Arthroscopic Latarjet procedure with double-button fixation: short-term complications and learning curve analysis

Suture Button Fixation in Latarjet Has Similar Load to Failure and Clinical Outcomes but Lower Bone Resorption Compared With Screw Fixation: A Systematic Review

PURPOSE

To compare the 2 Latarjet fixation techniques-screw fixation (SF) versus suture button (SB) -for clinical, biomechanical, and radiologic outcomes.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic and Meta-Analyses guidelines using MEDLINE and Embase databases and was prospectively registered on PROSPERO. Only comparative clinical and biomechanical studies of Latarjet with SF and SB were included. Studies were appraised using the Methodical Index for Non-Randomised Studies (MINORS) tool.

RESULTS

Eleven studies met eligible criteria: 7 clinical studies (SB, n = 279; SF, n = 845) and 4 biomechanical. In total, 80.9% (SB) and 84.2% (SF) of patients were male. Follow-up ranged from 6 to 63.6 months. The overall recurrent instability rate for SB ranged from 0 to 8.3% and for SF ranged from 0 to 2.75%. Only one study demonstrated a greater recurrent instability rate with SB (P = .02). Overall SB complication rates ranged from 0 to 12.5% and SF ranged from 0 to 27%. Two studies reported greater complications and reoperations with SF related to hardware. Summary forest plots from 4 studies showed no significant difference in Walch Duplay score (mean difference, range -5.00 to 1.20 [95% confidence interval {CI} -12.13 to 8.56], I2 inconsistency = 0%), Rowe score (mean difference, range -2.00 to 4.00 [95% CI -7.37 to 7.66], I2 inconsistency = 45%), and VAS for pain (mean difference, range -0.10 to 0.60 [95% CI -0.72 to 1.33], I2 inconsistency = 0%). There was no statistically significant difference between SB and SF in the postoperative range of motion. Radiologically, there was no significant difference in graft positioning and union at final follow-up, but graft resorption was greater in SF (range 25.2%-47.6%) compared with SB (range 10.1%-18.5%). Biomechanical studies showed no significant difference in maximum load to failure (SB, range 184-266 N vs SF, range 148-288 N).

CONCLUSIONS

Clinically, SB fixation demonstrated similar functional outcome and range of motion when compared with SF, with the potential benefit of lower rates of graft resorption and hardware-related complications. Biomechanically there was no difference in maximum load to failure.

LEVEL OF EVIDENCE

Level III, systematic review of Level III and biomechanical studies.

Faster strength recovery and better strength ratio with arthroscopic Latarjet compared to the open technique: An observational study

INTRODUCTION

The arthroscopic bone block has shown reliability and reproducibility regarding functional scores and shoulder mobility compared to the open bone block technique. The recovery of muscle strength, especially the strength ratio external rotator/internal rotator (ER/IR), is crucial to recovering satisfactory function. This ratio should be as near to 1 as possible, meaning a good strength balance. Little is known about the difference in strength recovery between the open and arthroscopic techniques.

HYPOTHESIS

Arthroscopic Latarjet reduces surgical stress and improves the strength recovery and strength ratio.

OBJECTIVES

To compare arthroscopic and open Latarjet procedures for shoulder muscle strength and functional outcomes.

MATERIAL AND METHODS

It was an observational longitudinal and prospective cohort follow-up. Two groups of patients were accessible for comparison: 35 in an arthroscopy group and 38 in an open group. The main outcome was the muscle strength of shoulder muscles measured with a dynamometer and expressed in Newton (N) at day 21 (D21), D45, D90, D180, and D365 in the operated and contralateral shoulders. The measurements were made for the pectoralis major, the three deltoid fascicles, and the subscapularis. The shoulder ER/IR strength ratio was calculated. Other variables were the range of motion (ROM), the Walch-Duplay (WD), the Western Ontario Shoulder Instability score (WOSI), and the Visual Analogic Scale for pain assessment. The strength, ROM, and functional scores were compared between open and arthroscopy with linear mixed models.

