitive rugby players who underwent CPT combined with open Bankart repair by the Bristow (group B; 66 shoulders) or Latarjet (group L; 35 shoulders) procedure between 2007 and 2017. The extent of GBL was calculated from the en face view of the glenoid on preoperative 3-dimensional computed tomography scans and was used to categorize shoulders into 4 grades (grade 0, 0%; grade 1, >0% and ≤10%; grade 2, >10% and ≤20%; grade 3, >20%). At the minimum 2-year follow-up, the authors analyzed the relationship between GBL or GBL grade and postoperative outcome scores (American Shoulder and Elbow Surgeons score, Rowe score, Western Ontario Shoulder Instability Index, and patient satisfaction), return-to-play (RTP) times, graft failure (insufficient union or translocation), and recurrence.

Results

The mean GBL in all shoulders was 10.9% ± 9.2% and was not significantly different between the 2 groups. There were no significant correlations between GBL and any outcome measure in either group. The mean RTP time was significantly shorter in group L versus group B (4.8 ± 1.1 vs 5.8 ± 1.8 months, respectively; P = .002), but it was not associated with GBL. In group B, the rate of graft failure was not significantly higher in shoulders with grade 0 or 1 GBL versus grade 2 or 3 GBL (8 [25.0%] vs 4 [11.8%], respectively; P = .21). In group B, graft failure was confirmed in 12 shoulders (18.2%), compared with 1 shoulder (2.9%) in group L. Postoperative recurrence occurred in significantly fewer shoulders in group B than in group L (2 [3.0%] vs 5 [14.3%], respectively; P = .047).

Conclusion

The extent of GBL did not affect outcome scores after CPT, regardless of operative procedure.

Radiological and Histological Analyses of Nonrigid Versus Rigid Fixation for Free Bone Block Procedures in a Rabbit Model of Glenoid Defects

BACKGROUND

Nonrigid fixation techniques have been recently introduced in free bone block (FBB) procedures to treat substantial glenoid bone loss in patients with anterior shoulder instability. However, the radiological and histological effectiveness of nonrigid fixation versus conventional rigid fixation have not been comprehensively understood in vivo.

PURPOSE

To (1) explore the radiological and histological characteristics of nonrigid fixation for FBB procedures in a rabbit model of glenoid defects and (2) further compare them with those of conventional rigid fixation.

STUDY DESIGN

Controlled laboratory study.

METHODS

Unilateral shoulder glenoid defects were created in 36 mature New Zealand White rabbits, of which 24 underwent FBB procedures using allogenic iliac crest bone and were randomly divided into rigid fixation (RF) and nonrigid fixation (N-RF) groups, with the remaining divided into 2 control groups: 6 with sham surgery for glenoid defects (GD group) and 6 native glenoids (normal group). In the RF and N-RF groups, 6 rabbits were sacrificed at 6 or 12 weeks postoperatively for radiological and histological analyses of the reconstructed glenoid, and all rabbits in the GD and normal groups were sacrificed at 12 weeks. The radiological glenoid morphology was evaluated via micro-computed tomography. Moreover, the graft-glenoid healing and graft remodeling processes were determined using histological staining.

RESULTS

At 6 weeks, both the N-RF and RF groups had similarly improved radiological axial radian and en face area of the glenoid compared with the GD group, but the N-RF group showed superiority in restoration of the glenoid radian and area compared with the RF group at 12 weeks, with the native glenoid as the baseline. Histologically, the bone graft in both groups was substantively integrated into the deficient glenoid neck at 6 and 12 weeks, showing similar osseous healing processes at the graft-glenoid junction. Moreover, the bone graft histologically presented similar regenerated vascular density, total graft bone, and integrated graft bone in both groups. In contrast, the N-RF group had a different remodeling profile on radiological and histological analyses regarding regional bone resorption, mineralization, and fibrous tissue replacement during osseointegration.

CONCLUSION

Compared with rigid fixation, nonrigid fixation resulted in superior reconstructed glenoid morphology radiologically and similar graft-glenoid osseous healing histologically, showing different graft remodeling profiles of regional bone resorption, mineralization, and fibrous tissue replacement.

CLINICAL RELEVANCE

The nonrigid fixation technique can be feasible for FBB procedures to treat glenoid bone loss in anterior shoulder instability. More clinical evidence is required to determine its pros and cons compared with conventional rigid fixation.

Coracoid graft resorption after the Latarjet procedure does not depend on the preoperative glenoid defect

BACKGROUND

The primary purpose was to compare coracoid graft resorption after the Latarjet procedure in patients without preoperative glenoid bone loss vs. those with more than critical glenoid loss. The secondary purposes were to compare the functional outcomes and to investigate the association of graft position, angle of the screws, preoperative glenoid defect, age at surgery, and smoking status with graft resorption.

METHODS

Sixty consecutive patients with recurrent anterior instability were treated by the Latarjet procedure as the index procedure, irrespective of the glenoid bone loss between 2018 and 2021. Fifty-five patients were evaluated via computed tomography scans after a minimum of 1 year after surgery (range: 1-4 years). Twenty-five patients had no prior glenoid defect (No-defect group), 24 patients had preoperative glenoid defects ≥15% (Critical defect group), and 6 patients had glenoid defects between 5% and 15%. The No-defect group (n = 25) was compared with the Critical defect group (n = 24). Multivariate logistical regression was performed to evaluate the association of independent factors with the grade of resorption for all 55 patients in the cohort.

