The arthroscopic Latarjet: a multisurgeon learning curve analysis

Editorial Commentary: Suture Button Fixation for the Latarjet Procedure Is Superior to Screw Fixation

An increasing body of evidence suggests that suture button fixation is comparable with screw fixation in Latarjet and potentially associated with reduced graft resorption. Suture button fixation may facilitate performing the Latarjet procedure, particularly when done in an arthroscopic manner. The use of suture button fixation technique theoretically facilitates improved positioning of the graft on the glenoid, as it frees the surgeon from the potential of the soft-tissue envelope to impact positioning of the graft, which can occur with screw-based guides. The bone graft can be shuttled into an optimal position and then tensioned with relative ease in comparison with screw-based techniques. Suture button fixation results in lower complication rates compared with screw fixation; almost one third of the screw fixation complications are hardware-related, and screw fixation results in a high rate of hardware removal. Moreover, the arthroscopic Latarjet suture button literature is published by experienced surgeons. Arthroscopic Latarjet has a significant learning curve, reducing the translatability of studies that report superior findings with any one technique. The generalizability of results reminds us that evidence-based medicine should be practiced through the lens of not only patient preferences, but also through an honest appraisal of a surgeon's own ability.

The Subscapularis-Sparing "Flipped Latarjet" Procedure

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

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

Background

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

Objective

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

Materials and method

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

Results

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

Discussion

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

Conclusion

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV.

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

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

Biomechanical Analysis Reveals Shoulder Instability With Bipolar Bone Loss Is Best Treated With Dynamic Anterior Stabilization for On-Track Lesions and with Remplissage for Off-Track Lesions

PURPOSE

To compare the biomechanical effects of augmenting Bankart repair (BR) with either remplissage or dynamic anterior stabilization (DAS) in the treatment of anterior shoulder instability with on-track or off-track bipolar bone loss.

METHODS

Eight fresh-frozen cadaveric shoulders were tested at 60° of glenohumeral abduction in the intact, injury, and repair conditions. Injury conditions included 15% glenoid bone loss with an on-track or off-track Hill-Sachs lesion as previously recommended. Repair conditions included isolated BR, BR with remplissage, and BR with DAS (long head of biceps transfer). The glenohumeral stability was assessed by measuring the anterior translation under 0, 10, 20, 30, 40, 50 N load and maximum load without causing instability at mid-range (60°) and end-range (90°) external rotation (ER). Maximum range of motion (ROM) was measured by applying a 2.2-N·m torque in passive ER and internal rotation.

RESULTS

Isolated BR failed to restore native glenohumeral stability in both on-track and off-track bipolar bone loss models. Both remplissage and DAS significantly decreased the anterior instability in the bipolar bone loss models, showing better restoration than the isolated BR. In the on-track lesions, DAS successfully restored native glenohumeral stability and mobility, whereas remplissage significantly decreased anterior translation without load (-2.12 ± 1.07 mm at 90° ER, P = .003; -1.98 ± 1.23 mm at 60° ER, P = .015). In the off-track lesions, remplissage restored native glenohumeral stability but led to significant ROM limitation (-8.6° ± 2.3° for internal rotation, P < .001; -13.9° ± 6.2° for ER, P = .003), whereas DAS failed to restore native stability at 90° ER regarding the increased anterior translation under 50 N (4.10 ± 1.53 mm, P < .001) and decreased maximum load (-13.8 ± 9.2 N, P = .021).

CONCLUSIONS

At time-zero, both remplissage and DAS significantly reduced residual anterior instability compared with isolated BR in the bipolar bone loss models and restored the native glenohumeral stability under most translational loads. However, remplissage could decrease the anterior translation without load for on-track lesions and may restrict ROM for off-track lesions, whereas DAS failed to restore native stability under high translational loads for off-track lesions.

CLINICAL RELEVANCE

DAS could be recommended to treat on-track bipolar bone loss with less biomechanical adverse effects, whereas remplissage might be the preferred procedure to address off-track bipolar bone loss for better stability.

Comparison of Outcomes between Open and Arthroscopic Rotator Cuff Repair

Objective

The objective of this retrospective cohort study is to evaluate the long-term clinical and functional outcomes of two surgical techniques for rotator cuff repair, namely, open and arthroscopic methods.

