Double-screw and quadruple-button fixation for the glenoid: Latarjet versus bone block applications

Non-screw glenoid augmentation constructs for shoulder instability with bone loss: A biomechanical assessment of static and elastic cerclage constructs

Purpose

This study aims to compare the biomechanical performance of elastic and static suture-based cerclage systems to traditional screw constructs in the setting of modeled glenoid bony augmentation.

Methods

Biomechanical testing was conducted on polyurethane cellular foam blocks modeling a 20 % glenoid defect repaired with a coracoid graft. Constructs consisted of an elastic suture-based cerclage, static suture-based cerclage, and a two-screw construct. Biomechanical testing was performed on material testing system, using a 7-phase, 100 cycle per phase, 1Hz, sinusoidal cyclic loading protocol, following a stair-step pattern in load control. Failure for cyclic loading was assessed at 0.8 mm linear displacement. The absolute end level for load-to-failure was 7.0 mm.

Results

Static suture-based cerclage failed at 5-50 N (Cycles 2 through 4), 2-screw constructs failed at 25-50 N (Cycle 4), and elastic suture-based cerclage failed at 100-200N (Cycles 6 and 7). Elastic cerclage exhibited superior performance compared to static cerclage beginning in Cycle 2 (p = 0.0440) and compared to SOC 2-screw construct beginning in Cycle 4 (p = 0.0118). 2-screw construct exhibited superior stability performance compared to static cerclage beginning in Cycle 3 (p = 0.0001). Elastic cerclage reached failure at 558.141 ± 4.508 N, while 2-screw construct and static cerclage reached failure at 422.009 ± 24.998 N and 366.770 ± 66.653 N, respectively. Elastic cerclage demonstrated superior biomechanical stability in load-at-failure performance to static cerclage (p < 0.0001) and the screw construct (p < 0.0001), while static cerclage demonstrated inferior biomechanical stability to the screw construct (p = 0.0343).

Conclusion

This biomechanical study comparing the performance of elastic cable and static suture tape cerclage fixation methods identified that the elastic cable cerclage exhibits a higher load-at-failure and less displacement under repetitive stress. In addition, elastic cable cerclage fixation exhibits greater strength and construct rigidity than traditional metal screw fixation.

Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement

PURPOSE

To establish consensus statements on glenoid bone grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability.

METHODS

A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their greater risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain.

CONCLUSIONS

The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired.

LEVEL OF EVIDENCE

Level V, expert opinion.

Biomechanical Outcomes of Glenoid Bone Graft Fixation Techniques: A Systematic Review

BACKGROUND

The Latarjet and other bony augmentation procedures are commonly used to treat anterior shoulder instability in the setting of significant glenoid bone loss. Although several fixation strategies have been reported, the biomechanical strength of these techniques remains poorly understood.

PURPOSE

To perform a systematic review of the biomechanical strength of glenoid bony augmentation procedures for anterior shoulder instability.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search of the Medline, Embase, Web of Science, and Cochrane Library databases was performed to identify biomechanical studies evaluating various fixation strategies for coracoid and other bone transfer procedures for anterior shoulder instability. Biomechanical results included load to failure with both compression and traction forces, stiffness, and cyclic displacement. The quality of included articles was assessed based on the Quality Appraisal for Cadaveric Studies (QUACS) scale.

RESULTS

A total of 21 biomechanical studies comprising 486 specimens were included. The number of screws used and the addition of washers were found to significantly increase rigidity and load to failure. The comparison of fixation techniques demonstrated mixed results in load to failure between screw and alternative constructs including suture buttons and suture anchors. However, studies that tested graft displacement consistently found more graft displacement in buttons compared with screws. The median and mean of the QUACS scale were both 12, with a range of 10-13.

CONCLUSION

Biomechanical studies consistently demonstrated that when glenoid bone grafts were fixed with screws, the number of screws and use of washers significantly increased construct rigidity and load to failure. Different metal screw materials and sizes did not consistently demonstrate a significant difference in biomechanical strength. There are mixed results when comparing suture buttons to screw fixation. The evaluated studies revealed that all double metal screw constructs and the majority of suture button and anchor constructs were able to withstand the glenohumeral load reflective of activities of daily living using a 150-N threshold.