RESULTS

Major graft resorption at the level of the superior screw was observed in 72%-84% of patients in the No-defect group (n = 25) and in 75%-83% of patients in the Critical defect group (n = 24) (P = 1, P = 1; no significant difference). No to mild resorption at the level of the inferior screw was observed in 96% of patients in the No-defect group and 100% of patients in the Critical defect group (P = 1; no significant difference). Postoperative Rowe scores (100 [95-100] vs. 100 [95-100]; P = .8) and shoulder subjective value (87 [11] vs. 86 [9]; P = .9) were not significantly different between the 2 groups. None of the independent factors, including the corresponding screw angle, the mediolateral graft positioning, prior glenoid defect, age, and smoking status, were associated with graft resorption in multivariate logistical regression.

CONCLUSIONS

Graft resorption after the Latarjet procedure does not depend on the preoperative glenoid defect. The coracoid graft may be mostly resorbed around the superior screw but mildly or none at the level of the inferior screw, but this graft resorption is not dependent on the smoking status, age, prior glenoid defect, mediolateral graft positioning, and the angle of the screws.

Recurrence of instability after Latarjet procedure: causes, results and treatment algorithm

Latarjet modifies the anatomy of the shoulder, and subsequent revision surgery is challenging. It is mandatory to determine the cause of recurrence in order to select the best treatment option. A CT scan is needed to measure glenoid track and evaluate coracoid graft status: position, degree of consolidation, and osteolysis. Conservative management can be advocated in selected patients in whom the instability level does not interfere with the activities they wish to perform. Surgical treatment is based on the glenoid track measurement and coracoid graft suitability. The coracoid graft is considered suitable if it preserves the conjoint tendon insertion, does not show osteolysis, and is large enough to reconstruct the glenoid surface. Adding a remplissage is recommended for those cases with a coracoid graft insufficient to convert large off-track Hill-Sachs lesions into on-track. If the coracoid graft is suitable to reconstruct bone defects in terms of size and viability but is poorly positioned or avulsed, graft repositioning can be a valid option. In patients with unsuitable coracoid bone graft, free bone graft is the revision technique of choice. The size of the graft should be large enough to restore the glenoid surface and to convert any off-track Hill-Sachs lesion into on-track. There is a small group of patients in whom bone defects were properly addressed but Latarjet failed due to hyperlaxity or poor soft tissue quality. Extraarticular capsular reinforcement is suggested in this population.

Arthroscopic double-button Latarjet osteolysis and remodeling at 1-year follow-up

HYPOTHESIS

The aim of this study was to evaluate the osteolysis rate, graft remodeling, and risk factors for osteolysis at the 1-year threshold after an arthroscopic Latarjet procedure with double-button fixation.

METHOD

In this multicenter, retrospective study, postoperative computed tomography scans obtained after an arthroscopic Latarjet procedure with double-button fixation to treat anterior shoulder instability were analyzed at 15 days and at 3, 6, and 12 months. Graft volume, dimensions, and morphologic remodeling were analyzed.

RESULTS

Twenty-seven patients were included (mean age, 26 years). At 1 year, osteolysis occurred in 19 of 27 patients (70%). The volume initially decreased until 6 months' follow-up (-35%; range, -75% to +26%) and then increased until our last follow-up. At 1 year, the graft volume decreased by 17% (range, -61% to +56%) compared with the immediate postoperative volume. In multivariate analysis, the rate of osteolysis was inversely associated with an unhealed graft at 3 months (P = .02; β coefficient = -44.50 [95% confidence interval, -81 to -8]). The maximal height of the graft significantly grew 0.2 cm (range, -55 to +124 mm) (P = .015). In the sagittal plane, osteolysis occurred in the superior part in 100% of patients (27 of 27) whereas bone formation occurred in the inferior part. In the axial plane, osteolysis occurred in the anterior part whereas bone formation occurred in the posterior part. In the articular part, the observed remodeling was aimed to obtain a new anatomic and congruent glenoid.

CONCLUSIONS

At 1 year after an arthroscopic Latarjet procedure with double-button fixation, osteolysis occurred in 70% of patients. The rate of osteolysis was 17% of the initial volume. Osteolysis occurred mainly during the first 6 months, in the anterior and superior parts. Remodeling led to a circular anatomic glenoid. This osteolysis did not cause any recurrence of instability or require revision surgery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Validation of a Novel Patient Specific CT-Morphometric Technique for Quantifying Bone Graft Resorption Following the Latarjet Procedure

Bone graft resorption following the Latarjet procedure has received considerable concern. Current methods quantifying bone graft resorption rely on two-dimensional (2D) CT-scans or three-dimensional (3D) techniques, which do not represent the whole graft volume/resorption (i.e., 2D assessment) or expose patients to additional radiation (i.e., 3D assessment) as this technique relies on early postoperative CT-scans. The aim of the present study was to develop and validate a patient-specific, CT-morphometric technique combining image registration with 3D CT-reconstruction to quantify bone graft resorption following the Latarjet procedure for recurrent anterior shoulder instability. Pre-operative and final follow-up CT-scans were segmented to digitally reconstruct 3D scapula geometries. A virtual Latarjet procedure was then conducted to model the timepoint-0 graft volume, which was compared with the final follow-up graft volume. Graft resorption at final follow-up was highly correlated to the 2D gold standard-technique by Zhu (Kendall tau coefficient = 0.73; p < 0.001). The new technique was also found to have excellent inter- and intra-rater reliability (ICC values, 0.931 and 0.991; both p < 0.001). The main finding of this study is that the technique presented is a valid and reliable method that provides the advantage of 3D-assessment of graft resorption at long-term follow-up without the need of an early postoperative CT-scan.

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.

Comparison of two coracoid process transfer techniques on stress shielding using three-dimensional finite-element model

Background

We created patient-based 3D finite-element (FE) models that simulate the congruent-arc Latarjet (CAL) and traditional Latarjet (TL) procedures and then compared their stress distribution patterns with different arm positions and glenoid defects.