Methods

A total of 100 patients diagnosed with rotator cuff tears and treated at Seyhan State Hospital in the past five years were enrolled, considering the same inclusion criteria for both groups. The study groups consisted of 50 patients who underwent open rotator cuff repair and 50 patients who underwent arthroscopic rotator cuff repair. We used the SPSS programme to analyse the data, focusing on parameters such as postoperative recovery time, functional capacity scores, pain levels measured by the VAS scale, quality of life evaluated by the SF-36 scores, and complication rates.

Results

Both methods resulted in similar recovery times and functional capacity scores, but patients treated with the open method reported slightly lower pain levels (average VAS score: 2.8) compared to those treated with the arthroscopic method (average VAS score: 3.1). The study also found slightly better quality of life scores in the arthroscopic group (average SF-36 score: 71.4) compared to the open surgery group (average SF-36 score: 68.7). The complications rates were lower in the arthroscopic group (2%) than in the open surgery group (4%), but these differences were not statistically significant.

Conclusions

The study suggests that, while there are no significant differences in terms of clinical outcomes between the two surgical methods, short-term pain levels may be influenced by the more frequent application of acromioplasty in arthroscopic methods. Therefore, the choice of the surgical method should be made based on the unique characteristics, including the location and size, the patient's overall health status, and the surgeon's experience. These findings should be used as a guide and not as absolute results.

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

Background

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

Methods

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

Results

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

Conclusions

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

Effect of open versus minimally invasive surgery on postoperative wound site complications in patients with recurrent shoulder instability: A meta-analysis

The Latarjet procedure is the accepted method of operation for patients with anterior shoulder instability. However, as arthroscopy becomes more and more popular, more and more patients are being treated with minimally invasive techniques for the treatment of anteriorly unstable shoulder. This research aims to compare the curative effects of arthroscopic Latarjet (AL) and open Latarjet (OL) on postoperative anterior shoulder instability. Our hypothesis is that arthroscopy will produce better results than open surgery. During the study, a review was conducted on four main databases, including EMBASE and Cochrane Library. Six cohort studies comparing AL with OL in the treatment of anterior shoulder instability were included. Patients who were operated by open technique up to 2023 were referred to as OL and those who underwent arthroscopic surgery were referred to as AL. Comparison was made between the two methods of operation. The statistical analysis was done with RevMan 5.3. The analysis included Visual Analogue Scale (VAS) scores and postoperative wound infections. A total of six studies were included for analysis under inclusion and exclusion criteria. There were 798 patients, 476 was AL group and 322 was OL group. No statistical significance was found on the incidence of postoperative wound infection in the patients who underwent the Latarjet procedure (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.28-7.31; p = 0.67) and the VAS score after surgery (mean difference [MD], 0.70; 95% CI, -0.67 to 2.06; p = 0.32) for patients. However, it has now been demonstrated that arthroscopy is a safe and viable alternative. The only drawback of arthroscopic Latarjet surgery is probably that it has a long learning curve and requires a lot of practice from the surgeon.

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

Background

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

Purpose

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

Study Design

Systematic review; Level of evidence, 3.

Methods

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

Results

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

Conclusion

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

Open Latarjet with Metal-Free Cerclage Fixation

Despite multiple modifications, the Latarjet is still the most popular procedure for recurrent anterior shoulder instability with glenoid bone loss. Partial or subtotal resorption of the graft is common, potentially leading to hardware prominence and risk of anterior soft-tissue impingement. To minimize the technical difficulties and morbidity associated with metallic implants, a coracoid and conjoint tendon transfer with a mini-open approach using Cerclage tape suture is described, as an alternative for the Latarjet procedure typically performed with metal screws and plates.

Arthroscopic Latarjet procedure and suture-button fixation: can we predict nonunion early?

BACKGROUND

The arthroscopic Latarjet procedure is a technically challenging technique that provides well-known results. The first series reported fixation with screws. An alternative fixation technique has been proposed, using a button, to improve the reproducibility and to decrease the complications due to screws. The first reports using this fixation technique have yielded comparable rates of fusion. The objective of this study was to assess the fusion rate and bone modifications with this type of fixation.