RESULTS

The median strengths at 52 weeks were significantly higher than at 3 weeks (P<10-4): anterior deltoid (AD) 8N (Q1:7, Q3: 9) versus 4N (Q1:2, Q3: 5), lateral deltoid (LD) 9N (Q1:9, Q3: 11) versus 6N (Q1:4, Q3: 7), posterior deltoid (PD) 14N (Q1:12, Q3: 15) versus 9N (Q1:8, Q3: 10), subscapularis 10N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 8), and pectoralis major (PM) 11N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 10). The overall strengths were lower in the open group compared to the arthroscopy group: AD -2.1N (CI95%[-3.1--1.2], p=0.0005), LD -1.3N (CI95% [-2.4--0.15], p=0.03), PD -0.35N (CI95% [-1-0.9], p=0.52), subscapularis -2.1N (CI95% [-3.3--0.7], p=0.006), and PM -1.4N (CI95% [-2.2--0.02], p=0.03). The ER/IR ratio was stable throughout the follow-up for both the operated and contralateral shoulders (p>0.5). The overall mean ratio was 1.3 (median 1.2, Q1: 1, Q3:1.45) for the operated shoulder and 1.1 (median 1, Q1: 0.9, Q3:1.3) for the contralateral shoulder (p=0.0004). The average ER/IR ratio was 0.27 points higher in the open group (CI95% [0.1-0.46], p=0.003). The ROM was similar between the two groups, and there was no correlation between the ER/IR ratio and the ROM (p>0.5). The VAS < 3 weeks and WD > 12 weeks were significantly poorer in the open group: +0.61 (CI95% [0.03-1.16] p=0.02), and -7.3 points (CI95% [-13--0.01], p=0.05), on average, respectively.

CONCLUSION

The patients in the arthroscopy group had a better ER/IR strength ratio (closer to 1) and better WOSI after 12 weeks. The strength and the ROM were not correlated with each other.

LEVEL OF EVIDENCE

III.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level IV, therapeutic case series.

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 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.

The arthroscopic double-button Latarjet does not modify the static posterior translation of the humeral head

INTRODUCTION

The Latarjet procedure treats anterior instability of the shoulder and is based on a triple anterior lock, where the conjoint tendon straps the lower third of the subscapularis muscle. Excessive posterior translation of the humeral head is a known risk factor for shoulder osteoarthritis. No in vivo study has investigated the effect of the bone block on the posterior static translation of the humeral epiphysis. The purpose of this study was to evaluate the effect of the bone block on the static posterior translation of the humeral head. The hypothesis was that this procedure increased this translation.

MATERIALS AND METHODS

This retrospective study included patients treated arthroscopically for anterior shoulder instability by a double-button Latarjet. An independent examiner analyzed the CT scans preoperatively, at 15 days, and at least 6 months postoperatively according to a standardized protocol. The analysis focused on the position of the bone block in the axial and coronal planes relative to the glenoid. The posterior translation was automatically calculated using the Blueprint© planning software.

RESULTS

Thirty-five patients were included with a mean age of 25 years (16-43), according to a 4M/1F sex ratio. The graft was perfectly flush to the subchondral bone in 63% (n=22) of cases and subequatorial in 91% (n=32). Preoperative posterior humeral translation was 52%. The mean immediate postoperative posterior humeral translation was 56%, and 57% at more than 6 months. The change in mean posterior humeral translation between preoperative/6 months was +0.94% [-20%; +12%] (p=0.29) and immediate postoperative/6 months +0.34% [-18%; +15%] (p=0.84). Gender, hypermobility and the axial position of the bone block did not influence the change in posterior humeral translation. The equatorial position of the bone block appeared to increase posterior humeral translation by +10%±5.2% [-0.427; 20.823] (p=0.07).

CONCLUSION

This work refutes our initial hypothesis. The change in static posterior humeral translation after arthroscopic Latarjet bone block remains stable at more than 6 months of follow-up. This procedure does not alter the anatomical position of the humeral head in relation to the glenoid. On the other hand, a more cranial positioning of the bone block could have an influence.

LEVEL OF EVIDENCE

IV.

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.

Remodeling process and clinical outcomes following all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and 1-tunnel double Endobutton fixation system

BACKGROUND

Arthroscopically modified Eden-Hybinette procedures for glenohumeral stabilization have been used for a long time. With the advancement of arthroscopic techniques and the development of sophisticated instruments, a double Endobutton fixation system has been used clinically to secure bone graft to the glenoid rim placed through a specifically designed guide. The purpose of this report was to evaluate clinical outcomes and serial glenoid remodeling process following all-arthroscopic anatomical glenoid reconstruction using autologous iliac crest bone grafting technique through 1-tunnel fixation.