Clinical and radiographic outcomes using standard length of cannulated screws for traditional Latarjet procedure

Background

The purpose of this study was to evaluate the clinical and radiographic outcomes of open traditional Latarjet stabilization using 32-mm-long and 30-mm-long cannulated screws in males and females, respectively, with a minimum of 2 years of follow-up.

Methods

We retrospectively reviewed open Latarjet procedures using cannulated screws of standard length with a minimum of 2 years of follow-up. Functional evaluation was performed with postoperative Rowe and Walch score, visual analog scale for pain and return to sport. Graft healing was assessed with computed tomography scans at 4 to 6 months postoperatively. Patients were divided into 2 groups according to postoperative radiographic measurements: a bicortical or unicortical screw group. The α angle between the shaft of the screw and the glenoid subchondral bone was measured for superior and inferior screws. Level of significance was 0.05. The post hoc power analysis was 0.89.

Results

A total of 69 patients met the criteria for inclusion. Of these patients, 60 (87%) were available for final follow-up (n = 62 shoulders), with a mean age of 28.4 ± 9.5 years (range, 16-55 years) at the time of surgery. Fifty six males (93.3%) and 4 females (6.7%) were included. The mean final follow-up period was a mean of 38 months after the procedure (range, 25-48 months). Eight of 60 patients (13.3%) had persistent apprehension in abduction-external rotation position. One patient (1.7%) had a recurrence of shoulder subluxation. The mean Walch-Duplay score was 90 ± 11.6 points (range, 40-100 points), and the mean Rowe score was 93.4 ± 11 points (range, 50-100 points). The mean visual analog scale score for the evaluation of pain was 0.9 ± 1.3 (range, 0-4). The coracoid healed the glenoid neck in 87.1% (54/62) of the shoulders on the postoperative computed tomography scan. Lower alpha angle for inferior and superior screws had more rate of unicortical fixation (P = .05 and P = .04, respectively). Fourteen of 62 (22.6%) shoulders were found unicortical screws. Six bicortical cases and 2 cases of unicortical screws (25%) showed nonunion (P = .86). There were 2 complications, 1 patient had hematoma that required drainage and 1 case had transient axillary nerve palsy which resolved spontaneously. No complications associated with the hardware were found.

Conclusion

Open traditional Latarjet procedure using 32-mm-long and 30-mm-long cannulated screws in males and females, respectively, provided good outcomes with acceptable complication rates. Unicortical screws fixation does not have a higher rate of nonunion than bicortical screws.

Screw fixation versus suture-button fixation for the Latarjet procedure-a systematic review and meta-analysis

Objective

To perform a systematic review and meta-analysis to compare the results of the Latarjet procedure performed using screws (S) or suture-button for coracoid graft fixation.

Methods

A systematic search in Pubmed, EMBASE, and The Cochrane Library databases was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Cohort studies comparing outcomes in the Latarjet procedure with screw fixation versus the Latarjet procedure with suture-button fixation were included.

Results

Five studies with 877 patients were included. There was a significantly lower rate of recurrent instability in those with S fixation compared to the suture-button fixation (1.5% vs 5%, p = 0.001). There was a significantly higher rate of reoperations with S fixation compared to suture-button fixation (4.3% vs 0%, p = 0.001). There were no significant differences between the groups regarding total complications (S: 7.5% vs suture-button: 3.6% p = 0.12) graft fracture (S: 0.8% vs suture-button: 0.5% p = 0.62) and symptomatic hardware (S: 2.7% vs suture-button: 0% p = 0.12).

Conclusion

The Latarjet surgery was associated with favorable results and a low rate of complications regardless of the type of fixation used. Screw fixation was associated with a significantly lower rate of recurrences, but greater reoperations due to irritation or pain after surgery.

Level of evidence

Systematic review and meta-analysis, level III.

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.

Does the use of a tensioning device improve stability for suture fixation of glenoid bone constructs? A biomechanical analysis

Purpose

The purpose of this study is to quantify the difference in biomechanical stability of suture button (SB) and suture tape cerclage (STC) constructs with hand tensioning versus device tensioning of anterior glenoid augmentation bone grafts in an anterior glenoid bone loss model.