METHODS

Two hundred sixteen patients were included in this prospective study. An arthroscopic Latarjet procedure, fixed with 1 button according to the Smith & Nephew technique, was performed by a single surgeon for the treatment of anterior instability. The radiographic protocol consisted of computed tomography scans at 3, 12, and 24 weeks postoperatively. We measured the coronal and sagittal positions of the bone block, distance between the bone block and the glenoid, diameter of the glenoid tunnel, fusion rate, and time to fusion.

RESULTS

The position was deemed flush in 92.6% of cases in the coronal plane and under the equator in 87.5% of cases in the sagittal plane. At last follow-up, we observed 9 cases of nonunion (4%), as well as 18 cases of delayed fusion. The fusion rate was 92% at 3 months and 96% at 6 months. For bone blocks that ultimately healed, the diameter of the glenoid tunnel was <2 mm in 62% of cases at 3 weeks and <1 mm in 90% of cases at 3 months. Conversely, the diameter of this tunnel significantly increased and was >3 mm in all cases of delayed union or nonunion.

CONCLUSION

The described technique achieved a reliable position of the bone block and a very good fusion rate with a new type of fixation. The time to obtain fusion can be lengthy, occurring between the third and sixth months. The diameter of the glenoid tunnel was the best predictive factor for fusion. Widening of the glenoid tunnel diameter >3 mm during the first 3 weeks was the most predictive factor for delayed union or nonunion of the bone block. This finding is probably explained by a sliding effect of the sutures through this tunnel, comparable to the bungee effect in anterior cruciate ligament repair in the knee.

Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate

PURPOSE

To compare the clinical outcomes of arthroscopic dynamic anterior stabilization (DAS) between transferring the long head of the biceps (DAS-LHB) and the conjoined tendon (DAS-CT) for anterior shoulder instability with <15% glenoid bone loss.

METHODS

From January 2016 to May 2019, a total of 63 patients who underwent DAS for recurrent anterior shoulder dislocation with <15% glenoid bone loss were included, comprising 33 patients in DAS-LHB group and 30 patients in DAS-CT group. Clinical outcomes were assessed preoperatively and at a minimum 3-year follow-up, including patient-reported outcomes, range of motion, and return to sports (RTS). Postoperative recurrent instability (including dislocation, subluxation, and subjective instability with a positive apprehension test), revisions and complications also were recorded.

RESULTS

No significant demographic characteristics difference was detected between the DAS-LHB (26.3 ± 7.9 years) and DAS-CT groups (26.0 ± 6.7 years). At the latest follow-up, there were no significant differences between the 2 groups in functional scores: Oxford Shoulder Instability Score (14.8 ± 2.8 vs 15.2 ± 3.6), Rowe score (95.9 ± 6.5 vs 93.2 ± 10.2), visual analog scale for pain (0.8 ± 1.2 vs 0.7 ± 1.7), and American Shoulder and Elbow Surgeons (95 ± 8.8 vs 95.2 ± 9.1) (all P > .218). No significant difference was detected between groups in the rates of RTS (90.1% vs 86.7%, P = .700) and RTS at previous level (78.7% vs 73.3%, P = .258), respectively. No recurrent dislocation occurred in either group. One patient felt occasional subluxation in the DAS-LHB group, and one was positive for the apprehension test in each group. One patient presented with postoperative shoulder stiffness and underwent a secondary arthroscopic debridement in the DAS-CT group.

CONCLUSIONS

Comparable rates of recurrence, complication, return to sports, and subjective shoulder function were observed between DAS-LHB and DAS-CT groups.

LEVEL OF EVIDENCE

Ⅲ; retrospective comparative therapeutic trial.

Learning and Short-Term Retention of Simulation-Based Arthroscopic Skills

OBJECTIVE

The study aimed to examine the learning curve and short-term retention of arthroscopic skills acquired on a simulator.

DESIGN

Cohort study.

SETTING

Clinical Skills Training Center of Zhujiang Hospital of Southern Medical University PARTICIPANT AND METHODS: Orthopaedic residents (n = 14) without previous arthroscopy experience were included. After basic information was collected and an initial arthroscopy knowledge level test was administered, the subjects received standardised training on the simulator (day 1); then, they completed tasks on the simulator, including guided diagnostics (4 times), triangulation (5 times) and loose body removal (7 times). A learning curve for each skill was generated based on the total scores. The score of the last repetition of each task was the training level.