Methods

The computed tomography data of 10 adult patients (9 men and 1 woman, ages: 18–50 years) were used to develop the 3D FE glenohumeral joint models. Twenty-five and 35% bony defects were created on the anterior glenoid rim, and the coracoid process was transferred flush with the glenoid by the traditional and congruent-arc techniques using two half-threaded screws. A load was applied to the greater tuberosity toward the center of the glenoid, and a tensile force (20 N) was applied to the coracoid tip along the direction of the conjoint tendon. The distribution patterns of the von Mises stress in the traditional and congruent-arc Latarjet techniques were compared.

Results

The mean von Mises on the graft was significantly greater for the TL technique than for the CAL. While the von Mises stress was greater in the distal medial part of the graft in the TL models, a higher stress concentration was observed in the distal lateral edge of the coracoid graft in the CAL models. The proximal medial part of the graft exhibited significantly lower von Mises stress than the distal medial part when compared according to technique, defect size, and arm position. Increasing the glenoid defect from 25 to 35% resulted in a significant increase in stress on the lateral side of the graft in both models.

Conclusion

The stress distribution patterns and stress magnitude of the coracoid grafts differed according to the procedure. Due to placing less stress on the proximal–medial part of the graft, the CAL technique may lead to insufficient stimulation for bone formation at the graft–glenoid interface, resulting in a higher incidence of graft osteolysis.

Clinical relevance The CAL technique may lead to a higher incidence of graft osteolysis.

Level of evidence

Basic Science Study; Computer Modeling.

Open Bristow Versus Open Latarjet for Anterior Shoulder Instability in Rugby Players: Radiological and Clinical Outcomes

Background:

Coracoid transfer is a reliable method for managing anterior shoulder instability in athletes who play contact sports; however, differences between the Bristow and Latarjet procedures are unclear.

Purpose:

To compare clinical outcomes and rates of bone union and bone resorption of the coracoid process between the open Bristow and open Latarjet procedures in rugby players.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Rugby players who underwent an open Bristow or an open Latarjet procedure were retrospectively reviewed for anterior shoulder instability, and 66 shoulders in the Bristow group and 35 in the Latarjet group were included. Graft union and resorption were evaluated using computed tomography at 3 months to 1 year postoperatively. Patient-reported outcome measures (American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate) were obtained at a mean follow-up of 74 months (range, 45-160 months) for Bristow and 64 months (range, 50-76 months) for Latarjet procedures. Recurrence and the rate of return to play (RTP), frequency of pain after RTP, and retirement rate after RTP were also assessed.

Results:

In 97.1% of the Latarjet procedure cases, bone union of the coracoid was achieved at 3 months postoperatively; however, bone union was achieved in only 72.7% of the Bristow procedure cases at 6 months postoperatively. Bone resorption of the coracoid process occurred in 6.1% of shoulders after the Bristow procedure, whereas 100% of shoulders showed bone resorption after the Latarjet procedure. No statistical differences were found in outcome scores between the 2 procedures. Subluxation and persistent pain after returning to sports were identified at a significantly higher rate in the Latarjet group (5 shoulders [14%] and 9 shoulders [26%], respectively) than in the Bristow group (2 shoulders [3%] and 2 shoulders [3%]) (P = .0471 and P = .001, respectively).

Conclusion:

The Latarjet procedure had an advantage in the early and high rate of bone union but was at a disadvantage in bone resorption compared with the Bristow procedure. Subluxation and pain after returning to sports were more frequent in patients who underwent the open Latarjet procedure than in those who underwent the open Bristow procedure.

Free bone grafting improves clinical outcomes in anterior shoulder instability with bone defect: a systematic review and meta-analysis of studies with a minimum of 1-year follow-up

BACKGROUND

Evidence on the efficacy and safety of the free bone grafting in treating anterior shoulder instability is limited. The purpose of this study was to systematically evaluate the clinical and imaging results of free bone grafting in treating anterior shoulder instability with glenoid bone defect and to explore the incidence of complications in clinically relevant subgroups.

METHODS

This systematic review was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched up to January 29, 2021, for studies that had reported on free bone grafting in treating anterior shoulder instability with glenoid bone defect with a minimum of 1-year follow-up. Two researchers independently screened studies and extracted data. A random-effects model was used to pool data on clinical function scores, imaging results, and incidence of complications (recurrent instability and non-instability-related complications). Meta-regression analysis was used to evaluate the incidence of complications in different subgroups and investigate the sources of heterogeneity.

RESULTS

A total of 29 studies were included in the meta-analysis, comprising 840 patients (845 shoulders) with average ages ranging from 21 to 34.6 years. Compared with preoperatively, free bone grafting increased the postoperative Rowe score, American Shoulder and Elbow Surgeons score, Constant score, Subjective Shoulder Value, and Oxford Shoulder Instability Score by 53.16, 31.80, 20.81, 38.63, and 4.07 points, respectively, and reduced the visual analog scale pain score by 3 points on average. During the postoperative follow-up period, the rates of return to sport and return to preoperative levels were 84.2% and 73.1%, respectively. The imaging results showed that the free bone healing rate was 98.9% and the incidence of osteoarthritis was 10.9%. The incidence rates of recurrent instability and non-instability-related complications were 3.4% and 5.6%, respectively. Meta-regression analysis showed no evidence of effect modification by the year, follow-up time, proportion of male patients, autograft or allograft, and arthroscopy or open surgery on the incidence of complications. Subgroup analysis showed that the incidence rates of recurrent instability for open surgery, arthroscopy, allograft, autograft, Latarjet revision, and non-bone block revision were 4.1%, 2.3%, 1.5%, 4.4%, 10.3%, and 3.5%, respectively.