Methods

Artificial bone blocks with a density of 15 lb/ft3 (240.3 kg/m3) were used as models for glenoid fixation with bone graft. The biomechanical stability of SB and STC tensioned by hand was compared to those tensioned by a device. Average displacement (mm) following application of various forces (50, 100, 150, and 200 N) during a 7-phase, 100-cycle, stairstep cyclic loading protocol was recorded.

Results

Both SB and STC fixation displayed significantly lower construct displacement at all tested forces when tensioned with a device versus hand (p < 0.001). Device-tensioned SB and STC were comparable in construct stability at forces below 100N. However, at forces above 100 N, device-tensioned SB exhibited significantly less displacement than device-tensioned STC.

Discussion

Using a tensioning device for SB or STC fixation of a coracoid graft model results in less displacement and improved stability compared to hand tensioning. Biomechanically, a tensioning device enhances the stability of suture fixation in glenoid bone graft constructs.

Sutures, Screws, Buttons, and Anchors: A Review of Current Bone Graft Fixation Devices for Glenoid Bone Loss in the Unstable Shoulder

PURPOSE OF REVIEW

Anterior shoulder instability is associated with concomitant injury to several stabilizing structures of the shoulder, including glenoid bone loss. While instability is most common in young athletes and patients with predisposing conditions of hyperlaxity, recurrent shoulder instability can occur throughout various age ranges and may lead to longer term effects including pain and shoulder arthritis. Glenoid bone loss exceeding certain thresholds is generally treated by glenoid reconstruction via bone block augmentation to adequately stabilize the glenohumeral joint. These procedures increase the width of the articular surface on which the humeral head can translate before dislocation and, based on the procedure performed, provide a sling effect via the conjoined tendon, and increase tension to support the anterior capsule. The purpose of this review is to summarize the available literature regarding bone block fixation techniques.

RECENT DEVELOPMENTS

Various fixation techniques have been utilized to secure bone block transfers. Though screw fixation has traditionally been used for bone block fixation, suture buttons, suture anchors, and all-suture techniques have been utilized in attempts to avoid complications associated with the use of screws. Biomechanical studies report variable force-resistance, displacement, and mode of failure when comparing screw to suture button-based fixation of glenoid bone blocks. Clinical and radiographic studies have shown these novel suture-based techniques to be comparable, and in some cases advantageous, to traditional screw fixation techniques. While screw fixation has long been the standard of care in glenoid bone block procedures, it is associated with high complication rates, leading surgeons to endeavor toward new fixation techniques. In available biomechanical studies, screw fixation has consistently demonstrated high maximal load-to-failure and displacement with cyclic loading. Studies have reported similar clinical and radiographic outcomes in both screw and suture-based fixation methods, with evidence of reduced bone resorption with suture fixation. While suture button fixation is associated with a higher rate of recurrent instability, overall complication rates are low. Future research should address biomechanical shortcomings of suture-based fixation techniques and continue to assess long-term follow-up of patients treated with each fixation method.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Suspensory fixation for bone transfer procedures in shoulder instability is superior to screws in an angled construct: a biomechanical analysis

Background

The Latarjet procedure is a common bony augmentation procedure for anterior shoulder instability. Historically, screw fixation is used to secure the coracoid graft to the anterior glenoid surface; however, malpositioning of the graft leads to oblique screw insertion that contributes to complications. Suture buttons (SBs) are a more recent fixation technique that have not been studied alongside standard screw fixation in the context of biomechanical models of angulated fixation. This study aims to compare the biomechanical strength of single and double, screw and SB fixation at various levels of angulation.

Methods

Testing was performed using polyurethane models from Sawbones. The graft piece was secured with screw fixation (Arthrex, Naples, FL, USA) or suspensory button (ABS Tightrope, Arthrex, Naples, FL, USA). Single or double constructs of screws and SBs were affixed at 0°, 15°, and 30° angles to the face of the glenoid component. An aluminum testing jig held the samples securely while a materials testing system applied loads. Five constructs were used for each condition and assessed load to failure testing.

Results

For single fixation constructs, suspensory buttons were 60% stronger than screws at 0° (P < .001), and 52% stronger at 15° (P = .004); however, at 30°, both were comparable (P = .180). Interestingly, single suspensory button at 15° was equivalent to a single screw at 0° (P = .310). For double fixation, suspensory buttons (DT) were 32% stronger than screws at 0° (P < .001) and 35% stronger than screws at 15° (P < .001). Both double fixation methods were comparable at 30° (P = .061). Suspensory buttons at 15° and 30° were equivalent to double screws at 0 (P = .280) and 15° (P = .772), respectively.