METHODS

Forty-six patients with recurrent anterior dislocations and significant glenoid defects greater than 20% underwent arthroscopic surgery with a modified Eden-Hybinette technique. Instead of firm fixation, autologous iliac bone graft was fixed to the glenoid by double Endobutton fixation system through 1-tunnel placed in the glenoid surface. Follow-up examinations were performed at 3, 6, 12, and 24 months. The patients were followed up for a minimum of two years using the Rowe score, the Constant score, the Subjective Shoulder Value, and the Walch-Duplay score; patient satisfaction with the procedure outcome was also rated. Graft positions, healing, and absorption were evaluated postoperatively with computed tomography imaging.

RESULTS

At a mean follow-up of 28 months, all patients were satisfied and had a stable shoulder. The Constant score improved from 82.9 to 88.9 points (P ＜ .001), the Rowe score, improved from 25.3 to 89.1 points (P < .001), the Subjective Shoulder Value improved from 31% to 87% (P < .001), and the Walch-Duplay score improved from 52.5 to 85.7 points (P ＜ .001). One donor-site fracture occurred during the follow-up period. All grafts were well-positioned and achieved optimal bone healing with zero excessive absorption. The preoperative glenoid surface (72.6% ± 4.5%) increased significantly immediately after surgery to 116.5% ± 9.6% (P ＜ .001). After a physiological remodeling process, the glenoid surface remained significantly increased at the last follow-up (99.2% ± 7.1%) (P ＜ .001). The glenoid surface area appeared to decrease serially when compared between the first 6 months and 12 months postoperatively, while there was no significant interval change between 12 and 24 months postoperatively.

CONCLUSION

Patient outcomes were satisfactory following the all-arthroscopic modified Eden-Hybinette procedure using an autologous iliac crest grafting technique through one-tunnel fixation system with double Endobutton. Graft absorption mostly occurred on the edge and outside the ''best-fit'' circle of the glenoid. Glenoid remodeling occurred within the first year after all-arthroscopic glenoid reconstruction with an auto iliac bone graft.

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

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

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.

The Arthroscopic Trillat Procedure Is a Valuable and Durable Treatment Option for Recurrent Anterior Instability Associated With Massive Irreparable Cuff Tears

PURPOSE

The purpose of the present study is to report the mid- and long-term clinical and radiologic outcomes of the arthroscopic Trillat for the treatment of recurrent anterior instability in patients with chronic massive irreparable rotator cuff tears (MIRCTs) and maintained active shoulder motion where reverse shoulder arthroplasty (RSA) is not indicated.

METHODS

Twenty-one consecutive patients (mean age 61 years) were identified and retrospectively reviewed. All patients had recurrent anterior dislocations and conserved active forward elevation and active external rotation. The MIRCTs included a retracted (stage 3) supraspinatus tear in 14%, a supra- and infraspinatus tear in 76.5%, and a 3-tendon tear in 14%. A closed-wedge osteotomy of the coracoid was performed, and the coracoid was fixed above the subscapularis with a cannulated screw (10 cases) or suture buttons (11 cases). We followed patients with x-rays and computed tomography scan at 6 months, along with Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. The mean clinical and radiographic follow-up was 58 months (24-145 months).

RESULTS

Overall, 96% (20/21) of the patients had a stable and functional shoulder and were satisfied with the procedure; no patient lost active shoulder motion. The Subjective Shoulder Value increased from 44% (10%-75%) to 94% (80%-100%), P < .001. The Constant and Rowe scores improved from 60 (25-81) to 81 (66-96) and from 54 (35 to 65) to 92 (70-100), respectively (P < .001). Among the 13 patients practicing sports before surgery, 10 (77%) went back to sports. At last follow-up, only 1 patient was revised to RSA.

CONCLUSIONS

The arthroscopic Trillat procedure is a valuable and durable option for the treatment of recurrent anterior dislocations in older patients with chronic MIRCTs and conserved active shoulder motion.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Complications Related to Latarjet Shoulder Stabilization: A Systematic Review

BACKGROUND

In cases of recurrent anterior shoulder instability with a glenoid defect, Latarjet procedures are widely used for stabilization. Although complications with this procedure have been reported, few studies have comprehensively analyzed issues related to the Latarjet procedure.

PURPOSE

To identify the overall complication rate of the Latarjet procedure used for anterior shoulder instability and to compare the rate of complications between arthroscopic and open approaches.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed by using the PubMed, EMBASE, Scopus, and Cochrane Library databases. Data on complications were extracted and classified as intraoperative, postoperative, or instability-related for further analysis. Quality assessments were performed with criteria from the Methodological Index for Nonrandomized Studies (MINORS). A quantitative synthesis of data was conducted to compare the complication rates between arthroscopic and open approaches.