CONCLUSION

The application of free bone grafting in treating anterior shoulder instability with glenoid bone defect can effectively improve shoulder joint function and is associated with a high return-to-sport rate and a low overall recurrence rate, but there were some differences in the complications of recurrent instability and non-instability-related complications among the subgroups. Given that these results need to be confirmed via head-to-head comparisons, we recommend that future clinical and biomechanical studies focus on comparing and investigating the advantages and disadvantages of different surgical approaches, thus providing a basis for orthopedic surgeons to make reliable choices.

Comparison of the Coracoid, Distal Clavicle, and Scapular Spine for Autograft Augmentation of Glenoid Bone Loss: A Radiologic and Cadaveric Assessment

BACKGROUND

Glenohumeral instability caused by bone loss requires adequate bony restoration for successful surgical stabilization. Coracoid transfer has been the gold standard bone graft; however, it has high complication rates. Alternative autologous free bone grafts, which include the distal clavicle and scapular spine, have been suggested.

STUDY DESIGN

Controlled laboratory study.

PURPOSE

The purpose of this study was to determine the percentage of glenoid bone loss (GBL) restored via coracoid, distal clavicle, and scapular spine bone grafts using a patient cohort and a cadaveric evaluation.

METHODS

Autologous bone graft dimensions from a traditional Latarjet, congruent arc Latarjet, distal clavicle, and scapular spine were measured in a 2-part study using 52 computed tomography (CT) scans and 10 unmatched cadaveric specimens. The amount of GBL restored using each graft was calculated by comparing the graft thickness with the glenoid diameter.

RESULTS

Using CT measurements, we found the mean percentage of glenoid restoration for each graft was 49.5% ± 6.7% (traditional Latarjet), 45.1% ± 4.9% (congruent arc Latarjet), 42.2% ± 7.7% (distal clavicle), and 26.2% ± 8.1% (scapular spine). Using cadaveric measurements, we found the mean percentage of glenoid restoration for each graft was 40.2% ± 5.0% (traditional Latarjet), 53.4% ± 4.7% (congruent arc Latarjet), 45.6% ± 8.4% (distal clavicle), and 28.2% ± 7.7% (scapular spine). With 10% GBL, 100% of the coracoid and distal clavicle grafts, as well as 88% of scapular spine grafts, could restore the defect (P < .001). With 20% GBL, 100% of the coracoid and distal clavicle grafts but only 66% of scapular spine grafts could restore the defect (P < .001). With 30% GBL, 100% of coracoid grafts, 98% of distal clavicle grafts, and 28% of scapular spine grafts could restore the defect (P < .001). With 40% GBL, a significant difference was identified (P = .001), as most coracoid grafts still provided adequate restoration (congruent arc Latarjet, 82.7%; traditional Latarjet, 76.9%), but distal clavicle grafts were markedly reduced, with only 51.9% of grafts maintaining sufficient dimensions.

CONCLUSIONS

The coracoid and distal clavicle grafts reliably restored up to 30% GBL in nearly all patients. The coracoid was the only graft that could reliably restore up to 40% GBL.

CLINICAL RELEVANCE

With "subcritical" GBL (>13.5%), all autologous bone grafts can be used to adequately restore the bony defect. However, with "critical" GBL (≥20%), only the coracoid and distal clavicle can reliably restore the bony defect.

Early outcomes of the arthroscopic Latarjet procedure in a series of 37 patients with shoulder instability

Background

Anterior shoulder dislocation remains a clinical challenge. This study aimed to assess the graft position and clinical outcomes of the arthroscopic Latarjet procedure and capsular repair for the treatment of recurrent anterior shoulder dislocation with significant glenoid bone loss in 37 patients.

Methods

Between 2017 and 2017, 37 patients underwent arthroscopic Latarjet plus capsular repair procedure for recurrent anterior shoulder dislocation combined with significant glenoid bone loss. In follow-up examinations, Walch-Duplay scores, subjective shoulder value (SSV) scores, Rowe scores, and active range of motion (AROM) were assessed. Three-dimensional computed tomography (CT) was used to evaluate coracoid graft position and bone resorption. A new method of evaluating the position of the coracoid bone block after Latarjet (H-Z method) was developed.

Results

Thirty-seven patients were included in this study. Follow-up ranged from 6 to 36 months postoperatively (with an average of 13 months). No recurrent dislocation occurred at the final follow-up, and there was no significant effect on the AROM (all p > 0.05). Rowe (from 42.2 ± 5.6 to 91.1 ± 3.3), Walch-Duplay (from 31.5 ± 8.0 to 92.6 ± 3.7), and SSV (from 63.9 ± 6.1 to 79.3% ± 5.0%) scores were improved significantly after surgery (all p < 0.001). CT showed that the 29 patients had varying degrees of bone resorption, and 23 recovered to the preinjury level of motional function within 6–12 months after surgery.

Conclusions

In active patients with recurrent anterior shoulder dislocations and significant glenoid bone loss, the arthroscopic Latarjet procedure plus capsular repair could restore shoulder stability satisfactory.

Intra-articular biomechanical environment following modified Bristow and Latarjet procedures in shoulders with large glenoid defects: relationship with postoperative complications

BACKGROUND

Although coracoid transfers including the modified Bristow and Latarjet procedures are widely used to treat anterior shoulder instability, the influence of the choice of procedure on the biomechanical outcomes is not well characterized. We aimed to clarify the intra-articular stress distribution following these 2 procedures using 3-dimensional finite-element analysis and to investigate the role of stress distribution in the pathophysiology of postoperative complications.