Conclusion

These measurements indicate that the suspensory button has a significantly higher load to failure capacity over the screw fixation technique, perpendicularly and with up to 15° of angulation. These analyses also indicate that the suspensory button fixation offers superior strength even when positioned more obliquely than the screw fixation. Therefore, suspensory button fixation may confer more strength while offering greater margin for error when positioning the graft.

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.

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.

Primary Stability and Bone Contact Loading Evaluation of Suture and Screw based Coracoid Graft Fixation for Anterior Glenoid Bone Loss

BACKGROUND

Reconstruction techniques for anterior glenoid bone loss have seen a trend from screws to suture-based fixations. However, comparative biomechanical data, including primary fixation and glenoid-graft contact pressure mapping, are limited.

HYPOTHESIS

Suture-based bone block cerclage (BBC) and suspensory suture button (SB) techniques provide similar primary fixation and cyclic stability to double-screw fixation but with higher contact loading at the bony interface.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 60 cadaveric scapulae were prepared to simulate anterior glenoid bone loss with coracoid autograft reconstruction. Graft fixation was performed with 3 different techniques: (1) an interconnected all-suture BBC, (2) 2 SB suspensions, and (3) 2 screws. Initial compression was analyzed during primary fixation. Cyclic peak loading with 50 N and 100 N over 250 cycles at 1 Hz was performed with a constant valley load of 25 N. Optical recording and pressure foils allowed for spatial bone block tracking and contact pressure mapping at the glenoid-graft interface. Load-to-failure testing was performed at a rate of 1.5 mm/s with ultimate load and stiffness measured.

RESULTS

Initial graft compression was higher with screw fixation (141 ± 5 N) compared with suture-based fixations (P < .001), with BBC fixation providing significantly higher compression than SB fixation (116 ± 7 N vs. 91 ± 5 N; P < .001). Spatial bone block migration and ultimate failure load were similar between the BBC and screw groups. The SB group showed significantly increased bone block translation (3.1 ± 1.0 mm; P≤ .014) and rotation (2.5°± 1.4°; P≤ .025) and significantly lower ultimate failure load (180 ± 53 N) compared with the BBC (P = .046) and screw (P = .002) groups. Both suture-based fixations provided significantly increased graft-glenoid contact loading with higher pressure amplitudes (P≤ .032) and contact pressure after cyclic loading (+13%; SB: P = .007; BBC: P = .004) compared with screw fixation.

CONCLUSION

Both SB and interconnected cerclage fixation improved dynamic contact loading compared with screw fixation in a biomechanical glenoid bone loss model. Cerclage fixation was biomechanically comparable with screw fixation but with a greater variability. SB fixation showed significantly lower primary fixation strength and greater bone block rotation and migration.

CLINICAL RELEVANCE

Suture-based bone block fixations improved graft-glenoid contact loading, but the overall clinical consequence on healing remains unclear.

Posterior Glenoid Bone Loss and Instability: An Evidence-based Approach to Diagnosis and Management

Posterior glenohumeral instability is an underappreciated cause of disability that may necessitate surgical intervention to allow functional glenoid restoration. However, posterior glenoid bone abnormalities, when sufficiently severe, may contribute to persistent instability despite a well-performed capsulolabral repair. Recognition and understanding of these lesions is critical to both surgical decision making and execution of the surgical plan. Numerous procedures have been described to address posterior instability including recent developments in arthroscopic grafting techniques. The purpose of this article was to provide an evidence-based strategy for diagnosis and management of posterior shoulder instability and glenoid bone loss.

Clinical and Radiologic Outcomes of All-Arthroscopic Latarjet Procedure With Modified Suture Button Fixation: Excellent Bone Healing With a Low Complication Rate

PURPOSE

To investigate the clinical outcomes and radiologic evaluation of an all-arthroscopic Latarjet procedure with modified button fixation.

