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

Suture Button Fixation in Shoulder Instability Surgery to Achieve Bone Healing: A Critical Analysis Review

» Suture button fixation has emerged as an effective surgical construct in arthroscopic and open Latarjet and anterior glenoid reconstruction with free autograft bone with high rates of bone block healing.» Biomechanical data suggest that screw and suture button mechanical fixation constructs provide similar load to failure and stability for the Latarjet procedure.» Preliminary bone healing models have identified that flexible fixation may exhibit a higher degree of bone callus maturation, whereas rigid fixation results in excessive callus hyperplasia» Mechanical tensioner use provides consistent tensioning of suture button constructs and improves bone-to-bone healing rates when used for anterior glenoid reconstruction surgery.» Evidence is lacking regarding the reliability of bone-to-bone healing of allografts to native bone with use of suture button constructs.» Suture button fixation provides good short- and mid-term clinical outcomes for the arthroscopic Latarjet and anterior glenoid reconstruction with free autograft bone.

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.

Comparison of Return to Sports and Competition After the Arthroscopic Bristow-Latarjet Procedure Versus Arthroscopic Bankart Repair in Adolescents With Recurrent Anterior Shoulder Instability

BACKGROUND

The use of isolated soft tissue repair versus bone block stabilization for the treatment of recurrent anterior shoulder instability in adolescents has no scientific evidence.

PURPOSE

To compare the clinical outcomes of adolescent patients who underwent isolated arthroscopic Bankart (iB) repair with those who underwent the arthroscopic Bristow-Latarjet procedure in addition to Bankart (BLB) repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 60 shoulders in adolescents (aged 13-18 years) were reviewed with a minimum 2 years' follow-up: iB repair (n = 36) and arthroscopic Bankart repair with an additional Bristow-Latarjet procedure (BLB; n = 24). The characteristics of the patients in each group in terms of age at the first instability episode, age at surgery, hyperlaxity, participation in at-risk sports, and Instability Severity Index Score were comparable. The mean follow-up was longer in the iB group (7.7 vs 4.1 years, respectively), whereas the rates of patients engaged in competition and those with glenoid lesions were higher in the BLB group. The primary outcome measures were failure, defined as the recurrence of instability (clinical dislocation or subluxation), and return to sports. The mean follow-up was 6.2 years (range, 2-16 years).

RESULTS

At the last follow-up, the rate of recurrence was significantly higher in the iB group, with 22% (8/36) failures, than in the BLB group, with 8% (2/24) instability recurrences (P < .05). The rate of return to sports at the same level was significantly higher after the BLB repair than after iB repair (79% vs 47%, respectively; P < .001). No statistical difference was found in patient-reported outcome scores between treatment groups (P > .05). Although failures occurred early after the BLB repair, 88% of failures after iB repair occurred after 2 years. On multivariate analysis, adolescents in the iB group with >3 episodes of preoperative dislocation and shoulder hyperlaxity (external rotation >90°) had a 60% recurrence rate (P < .005).

CONCLUSION

Adolescent patients undergoing the BLB repair had a lower rate of recurrent instability and higher rates of return to sports and competition than those undergoing iB repair. Patients with shoulder hyperlaxity (external rotation >90°) and >3 dislocations had an unacceptable failure rate of 60% after iB repair.

Stability of novel cow-hitch suture button coracoid bone graft fixation in Latarjet procedures: a biomechanical study

BACKGROUND

The Latarjet procedure is widely used to address anterior shoulder instability, especially in case of glenoid bone loss. Recently, cortical suture button fixation for coracoid transfer has been used to mitigate complications seen with screw placement. The aim of this biomechanical study was to evaluate the stability of a novel and cost-effective cow-hitch suture button technique, designed to be performed through a standard open deltopectoral approach, and compare this to a well-established double suture button technique.

MATERIALS AND METHODS

We randomly assigned 12 fresh frozen cadaveric shoulders to undergo the Latarjet procedure with either 4 suture button (S&N EndoButton) fixations (SB group; n = 6, age 72 ± 9.8 years) or cow-hitch suture button technique using a 1.7-mm FiberTape looped sequentially in 2 suture buttons (Arthrex Pectoralis Button) placed from anterior on the posterior glenoid (CH-SB group; n = 6, age 73 ± 9.3 years). After fixation, all shoulders underwent biomechanical testing with direct loading on the graft via a material testing system. Cyclic loading was performed for 100 cycles (10-100 N) to determine axial displacement with time; each graft was then monotonically loaded to failure.