METHODS

Overall, 6 male patients aged 17-47 years with unilateral anterior shoulder instability were recruited. Computed tomographic digital imaging and communications in medicine (CT-DICOM) data of the contralateral (healthy) shoulder of each patient was obtained and used for developing the 3-dimensional normal glenohumeral joint model. A 25% bony defect was created in the anterior glenoid rim where the coracoid process was transferred in the standing and lying-down positions to create the Bristow and Latarjet models, respectively. The arm position was set as 0° or 90° abduction. The Young moduli of the humerus and scapula were calculated using CT data, and set as 35.0 MPa and 113.8 GPa for the articular cartilage and inserted screw, respectively. A compressive load (50 N) was applied to the greater tuberosity toward the center of the glenoid, and a tensile load (20 N) was applied to the tip of the coracoid in the direction of conjoint tendon. Elastic analysis was used to determine the equivalent stress distribution.

RESULTS

A significant reduction in mean equivalent stress was observed within the glenoid cartilage for both models (P = .031); however, a new stress concentration appeared within the grafted coracoid-facing region of the humeral-head cartilage in both models. The proximal half of the coracoid graft exhibited lower equivalent stress than the distal half in 5 of the 6 Latarjet models, whereas the proximal half showed higher equivalent stress than the distal half in all 6 Bristow models. High stress concentration was identified at the midpoint of the inserted screw in Bristow models.

DISCUSSION AND CONCLUSIONS

Intra-articular stress distribution may explain the different rates of postoperative complications associated with the modified Bristow and Latarjet procedures. New stress concentration within the humeral-head cartilage might contribute to the development of glenohumeral osteoarthritis following both procedures. Stress shielding in the proximal part of the coracoid graft might contribute to osteolysis following the Latarjet procedure. Surgeons should be aware of the risk of breakage of the inserted screw following the modified Bristow procedure.

The Latarjet Procedure Without Remplissage Is Effective to Restore Stability in Athletes With Glenoid Bone Defects Greater Than 25% and Off-Track Hill-Sachs Lesions

PURPOSE

There were 2 main purposes in this study: (1) to report on clinical outcomes of the Latarjet procedure without remplissage in athletes with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions and (2) to determine whether the isolated Latarjet procedure converted off-track Hill-Sachs lesions to on-track Hill-Sachs lesions as measured on computed tomography (CT).

METHODS

During the study period, a total of 29 athletes who had anterior glenohumeral instability with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions, who underwent Latarjet surgery, and who had a minimum follow-up period of 24 months were included in this study. The glenoid track was analyzed before and 3 months after the procedure using 3-dimensional CT. Return to sport and range of motion, as well as the Rowe score, visual analog scale score for pain during sports activity, and Athletic Shoulder Outcome Scoring System score, were used to assess functional outcomes. Recurrences were also evaluated.

RESULTS

The mean follow-up period was 35 months (standard deviation [SD], 6 months), and the mean age was 30 years (SD, 2 years). Of the patients, 27 (93%) were able to return to sports and 25 (86%) returned to the same level as before their injury. No significant difference in shoulder range of motion was found between preoperative and postoperative results. The Rowe, visual analog scale, and Athletic Shoulder Outcome Scoring System scores showed statistically significant improvements after surgery (P < .001). The mean width of the glenoid pathway changed significantly from 21.5 mm (SD, 2.54 mm) in the preoperative period to 35.1 mm (SD, 5.46 mm) at 3 months' follow-up. All the Hill-Sachs lesions remained on track, and no patient had recurrence of instability at the end of follow-up. No complications occurred in this series.

CONCLUSIONS

The Latarjet procedure was effective to restore stability in athletes with recurrent glenohumeral instability with glenoid bone defects greater than 25% and off-track Hill-Sachs lesions, avoiding recurrence in all patients after an average follow-up period of 35 months. Moreover, the Latarjet procedure converted all off-track Hill-Sachs lesions to on-track Hill-Sachs lesions as measured on CT.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic Autologous Scapular Spine Bone Graft Combined With Bankart Repair for Anterior Shoulder Instability With Subcritical (10%-15%) Glenoid Bone Loss

PURPOSE

The purpose of our study is to prove that the autologous scapular spine bone graft is an alternative for the treatment of anterior shoulder instability and the clinical and radiological results are promising.

METHOD

From July 2016 to August 2018, patients who were diagnosed as having anterior shoulder instability with subcritical (10%-15%) glenoid bone loss were treated by arthroscopic repair with autologous scapular spine bone graft. The inclusion criteria were (1) anterior shoulder instability underwent arthroscopic autologous scapular spine bone graft; (2) glenoid bone loss was within 10% to 15% (measured by Sugaya's method); (3) three complete sets of computed tomography (CT) scans (preoperative, 1 week after surgery, and 1 year after surgery) available; and (4) clinical follow-up time was at least 2 years. The exclusion criteria were (1) concomitant rotator cuff tear; (2) concomitant remplissage or SLAP repair; (3) previous surgery of the affected shoulder; (4) open surgery; and (5) incomplete radiological or clinical follow-up. The preoperative and postoperative Constant-Murley score, dietary approaches to stop hypertension (DASH) score, visual analog scale (VAS) score, and range of motion (ROM) were recorded. CT scans with 3-dimensional reconstruction were obtained at the first week after operation and at 1 year after operation; the graft resorption rate was consequently calculated.

RESULTS

Twenty-seven patients were qualified and enrolled in the study. No severe complication was recorded during follow-up. No redislocation or subluxation was found, and the apprehension tests were all negative. At the last follow-up, the mean Constant-Murley score was 89.74 ± 3.71, the mean DASH score was 9.77 ± 5.31, the mean VAS score was 0.74 ± 0.64, which are all improved significantly compared with preoperative scores (P = .00,.00,.00, respectively). At the last follow-up, the ROM including anterior flexion, external rotation by side, and the internal rotation were well restored without significant difference compared with the contralateral shoulder (P =.48, .08, .47, respectively). At 1 year after operation, the resorption rate of the bone graft was 19.4%.