RESULTS

A total of 14 orthopedic residents were enrolled. All participants completed the training and testing. There was a learning curve over the course of training for all 3 arthroscopic skills (p < 0.001). On day 8 after the training, the mean score for guided diagnostics decreased from 49.9 to 48.9 (p = 0.001), and the retention rate was 97.8%. For triangulation, the mean total score decreased from 58.9 to 53.6 (p < 0.001), and the retention rate was 90.8%. For loose body removal, the mean total score decreased from 87.1 to 80.7 (p < 0.001), and the retention rate was 92.7%.

CONCLUSIONS

Orthopaedic residents' arthroscopic skills learned through simulator training declined significantly in 1 week after the training, especially more difficult skills.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Arthroscopic Latarjet With Cortical Buttons Versus Open Latarjet With Screws: A Short-Term Comparative Study

BACKGROUND

The arthroscopic bone block procedure according to Latarjet remains a controversial subject, and few comparative studies have demonstrated the benefit of arthroscopy over open surgery.

PURPOSE/HYPOTHESIS

The objective of this study was to compare both procedures by analyzing the short-term clinical results. The hypothesis was that the arthroscopic procedure is superior to the standard open procedure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHOD

This was a retrospective comparative study. Patients treated for chronic anterior instability by arthroscopic Latarjet with double cortical buttons (group A) or open Latarjet with screws (group O) with a minimum follow-up of 12 months were included. Intraoperative (duration, complications) and postoperative (complications, pain, mobility, functional scores, resumption of sport, Patient and Observer Scar Assessment Scale scar aesthetics, satisfaction) data were compared.

RESULTS

In total, 50 patients were included (n = 24 in group A, n = 26 in group O). Operating time was longer in group A (103 vs 61 min; P = .001). The average number of days on analgesics was higher in group A (8.9 vs 5.3 days; P = .04). The complication rate was similar for the 2 groups (12.5% vs 27%; P = .46). At 3 months, the loss of external rotation was greater in group A (-33° vs -18°; P = .01), and resumption of sports was less frequent (11% vs 48%; P = .01). At 12 months, the average scores were excellent, with no significants differences between the 2 groups: Walch-Duplay average, 90 points; Rowe, 94 points; Subjective Shoulder Value (SSV), 92.5%; sport SSV, 85%; and Patient and Observer Scar Assessment Scale score, 17.2 points.

CONCLUSION

Over the short term, this comparative study did not prove the superiority of the cortical-button arthroscopic Latarjet procedure over the open Latarjet procedure. A delay in the resumption of sports, longer time to recover range of motion, and no benefit regarding postoperative pain or the aesthetic aspect of the scar were observed in this study with the arthroscopic procedure.

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.

The Addition of Remplissage to Free Bone Block Restores Translation and Stiffness Compared to Bone Block Alone or Latarjet in a Bipolar Bone Loss Model

PURPOSE

The purpose of this study was to compare glenohumeral stability following a Latarjet, a free bone block (FBB), and a FBB with remplissage for bipolar bone loss.

METHODS

Nine matched pairs of fresh frozen cadavers were tested in a custom biomechanical apparatus with rotation and progressive translational loading. The free bone block group consisted of a distal tibial allograft with an all-suture tape construct. The Latarjet group was performed with the native coracoid and two partially threaded cannulated screws. A bipolar bone loss model was created with 20% glenoid bone loss and an off-track Hill-Sachs lesion. Testing conditions included the 1) native state, 2) bipolar bone loss model, 3) Latarjet, 4) FBB with distal tibial allograft secured with cerclage sutures, and 5) FBB with remplissage. Each condition was tested for translation, humeral head apex shift, stiffness, and dislocation force.

RESULTS

There were no differences in translation, stiffness, or dislocation forced between the FBB alone and Latarjet groups. The FBB with remplissage group demonstrated the lowest anterior-inferior translation at 90° of ER, which was statistically significant compared to Latarjet 20N (P = .013) and compared to the FBB alone at 40N (P = .024) and 50N (P = .011). The FBB with remplissage group was significantly stiffer compared to FBB alone at 90° ER with approximately 60% change in stiffness (P = .028). The force required to dislocate the humeral head after treatment was highest in the FBB with remplissage group, which was statistically significant compared to the FBB alone (P = .003) and Latarjet groups (P = .018).