RESULTS

The maximum cyclic displacement was 4.3 ± 1.6 mm for the cow-hitch suture button technique and 5.0 ± 1.7 mm for the standard double suture button technique (P = .46). Ultimate load to failure and stiffness were, respectively, 190 ± 82 N and 221 ± 124 N/mm for the CH-SB technique and 172 ± 48 N and 173 ± 34 N/mm for the standard double SB technique (P = .66 and .43). The most common failure mode was suture cut-through at the anteroinferior aspect of the glenoid for both fixation groups.

CONCLUSIONS

The cow-hitch suture button technique resulted in a similar elongation, stiffness, and failure load compared to an established double suture button technique. Therefore, this cost-effective fixation may be an alternative, eligible for open approaches, to the established double suture button techniques.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

PURPOSE

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure.

METHODS

Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up.

RESULTS

No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P = .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P = .030 and P = .034, respectively).

CONCLUSIONS

Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Size and morphology of the coracoid and glenoid in pediatric and adolescent patients: implications for Latarjet procedure

Background

Glenohumeral instability is a challenging problem in children and adolescents. For patients with anterior glenoid bone loss, the Latarjet procedure is an effective treatment option. However, concerns about coracoid size and morphology may limit its utilization within this patient population. The purpose of this study was to establish normative data on coracoid and glenoid size and morphology among a large cohort of adolescent patients and describe the anatomic relationships with demographic factors.

Methods

This is a retrospective cross-sectional study of a consecutive series of 584 patients aged 12-21 years after a chest computed tomography scan for non-shoulder related trauma at a single level I trauma center. Demographic characteristics were collected from the electronic medical record, and the following coracoid anatomic measurements were obtained from computed tomography scans: coracoid length, coracoid thickness, coracoid width, glenoid height, and glenoid width. The ratio of coracoid thickness to glenoid width was calculated to estimate the percent bone loss that could be addressed with a traditional Latarjet coracoid transfer. To ensure reliability among 3 reviewers, all measured the same 25 scans and inter-rater reliability was excellent with all Kappa coefficients >0.81. The remaining scans were divided equally and assessed separately by these reviewers. Correlation coefficients were used to quantify the relationships between all anatomic measures and the age, weight, and height of individuals. Growth curves for each measurement were modeled using quantile regression with height and height∗height as predictors. Additionally, we stratified the growth curves by sex, when significant. Of the 584 subjects, 55% were male, and average age was 19 years (range 12, 21).

Results

All growth curves illustrated increase anatomic size across the height range of 145-190 cm. The growth curve including all patients (Fig. 1) illustrated that the 50% percentile of median coracoid length increased from approximately 28 to 32 mm. In addition to height, sex was a significant predictor for coracoid width and glenoid width. The median coracoid width increased from approximately 9.5 to 10.2 mm for females compared to an increased width from approximately 10 to 11 mm for males. The median glenoid width for females increased from approximately 21 to 25 mm and for males the median glenoid width increased from just under 22 to 25.5 mm.

Conclusions

Among children and adolescents, coracoid and glenoid size are correlated with patient height. These data can help guide patient selection for the Latarjet procedure.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer

PURPOSE

Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts.

METHODS

A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded.

RESULTS

177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.).

CONCLUSION

The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates.

LEVEL OF EVIDENCE

Level II.

Acromion and Distal Clavicle Grafts for Arthroscopic Glenoid Reconstruction

BACKGROUND

We intended to determine if an acromion or distal clavicle bone graft could restore large glenoid defects using two novel, screw-free graft fixation techniques.

METHODS

Twenty-four sawbone shoulder models were divided into four groups (n = 6 per group) according to fixation technique and bone graft: (1) modified buckle-down technique with clavicle graft, (2) modified buckle-down technique with acromion graft, (3) cross-link technique with acromion graft, (4) cross-link technique with clavicle graft. Testing was performed sequentially in (1) intact models, (2) after creation of a 30% by-width glenoid defect and (3) after repair. The shoulder joint was translated anteriorly, and glenohumeral contact pressures and load were measured to quantify the biomechanical stability.