CONCLUSION

This study found that anterior shoulder instability with subcritical (10%-15%) glenoid bone loss treated with arthroscopic autologous scapular spine bone graft with suture anchor fixation is safe and could achieve satisfactory result at short-term follow-up.

LEVEL OF EVIDENCE

Therapeutic case series.

Computed Tomography-Based Preoperative Planning Provides a Pathology and Morphology-Specific Approach to Glenohumeral Instability With Bone Loss

PURPOSE

To use computed tomography (CT) to determine a reproducible method of coracoid measurement to compare the ability of the classic Latarjet technique and the congruent arc modification (CAM) to restore native glenoid diameter and to develop a preoperative planning algorithm for glenoid restoration with a goal of achieving an on-track shoulder.

METHODS

Coracoid dimensions were measured on multiplanar reconstructed shoulder CT scans of patients aged 18 to 45 years obtained between December 1, 2019, and March 13, 2020. Patients were excluded if CT demonstrated osteophyte formation, glenoid dysplasia, coracoid fracture, or tumor. The proportion of glenoid diameter able to be restored using classic Latarjet technique and CAM were calculated. A treatment algorithm was proposed considering the amount of bone loss present and coracoid dimensions.

RESULTS

Coracoid dimensions of 117 consecutive patients were measured and varied considerably (length: 17.5-31.8 mm, width: 9.1-20.5 mm, thickness: 6.1-15.7 mm). While most patients had harvestable coracoid length ≥20 mm (male: 96.3% vs female: 94.4%, P = .65), only 27.8% of female patients had coracoid thickness ≥10 mm. When comparing Latarjet techniques, there was no difference in the proportion of patients in whom 30% glenoid diameter could be fully restored, but CAM was able to restore at least 35% in more male and female patients (98.8% vs 79.0% and 100% vs 61.1%, respectively, P = .00001). Intra- and inter-rater reliability was excellent ( intraclass correlation coefficient ≥0.950 for all dimensions).

CONCLUSIONS

We describe a reliable method of measuring coracoid dimensions for preoperative planning of glenoid restoration. The classic Latarjet technique reliably restores the glenoid anteroposterior diameter with bone loss of up to 30%. The majority of female patients have coracoid thickness <10 mm, which may increase the risk of graft fracture when using CAM. The decision to use the classic Latarjet technique or CAM considers each individual's glenoid and coracoid dimensions with a goal of achieving an on-track shoulder.

CLINICAL RELEVANCE

Our reliable method of coracoid measurement demonstrated the differing abilities of the classic Latarjet and CAM to restore the native glenoid diameter. An evidence-based algorithm using these measurements was developed to assist in preoperative planning for glenohumeral instability in the setting of bone loss, with a goal of achieving an on-track shoulder. Alternative techniques may be considered if an on-track shoulder cannot be achieved with Latarjet.

Traditional versus congruent-arc Latarjet anatomic and biomechanical perspective

The congruent-arc Latarjet (CAL) allows reconstruction of a greater percentage of glenoid bone deficit because the inferior surface of the coracoid is wider than the lateral edge of the coracoid used with the traditional Latarjet (TL).

Biomechanical studies have shown higher initial fixation strength between the graft and the glenoid with the TL.

In the TL, the undersurface of the coracoid, which is wider than the medial edge used with the CAL, remains in contact with the anterior edge of the glenoid, increasing the contact surface between both bones and thus facilitating bone consolidation.

The shorter bone distance around the screw with the CAL is potentially less tolerant of screw-positioning error compared to the TL. Moreover, the wall of the screw tunnel is potentially more likely to fracture with the CAL due to the minimal space between the screw and the graft wall.

CAL may be very difficult to perform in patients with very small coracoids such as small women or skeletally immature patients.

Radius of curvature of the inferior face of the coracoid graft (used with the CAL) is similar to that of the native glenoid. This may potentially decrease contact pressure across the glenohumeral joint, avoiding degenerative changes in the long term.

Cite this article: EFORT Open Rev 2021;6:280-287. DOI: 10.1302/2058-5241.6.200074

Arthroscopic Latarjet Procedure: Indications, Techniques, and Outcomes

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The proposed advantages of the arthroscopic approach in the Latarjet procedure for shoulder dislocation include improved visualization for accurate positioning of the coracoid graft, the ability to address any associated intra-articular pathologies, and the diminished potential for the formation of postoperative scar tissue and stiffness associated with an open procedure.

»

Young age, the presence of glenoid and/or humeral bone loss, a history of dislocation, a history of failed arthroscopic stabilization surgery, and an active lifestyle are all associated with recurrent dislocation and are relative indications for an osseous augmentation procedure.

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Both the open and arthroscopic Latarjet procedures result in substantial improvements in patient function, with comparable rates of recurrent instability and complication profiles.

Two-year results of arthroscopic conjoint tendon transfer procedure for the management of failed anterior stabilization of the shoulder

Background

Management of failed anterior stabilization is difficult. There are two main options for revision either a revision labral repair which has published high failure rates because of poor quality capsulolabral tissues or a bone block/Latarjet procedure with associated morbidity and complication rates. On this background, the senior author (D.T.) has developed a new procedure to treat this difficult to manage clinical scenario.

Aim

The aim of this study was to evaluate the 2-year results of an arthroscopic conjoint tendon transfer procedure. The procedure has previously been developed to provide a potential solution for active patients with a failed labral repair, subcritical glenoid bone loss, and an on-track Hill-Sachs lesion.

Methods

Consecutive patients who fulfilled the inclusion criteria were prospectively recruited. Inclusion criteria were active patients with recurrent shoulder instability owing to failed labral repair, less than 10% anterior glenoid bone loss, and an on-track Hill Sachs lesion. Patients were fully consented and offered a choice of revision with an arthroscopic labral repair, a Latarjet procedure or the arthroscopic conjoint tendon transfer procedure. Preoperative and postoperative Western Ontario Shoulder Instability Index and Oxford Instability Score were collected.