CONCLUSION

The addition of remplissage to a FBB restores translation and stiffness closer to the intact state compared to a FBB alone or Latarjet in a bipolar bone loss model with an off-track Hill-Sachs lesion. In this model, dislocation force significantly increased with the addition of remplissage to the FBB.

CLINICAL RELEVANCE

This biomechanical study provides evidence that Latarjet and FBB are both acceptable forms of treatment for bipolar bone loss, but stability can be enhanced with the addition of remplissage following glenoid reconstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective comparative observation trial.

Patient Factors Associated With Increased Risk for Complications After the Latarjet Procedure

Background:

The open Latarjet has become the most common method of addressing significant glenoid bone loss in patients with recurrent glenohumeral instability.

Purpose:

To describe national trends in Latarjet procedures and risk factors for complications associated with this procedure.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Eligible patients were identified through the National Surgical Quality Improvement Program (NSQIP) data set over the years 2014 to 2018 by using the Current Procedural Terminology (CPT) code for “capsulorrhaphy anterior with coracoid process transfer” (CPT 23462). Patient and surgical outcome variables were extracted and analyzed from the NSQIP database. Logistic regression analysis and odds ratios (ORs) were performed to evaluate the relative risk of complications.

Results:

The authors identified 458 patients (399 men and 59 women) from the data set. The mean body mass index was 27.4 kg/m2, and mean operative time was 130.2 minutes. Statistically significant variables included smoking status and sex, which were further stratified. Smokers were 2.19 times more likely to experience at least 1 adverse outcome, including deep vein thrombosis (DVT), pulmonary embolism, reoperation, wound infection, unplanned readmission, or readmission (95% CI, 0.62-7.82). Specifically, smokers were 7.8 times more likely to have a DVT (95% CI, 0.58-105.96), 1.4 times more likely to undergo reoperation (95% CI, 0.14-5.73), and 2.4 times more likely to have an unplanned readmission (95% CI, 0.19-28.68). Women were 2.2 times more likely to experience at least 1 adverse outcome. Specifically, women were found to be 6.4 times more likely to have a DVT (95% CI, 0.76-54.87), 4.1 times more likely to have an unplanned readmission (95% CI, 0.00-106.21), and 4.7 times more likely to have a readmission (95% CI, 0.00-13.92).

Conclusion:

The results indicate that smokers and female patients are at a higher risk of experiencing adverse outcomes and may require additional pre- and postprocedural precautions when undergoing the Latarjet procedure. With the increase in frequency, providers should be aware of patient-related factors that may lead to adverse outcomes.

Arthroscopic Latarjet: 2 or 4 Cortical Buttons for Coracoid Fixation? A Case-Control Comparative Study

BACKGROUND

While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons.

PURPOSE

To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months).

RESULTS

The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B (P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B (P≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B (P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009).

CONCLUSION

A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).

Modified Arthroscopic Latarjet Procedure: Button Fixation Without Splitting of the Subscapularis

The Latarjet procedure is used for the treatment of anterior glenohumeral instability in the presence of bone loss. One decade after a fully arthroscopic Latarjet procedure was described, this technique has been modified to reduce the risk of complications and improve the fixation method. We aimed to simplify the components of this surgical procedure.

A hybrid open-arthroscopic latarjet coracoid bone-block technique using "HyLa" instrumentation

Latarjet coracoid bone-block is a gold-standard procedure for anteroinferior instability of the shoulder. Nowadays, it can be performed as open surgery or entirely under arthroscopy. The pure arthroscopic technique has the advantage of allowing concomitant intra-articular surgery, but involves a long learning curve. Here we present a hybrid concept using dedicated instrumentation comprising a specific guide with or without arthroscopic step, and notably ensuring the safety and reproducibility of the procedure, whatever the modality. This technique offers an alternative to arthroscopic coracoid bone block, performing the more complex steps as open surgery without major change to Latarjet's original technique, so as to enable concomitant intra-articular surgery if needed while getting around some of the limitations of the purely arthroscopic procedure.

Short-term complications of the Latarjet procedure: a systematic review

PURPOSE

The purpose of this study is to evaluate the short-term complication rate following the open and arthroscopic Latarjet procedures and to meta-analyze the studies comparing the 2 approaches.