METHODS

Patients who received all-arthroscopic Latarjet procedure with modified suture button fixation between September 2015 to September 2016 were retrospectively reviewed. Indications for surgery were recurrent anterior shoulder dislocation with any 1 of these 3 conditions: glenoid defect >15%, contact-sport athlete, or failure after Bankart repair. Inclusion criteria included cases who received this surgery. Clinical outcomes were evaluated by University of California Los Angeles, ASES and Rowe score with a minimal follow-up of 3 years. Radiologic assessment on 3D computed tomography scan was performed preoperatively and postoperatively at different time points. Complications were also recorded.

RESULTS

A total of 30 patients were eventually included in this study. The mean follow-up time was 38.0 ± 2.5 months. There were 25 patients who performed contact sports. Of them, 10 patients were without glenoid defect >15% or failed Bankart repair. The remaining 20 patients had glenoid defect >15%, including 2 failed Bankart cases. Ten patients had glenoid defect < 13.5%, and the rest 20 patients had > 13.5%. UCLA, American Shoulder and Elbow Surgeons, and Rowe score significantly improved during follow-up, and the improvement exceeded MCID for all patients. No severe complications were noted. In total, 86.7% of the graft positioning was measured as flush and 13.3% as medial. The bone union rate was 96.7% at 3 months postoperatively and at final follow-up. The remodeling process for the restoration of the normal anatomy of the lower part of glenoid was noted.

CONCLUSIONS

All-arthroscopic Latarjet with modified suture button fixation can achieve stable fixation of the coracoid, good clinical outcomes (all patients with improvement exceeding MCID), low complications rate. Furthermore, the bone remodeling process contributes to the recovery of the normal anatomy of anteroinferior glenoid.

STUDY DESIGN

Case series; Level of evidence, 4.

Arthroscopic Trillat procedure combined with capsuloplasty: an effective treatment modality for shoulder instability associated with hyperlaxity

PURPOSE

The aim of this study was to describe the results of an arthroscopic Trillat procedure utilized to treat patients with symptomatic antero-inferior shoulder instability associated with hyperlaxity.

METHODS

A retrospective review was performed on 19 consecutive shoulders (17 patients, 2 bilateral) who underwent a Trillat procedure combined with anterio-inferior capsulolabral plasty from 2016 to 2019. Patients included in the study presented with shoulder instability combined with shoulder hyperlaxity and no glenoid or humeral bone loss. Clinical assessment included range of motion, apprehension, and instability tests. Outcome measures Constant-Murley score (CMS) scale, Walch-Duplay, ROWE, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS). Post-operatively, healing of the coracoid osteoclasy was evaluated by CT scan.

RESULTS

The mean follow-up was 24.8 months (range, 12-51). Post-operatively, none of the patients experienced a recurrent dislocation or subluxation and the anterior apprehension test was negative in all shoulders. Post-operative motion deficits of 22.1° ± 15.8 [p < 0.05] and 12.4° ± 10.1 [p < 0.05] loss were documented for ER1 and ER2, respectively. All functional scores exhibited significant improvements. Post-operative CT scan was available in 16 shoulders and revealed coracoid union in 15/16 shoulders and an asymptomatic fibrous non-union without coracoid or implant migration in one patient.

CONCLUSION

The arthroscopic Trillat procedure combined with an antero-inferior capsulolabral plasty is effective in preventing recurrent instability and eliminating shoulder apprehension among patients suffering from anterior and or inferior hyperlaxity.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic "Double-Inlay" Eden-Hybinette Procedure with Modified Suture Button Fixation for the Revision of Failed Bristow-Latarjet

Bristow-Latarjet procedure has been widely regarded as a reliable and satisfactory operation for recurrent anterior glenohumeral instability, especially for patients with significant glenoid bone loss or high sports demand. Once failed, however, the subsequent revision surgery could be challenging. Eden-Hybinette procedure is the most common operation for revision of failed Bristow-Latarjet. It can perfectly restore the bone defect of the failed Bristow-Latarjet by harvesting a proper size of iliac bone block. Furthermore, several studies have shown the advantages of using suture button fixation in the revision surgery for failed Bristow-Latarjet procedure. However, the potential inferior biomechanical strength of suture button fixation is still a concern. This Technical Note introduced an arthroscopic "double-inlay" Eden-Hybinette procedure with modified suture button fixation for the revision of failed Bristow-Latarjet. With its "quadruple" reinforcement effect, this procedure can achieve an excellent biomechanical strength of fixation.