Results

Eight patients met the inclusion criteria and opted for the conjoint tendon transfer procedure. Mean age was 35 with a male:female ratio of 7:1. No patients had hyperlaxity clinically. At median follow-up of 31 months (range 24-41), there was a significant improvement in both the median Western Ontario Shoulder Instability Index (53.7 to 13.4, P = .0003) and Oxford Instability Score (27 to 44.5, P = .0017) scores. No patient had a further dislocation, and all were able to resume contact and noncontact sports.

Conclusion

Our results at a minimum of 2-year follow-up demonstrate that the arthroscopic transfer of the conjoint tendon confers clinical stability in patients with a failed primary labral repair who have minimal bone loss.

Restoration of the Posterior Glenoid in Recurrent Posterior Shoulder Instability Using an Arthroscopically Placed Iliac Crest Bone Graft: A Computed Tomography-Based Analysis

Background

Posterior shoulder instability is uncommon, and its treatment is a challenging problem. An arthroscopically assisted technique for posterior iliac crest bone grafting (ICBG) has shown promising short- and long-term clinical results. Changes as shown on imaging scans after posterior ICBG for posterior shoulder instability have not been investigated in the recent literature.

Purpose

To evaluate changes on computed tomography (CT) after arthroscopically assisted posterior ICBG and to assess clinical outcomes.

Study Design

Case series; Level of evidence, 4.

Methods

Patients with preoperative CT scans and at least 2 postoperative CT scans with a minimum follow-up of 2 years were included in the evaluation. Of 49 initial patients, 17 (follow-up rate, 35%) met the inclusion criteria and were available for follow-up. We measured the glenoid version angle and the glenohumeral and scapulohumeral indices on the preoperative CT scans and compared them with measurements on the postoperative CT scans. Postoperatively, graft surface, resorption, and defect coverage were measured and compared with those at early follow-up (within 16 months) and final follow-up (mean ± SD, 6.6 ± 2.8 years).

Results

The mean preoperative glenoid version was -17° ± 13.5°, which was corrected to -9.9° ± 11.9° at final follow-up (P < .001). The humeral head was able to be recentered and reached normal values as indicated by the glenohumeral index (51.8% ± 6%; P = .042) and scapulohumeral index (59.6% ± 10.2%; P < .001) at final follow-up. Graft surface area decreased over the follow-up period, from 24% ± 9% of the glenoid surface at early follow-up to 17% ± 10% at final follow-up (P < .001). All clinical outcome scores had improved significantly. Progression of osteoarthritis was observed in 47% of the shoulders.

Conclusion

Arthroscopically assisted posterior ICBG restored reliable parameters as shown on CT scans, especially glenoid version and the posterior subluxation indices. Graft resorption was common and could be observed in all shoulders. Patient-reported clinical outcome scores were improved. Osteoarthritis progression in almost 50% of patients is concerning for the long-term success of this procedure.

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (i.e., bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic vs open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

Arthroscopic double-button Latarjet: two-thirds of bone block healed at 90 days

PURPOSE

The aim of this study was to evaluate the union rate and risk factors for delayed union in the early postoperative period after an arthroscopic Latarjet with double-button fixation.

METHOD

In a retrospective study, postoperative CT scans at 3 months were analysed following an arthroscopic Latarjet with double-button fixation used to treat anterior shoulder instability. Healing of the bone block, its position in the sagittal and coronal planes, and the contact area graft/scapula were analysed.

RESULTS

Ninety-eight CT scans (98 patients) were included. The rate of healing at 3 months was 63/98 (64%) and four grafts clearly migrated. The position was perfectly flush to the glenoid rim in 67% and under the equator in 96%. The mean contact graft/scapula area was 135 mm 2 (4-420). In multivariate analysis, the risk of non-union at 3 months was associated with tobacco consumption (p = 0.001, aOR = 12.17 95% CI [2.62-56.49]), absence of preoperative glenoid bone defect (p = 0.003, aOR = 8.06 95% CI [2.06-31.56]), and a contact area graft/scapula less than 120 mm 2 (p = 0.010, aOR = 5.25 95% CI [1.50-18.40]). Among 31 non-united grafts, 93% definitively healed on CT scan at 1 year, leaving an overall rate of 93% of united grafts at last follow-up.

CONCLUSIONS

The rate of union at 3 months after an arthroscopic Latarjet with double-button fixation was 64%, reaching 93% at 1 year. This procedure should be carefully indicated in case of tobacco use or instability without glenoid bone defect, especially when the shoulder is exposed to high-energy trauma in the early phase after surgery.

High Rate of Return to Sports and Low Recurrences With the Latarjet Procedure in High-Risk Competitive Athletes With Glenohumeral Instability and a Glenoid Bone Loss <20

Purpose

To analyze return to sports, functional outcomes, and complications following the Latarjet procedure in competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%.

Methods

All the included patients were operated between 2010 and 2016. The inclusion criteria were competitive athletes with anterior glenohumeral instability, a glenoid bone defect <20% who participated in contact sports, forced overhead sports, or had a previous failed Bankart repair and had a minimum 2 years’ follow-up. Return to sports, range of motion (ROM), the Rowe score, and the Athletic Shoulder Outcome Scoring System score were used to assess functional outcomes. Complications and bone consolidation were also evaluated.

Results

A total of 65 athletes were included in the study. The mean follow-up was 53 months (±13), and the mean age was 23.9 years (range, 16-31 years). Overall, 94% were able to return to sports and 84% returned at the same level. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe and Athletic Shoulder Outcome Scoring System scores showed statistical improvement after operation (P < .001). No significant difference in shoulder ROM and functional scores was found between primary and revision cases. The total complication rate was 11% and the revision rate was 1.5% The recurrence rate was 4.6%. The bone block healed in 95% of the cases.