METHODS

PubMed was searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to find clinical and biomechanical studies comparing complication rates in open and arthroscopic Latarjet procedures. A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the PRISMA guidelines. Clinical studies reporting on the complications following the open or arthroscopic Latarjet were included. Meta-analysis was performed for comparative studies using Review Manager, version 5.3. A P value of <.05 was considered statistically significant.

RESULTS

Overall, 89 studies (Level of Evidence [LOE] I: 2, LOE II: 2, LOE III: 24, LOE IV: 61) met inclusion criteria, with 7175 shoulders. Following the open Latarjet procedure, the overall complication rate was 6.1%, with a 1.9% occurrence of graft-related complications, 1.1% hardware, 1.1% wound, 0.9% nerve, and 1.2% other complications. Following the arthroscopic Latarjet procedure, the overall complication rate was 6.8%, with a 3.2% occurrence of graft-related complications, 1.9% hardware, 0.5% wound, 0.7% nerve, and 0.5% other complications. Complications were reported in 7 studies comparing 379 patients treated with the open Latarjet and 531 treated with the arthroscopic Latarjet, with no statistically significant difference between the two (P = .81).

CONCLUSION

Our study established that the overall complication rate following the Latarjet procedure was 6%-7%, with the most common complication being graft-related. Furthermore, based on the current evidence, there is no significant difference in the complication rate between the open and arthroscopic Latarjet procedures.

No difference in 90-day complication rate following open versus arthroscopic Latarjet procedure

The purpose of this study was to compare the 90-day complication rate between the open and arthroscopic Latarjet procedure. A retrospective review of patients who underwent an open or arthroscopic Latarjet procedure at NYU Langone Health between 2012 and 2019 was performed. The complications, readmissions, and reoperations within 90 days were assessed. Outcomes were compared between the two approaches, and a p value of < 0.05 was considered to be statistically significant. The study included 150 patients (open: 110; arthroscopic: 40), with no patients lost to follow-up within the first 90 days. Both cohorts were similar in terms of patient demographics. No intra-operative complications were observed in either group. Overall, there were 4 post-operative complications with the open approach and 2 with the arthroscopic approach (3.6% and 5.0%, respectively; n.s.) during the study period. Three patients required a readmission within the 90-day period; one patient in both groups required a revision Latarjet for graft fracture, and one patient in the open Latarjet required irrigation and debridement for deep infection (n.s.). With the open approach, there were 2 (2.3%) wound complications, 1 graft complication, and 1 (1.1%) nerve injury. With the arthroscopic approach, there was 1 (2.8%) wound complication and 1 (2.8%) hardware complication. The safety, and 90-day complication and readmission profile of arthroscopic Latarjet is similar to open Latarjet procedure. LEVEL OF EVIDENCE: Level III.

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

BACKGROUND

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

PURPOSE/HYPOTHESIS

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Variation in technique and postoperative management of the Latarjet procedure among orthopedic surgeons

BACKGROUND

The Latarjet procedure has become a treatment of choice for glenohumeral instability in the setting of large glenoid osseous defects (>20%) and for prior failed soft tissue repairs. However, surgical techniques and postoperative rehabilitation protocols vary among expert shoulder surgeons. The purpose of this survey study was to characterize the variation in current practice patterns among fellowship-trained orthopedic shoulder surgeons and identify factors related to variation.

METHODS

A 9-question survey was created (SurveyMonkey, San Mateo, CA, USA) and distributed to orthopedic surgeons who are active members of the American Shoulder and Elbow Surgeons or American Orthopaedic Society for Sports Medicine. The survey asked questions regarding surgeon experience with the Latarjet procedure, fellowship training, open vs. arthroscopic approach, method of coracoid-to-glenoid fixation, period of sling use postoperatively, and time before clearance to return to sport. Subgroup analysis was performed to determine whether further variation was evident between surgeons who completed sports medicine vs. shoulder and elbow fellowship training.