RESULTS

Maximum contact pressures were restored to 42-56% of intact glenoid using acromion and clavicle grafts with novel fixation techniques. Acromion grafts attained higher maximum contact pressures than clavicle grafts in all groups. Peak translational forces increased by 171-368% after all repairs.

CONCLUSIONS

This controlled laboratory study on sawbone models found that both the acromion and distal clavicle are suitable autologous bone graft options for treating large anterior glenoid defects, having appropriate dimensions and contours for reconstructing the glenoid arc. The modified buckle-down and cross-link techniques are two graft fixation techniques that restore stability to the shoulder joint upon repairing a large glenoid defect and are advantageous in being screw-free and simple to execute.

Arthroscopic Remnant Coracoid Autograft for Revision of the Failed Latarjet Procedure With Persistent Glenoid Bone Loss

Recurrence of anterior instability after a Latarjet procedure with persistent glenoid bone loss can be related to coracoid bone block resorption, migration, or malposition. Multiple options are available to address anterior glenoid bone loss, including autograft bone transfers (such as iliac crest graft, distal clavicle autograft) or allografts (distal tibia allograft). Here, we present the use of the remnant coracoid process as an option for consideration in the treatment of glenoid bone loss after failed Latarjet procedure with persistent glenoid bone loss. The remnant coracoid autograft is harvested and transferred inside the glenohumeral joint, through the rotator interval, and fixed using cortical buttons. This arthroscopic procedure includes using 1) glenoid and coracoid drilling guides to optimize graft positioning and making the procedure more reproducible and safer and 2) a suture tensioning device to provide intraoperative graft compression and ensure bone graft healing.

Tensioning device increases coracoid bone block healing rates in arthroscopic Latarjet procedure with suture-button fixation

BACKGROUND

There is growing interest in using suture buttons for coracoid fixation to avoid the complications associated with screws during the Latarjet procedure. However, achieving bone block healing is critical for successful shoulder stabilization and return to sport. The purpose of this study was to assess and compare the healing rates and positioning of the coracoid bone block fixed with cortical suture buttons that were either manually tensioned (using a knot pusher) or mechanically tensioned (using a tensioning device) during arthroscopic Latarjet procedures.

METHODS

This prospective, nonrandomized, comparative study enrolled 69 consecutive patients (mean age, 27 years) who underwent an arthroscopic guided Latarjet procedure with suture-button fixation. Hand tensioning was performed in the first 34 shoulders, whereas the next 35 shoulders underwent mechanical tensioning. Twelve patients (17%) had a history of failed Bankart stabilization. The characteristics of the patients in each group in terms of age, sex, type of sport, bone loss, number of previous failed surgical procedures, smoking, and length of follow-up were comparable. Intraoperatively, the tensioning device was set at 100 N successively 3 times until complete immobilization of the bone block was confirmed, as assessed with a probe. The primary outcome measure was coracoid bone block union and position on computed tomography scan images at 6 months' follow-up. Secondary outcome measures included functional outcome scores, shoulder stability, return to sports, and complications at last follow-up.

RESULTS

Overall, the rate of bone block healing was 74% (25 of 34 patients) in the hand-tensioning group and 94% (33 of 35 patients) in the mechanical tensioning group (P = .043). Smoking was an independent risk factor associated with nonunion (P < .001) in each group. Patient age, size of the preoperative glenoid bone defect (<20% or >20%), and a history of surgery were not found to have any influence. The tensioning modality did not affect the bone block position, which was subequatorial in 92% of the cases and flush with the glenoid rim in 92%. At a mean of 34 months of follow-up (range, 24-62 months), 96% of the patients (65 of 69) had a stable shoulder and 87% returned to sports. At final follow-up, no significant difference in clinical scores was noted between the groups; no neurologic or hardware complications were observed.

CONCLUSION

Mechanical tensioning achieves significantly higher healing rates than hand tensioning during the arthroscopic Latarjet procedure with suture-button fixation. The use of a suture-tensioning device is a key step to the suture-button fixation technique during arthroscopic Latarjet procedures. By making the suture-button construct rigid, the tensioning device transforms the initially flexible suture into a "rigid fixation", similar to a bolt (or a rivet).