Conclusions

In high-risk competitive athletes with anterior glenohumeral instability and glenoid bone loss <20%, the Latarjet procedure resulted in excellent functional outcomes, with most of the patients returning to sports and at the same level they had before injury with a low rate of recurrences

Level of Evidence

Therapeutic case series; Level of evidence, IV

The Role of Remplissage in the Setting of Shoulder Instability

Recurrent anterior shoulder instability is a multifactorial problem for which many solutions exist. Often, the bony surface area of the humeral head and the glenoid needs to be addressed surgically. For large, engaging humeral head defects associated with <25% glenoid bone loss, a remplissage procedure can effectively "fill in" the humeral defect with minimal postoperative morbidity. Remplissage is an effective biological solution that should be considered any time there is a humeral head defect which is contributing to glenohumeral instability.

Risk Factors for Coracoid Graft Osteolysis after the Open Latarjet Procedure

Objective  Coracoid osteolysis has been described as a possible complication after the Latarjet procedure. The aim of the present study was to investigate the incidence and risk factors associated to coracoid graft osteolysis and to correlate them with clinical results.

Methods  A retrospective review of 38 Latarjet procedures was conducted. Computed tomography (CT) scans were obtained from all of the patients before and at least 1 year after the surgery. Coracoid osteolysis was evaluated and correlated to preoperative factors, namely: age, smoking status, and preoperative glenoid bone loss. The patients were divided into 2 groups: A (no or minor bone resorption) and B (major or total bone resorption). The functional outcome was determined by the Rowe score.

Results  Coracoid graft osteolysis occurred in 22 cases (57.8%). The mean preoperative glenoid defect was 22.8% in group A, and 13.4% in group B ( p  = 0.0075). The mean ages of the subjects in both groups were not significantly different. Smoking did not seem to affect the main outcome either, and no correlation was found between graft osteolysis and postoperative range of motion, pain, or Rowe score. There were no cases of recurrent dislocations in our sample, although four patients presented with a positive anterior apprehension sign.

Conclusion  Bone resorption of the coracoid graft is present in at least 50% of the patients submitted to the Latarjet procedure, and the absence of significant preoperative glenoid bone loss showed to be the only risk factor associated with severe graft osteolysis, even though this did not influence significantly the clinical outcome.

The Evaluation and Management of the Failed Primary Arthroscopic Bankart Repair

Primary arthroscopic Bankart repair is a common procedure that is increasing in popularity; however, failure rates can approach up to 6% to 30%. Factors commonly attributed to failure include repeat trauma, poor or incomplete surgical technique, humeral and/or glenoid bone loss, hyperlaxity, or a failure to identify and address rare pathology such as a humeral avulsion of the glenohumeral ligament lesion. A thorough clinical and radiographic assessment may provide insight into the etiology, which can assist the clinician in making treatment recommendations. Surgical management of a failed primary arthroscopic Bankart repair without bone loss can include revision arthroscopic repair or open repair; however, in the setting of bone loss, the anterior-inferior glenoid can be reconstructed using a coracoid transfer, tricortical iliac crest, or structural allograft, whereas posterolateral humeral head bone loss (the Hill-Sachs defect) can be addressed with remplissage, structural allograft, or partial humeral head implant. In addition to the technical demands of revision stabilization surgery, patient and procedure selection to optimize outcomes can be challenging. This review will focus on the etiology, evaluation, and management of patients after a failed primary arthroscopic Bankart repair, including an evidence-based treatment algorithm.

Biomechanical Analysis of Plate Fixation Compared With Various Screw Configurations for Use in the Latarjet Procedure

Background:

The biomechanical properties of coracoid fixation with a miniplate during the Latarjet procedure have not been described.

Purpose:

To determine the biomechanical properties of miniplate fixation for the Latarjet procedure compared with various screw fixation configurations.

Study Design:

Controlled laboratory study.

Methods:

A total of 8 groups (n = 5 specimens per group) were tested at a screw insertion angle of 0°: (1) 3.75-mm single screw, (2) 3.75-mm double screw, (3) 3.75-mm double screw with washers, (4) 3.75-mm double screw with a miniplate, (5) 4.00-mm single screw, (6) 4.00-mm double screw, (7) 4.00-mm double screw with washers, and (8) 4.00-mm double screw with a miniplate. In addition, similar to groups 1 to 3 and 5 to 7, there were 30 additional specimens (n = 5 per group) tested at a screw insertion angle of 15° (groups 9-14). To maintain specimen uniformity, rigid polyurethane foam blocks were used. Testing parameters included a preload of 214 N for 10 seconds, cyclical loading from 184 to 736 N at 1 Hz for 100 cycles, and failure loading at a rate of 15 mm/min until 10 mm of displacement or specimen failure occurred.

Results:

All single-screw constructs and 77% of 15° screw constructs failed before the completion of cyclical loading. Across all groups, group 8 (4.00-mm double screw with miniplate) demonstrated the highest maximum failure load (P < .001). There were no differences in failure loads among specimens with single-screw fixation (groups 1, 5, 9, and 12; P > .05). All specimens in groups 9, 10, 11, 12, 13, and 14 (insertion angle of 15°) had significantly lower maximum failure loads compared with specimens in groups 2, 3, 4, 6, 7, and 8 (insertion angle of 0°) (P < .001 for all).

Conclusion:

These results indicate significantly superior failure loads with the miniplate compared with all other constructs. Across all fixation techniques and screw sizes, constructs with screws inserted at 0° performed better than constructs with screws inserted at 15°.

Clinical Relevance:

The use of a miniplate for coracoid fixation during the Latarjet procedure may provide a more durable construct for the high-demand contact athlete.