RESULTS

In total, 242 surgeons completed the survey. Of these, 55% indicated performing a sports medicine fellowship and 39% indicated completing a shoulder and elbow fellowship. Among all surgeons, the classic open Latarjet procedure was the strongly preferred technique (79%), followed by the open congruent-arc (17%) and all-arthroscopic (3%) techniques. With respect to fixation, 98% used screw fixation and only 1% indicated cortical button use. With respect to the postoperative course, >85% of surgeons preferred immobilization for 3-6 weeks after the procedure and 42% of respondents stated they waited ≥6 months prior to clearing their patients to return to sport. Subgroup analysis revealed that surgeons who completed a shoulder and elbow fellowship performed the classic open technique 89% of the time compared with 63% of those who completed a sports medicine fellowship (P < .001).

CONCLUSION

The results of our survey study indicate an overall strong preference for the open classic Latarjet technique as well as an overall strong preference for screw fixation of the coracoid graft to the glenoid among all surgeons. Shoulder and elbow fellowship-trained surgeons are significantly more likely to perform open surgery with a classic technique compared with sports medicine fellowship-trained surgeons. Furthermore, the significant variation in postoperative sling use and return to sport suggests that further research is needed to develop an evidence-based postoperative Latarjet rehabilitation protocol.

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.

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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.

Clinical and radiographic outcomes after Latarjet using suture-button fixation

Background

Latarjet has become a common treatment option for patients with shoulder instability in the setting of bone loss. The coracoid is commonly secured with screws

Methods

All patients who underwent Latarjet with suture-button fixation with minimum 1-year follow-up were eligible for inclusion. Preoperative demographic and clinical outcome data including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), and Visual Analog Scale (VAS) were recorded and compared with postoperative scores. Radiographs were reviewed for signs of nonunion. Complications were recorded.

Results

Overall 21 patients (76% male, average age: 30.4 ± 11.3 years) underwent Latarjet with suture-button fixation. Significant improvements at 1 year were seen in ASES (P < 0.001), SANE (P < 0.001), and VAS (P = 0.011) scores compared with preoperative scores. Of the 21 patients who had reached 1-year follow-up, 17 (81%) reached 2-year follow-up. For the 17 patients who reached 2-year follow-up, there were significant improvements in ASES (P = 0.001), SANE (P = 0.001), and VAS (P = 0.005) scores from preoperative values. When isolating the 17 patients with 2-year follow-up, there were no significant differences between their 1-year and 2-year ASES (P = 0.73), SANE (P = 0.17), and VAS (P = 0.37) scores. Overall, 3 patients (14%) sustained a complication (one redislocation, one with coracoid migration and a fibrous union, and one superior labral tear requiring biceps tenodesis and superior labral repair).

Conclusion

Suture-button fixation of the coracoid during the Latarjet provides encouraging clinical and radiographic outcomes at 1 and 2 years.

Arthroscopic Iliac Crest Bone Allograft Combined With Subscapularis Upper-Third Tenodesis Shows a Low Recurrence Rate in the Treatment of Recurrent Anterior Shoulder Instability Associated With Critical Bone Loss

PURPOSE

To evaluate the clinical and radiologic outcomes of patients undergoing arthroscopic glenoid bone allograft combined with subscapularis upper-third tenodesis for anterior shoulder instability associated with clinically relevant bone loss and hyperlaxity.

METHODS

Between January 2016 and December 2017, patients with recurrent anterior shoulder instability associated with bone loss and hyperlaxity were selected and treated with arthroscopic iliac crest bone graft combined with subscapularis upper-third tenodesis. The selection criteria were as follows: more than 5 dislocations; positive apprehension, anterior drawer, and Coudane-Walch test results; glenoid bone defect between 15% and 30% and humeral bone defect with an engaging Hill-Sachs lesion; and no previous shoulder surgery. All patients were followed up with the Constant score, University of California-Los Angeles (UCLA) rating, Rowe score, and visual analog scale evaluation. Assessments were performed with plain radiographs and a PICO computed tomography scan before surgery and at 2 years of follow-up.

RESULTS

Nineteen patients were included in the study, with a mean follow-up duration of 34.6 months (range, 24-48 months). In 17 patients (89%), excellent clinical results were recorded according to the Rowe score. The Constant score improved from 82.9 (standard deviation [SD], 5.2) to 88.9 (SD, 4.3) (P = .002); Rowe score, from 25.3 (SD, 5.3) to 89.1 (SD, 21.8) (P < .001); UCLA score, from 23.7 (SD, 3) to 31.5 (SD, 4.8) (P < .001); and visual analog scale score, from 3.2 to 1.3 (P < .001). Patients met the minimal clinically important difference 94.7%, 89.5%, and 47.3% of the time for the Rowe score, UCLA score, and Constant score, respectively. Bone graft resorption was observed in all patients: partial in 9 and complete in 10. We recorded 2 recurrent traumatic dislocations (11%), with no case of persistent anterior apprehension or other complication.

CONCLUSIONS

An arthroscopic glenoid bone graft combined with subscapularis upper-third tenodesis may be a valid surgical option to treat recurrent anterior instability associated with both bone loss and hyperlaxity.

LEVEL OF EVIDENCE

Level IV, case series.

Latarjet procedure for anterior shoulder instability: a 24-year follow-up study

INTRODUCTION

Different surgical techniques (open and arthroscopic) have been described for the treatment of post-traumatic recurrent anterior instability. The aim of the surgery is to restore when possible, normal shoulder anatomy by repairing the underlying pathology responsible for the instability. Sometimes other surgical techniques are indicated. The purpose of this retrospective study was to investigate the long-term clinical and radiographic results and complications of the open Latarjet procedure after a minimum follow-up of 24 years.

MATERIALS AND METHODS

A retrospective study was performed for 67 patients treated with an open Latarjet procedure in a single center. Forty of these 67 patients returned for follow-up evaluation and clinical/radiological examination during the year 2018, having had a minimum of 24-year follow-up. Clinical outcomes were analyzed using two functional scores, in addition to the ROM and strength assessment. Radiographic evaluation included several views (AP views in neutral, internal and external rotation and a comparative Bernageau view) RESULTS: A total of 40 patients underwent an open Latarjet procedure. All the patients were avaible for follow-up at an average of 25.6 years. Clinically, no patient reported any episode of dislocation at the time of follow-up. The mean Rowe score and the Walch-Duplay score were 84.5 (range 45-100) and 83.5 (range 55-100), respectively. Non-union/fibrous union was reported in 12.5% of cases, partial resorption of the graft was found in 7.5% of cases, while total resorption was found in 5% of cases. Osteoarthritis was identified in 52.5% (21) of the patients.

CONCLUSIONS

This long-term follow-up study demonstrated that the open Latarjet procedure is a safe and reliable technique for recurrent anterior shoulder instability. The Latarjet procedure provides good long-term stability although associated with a slight limitation in external rotation.

LEVEL OF EVIDENCE

Level III; retrospective cohort comparison; treatment study.

Management of Traumatic Coracoid Fracture and Anterior Shoulder Instability With a Modified Arthroscopic Latarjet Technique

Coracoid fractures are an uncommon injury and typically occur in the setting of high-energy trauma. Isolated injury to the coracoid is rare; therefore, a high suspicion for concomitant shoulder injuries should exist. These associated injuries have been shown to be acromioclavicular dislocations, clavicular and acromial fractures, scapular spine fractures, rotator cuff tears, and anterior shoulder dislocations. Although most of these shoulder injuries respond to nonsurgical treatment, there are case reports and literature reviews that present more complicated injuries requiring surgical intervention. Shoulder dislocations with associated coracoid fractures can also manifest glenoid bone loss resulting in continued instability. In this scenario, the fractured coracoid can be used to address the glenoid bone loss, as well as the continued instability. Regarding technique, other authors have described an open procedure with screw or anchor fixation. This Technical Note describes our technique for treating a displaced Ogawa type II coracoid process fracture with concomitant anterior shoulder dislocation by an arthroscopic Latarjet procedure using the fractured coracoid.

Latarjet Cerclage: The Metal-Free Fixation

The Latarjet technique is a widely used technique for anterior shoulder instability with glenoid bone defects, irreparable capsuloligamentous lesion, or in patients at greater risk of recurrence. The use of this technique has been reported to obtain satisfactory clinical and biomechanical results. Although other methods exist, the coracoid process is typically fixed with 2 metal screws. Complications related to metal fixation are very frequently reported. In an attempt to avoid these complications, we developed this arthroscopically assisted metal-free Latarjet technique in which we fix a coracoid graft using four cerclage tapes to achieve a strong, stable fixation, thus mimicking a plate.