RESULTS

A total of 35 articles were included in this analysis. The MINORS score was 11.89. A total 2560 Latarjet procedures (2532 patients) were included. The overall complication rate was 16.1% (n = 412). The intraoperative complication rate was 3.4% (n = 87) and included a 1.9% (n = 48) incidence of nerve injuries and a 1.0% (n = 25) incidence of iatrogenic fractures. Screw problems, vascular injuries, and conversion arthroscopic to open surgery each occurred at a rate of <1%. The postoperative complication rate was 6.5% (n = 166), and the most common complication was nonunion (1.3%; n = 33). The instability-related complication rate was 6.2% (n = 159) and included a 1.5% (n = 38) rate of redislocation, a 2.9% (n = 75) rate of positive apprehension test, and a 1.0% (n = 26) rate of instability. Overall, 2.6% (n = 66) of patients required an unplanned secondary operation after the initial surgery. The arthroscopic approach was associated with a higher rate of intraoperative complications compared with the open approach (5.0% vs 2.9%; P =.020) and a lower rate of instability-related complications (3.1% vs 7.2%; P < .001).

CONCLUSION

The Latarjet procedure for anterior shoulder instability results in an overall complication rate of 16.1% and a reoperation rate of 2.6%. However, serious complications at short-term follow-up appear rare. When the arthroscopic approach was used, the rate of intraoperative complications was higher, although instability-related complications were lower when compared with the open approach.

Arthroscopic Latarjet Learning Curve: Operating Time Decreases After 25 Cases

Purpose

To demonstrate the learning curve associated with the arthroscopic Latarjet procedure and create a timetable to proficiency.

Methods

Using retrospective data of a single surgeon, consecutive patients who had an arthroscopic Latarjet procedure performed between December 2015 and May 2021 were initially reviewed for inclusion in the study. Patients were excluded if medical data were insufficient for accurate surgical time record, their surgery was transitioned to open or minimally invasive, or if their surgery was performed in conjunction with a second procedure for a separate issue. All surgeries were performed on an outpatient basis and sports participation was the most common reason for initial glenohumeral dislocation.

Results

Fifty-five patients were identified. Of these, 51 met the inclusion criteria. Analysis of operative times for all 51 procedures demonstrated that proficiency with the arthroscopic Latarjet procedure was obtained after 25 cases. This number was determined by 2 methods using statistical analysis (P < .05). The average operative time over the course of the first 25 cases was 105.68 minutes and beyond 25 cases was 82.41 minutes. Male gender was seen in 86.3 percent of the patients. The average age of the patients was 28.6 years old.

Conclusions

With continued transition towards bony augmentation procedures for addressing glenoid bone deficiency there is an increasing demand for the arthroscopic bony glenoid reconstruction procedures including the Latarjet procedure. It is a challenging procedure with a substantial initial learning curve. For a skilled arthroscopist there is a significant decrease in overall surgical time after the first 25 cases.

Clinical Relevance

The arthroscopic Latarjet procedure has advantages over the open Latarjet approach; however, it is controversial because it is technically challenging. It is important for surgeons to understand when they can expect to be proficient with the arthroscopic approach.

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

HYPOTHESIS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Arthroscopic Latarjet 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.

Use of Cannulated Screws for Primary Latarjet Procedures

Background

Rapid consolidation of the bone block is paramount for the success of the Latarjet procedure. Noncannulated screws have shown satisfactory long-term bone block fusion, while cannulated screws are challenged with inferior mechanical properties and fusion rates.

Purpose

To report outcomes of the Latarjet procedure using cannulated screws, notably bone block fusion and complication rates at 3 months, as well as clinical scores and return to sports at minimum 2 years postoperatively.

Study Design

Case series; Level of evidence, 4.

Methods

We reviewed the records of 124 consecutive patients (124 shoulders) who underwent primary Latarjet procedures using cannulated screws between 2015 and 2018. All patients underwent clinical examination at 3 months postoperatively, including range of motion and radiographs to assess graft fusion. The Walch-Duplay score, Rowe score, Subjective Shoulder Value, and visual analog scale for pain were collected at a minimum follow-up of 2 years.

Results

Overall, 9 patients (7%) required reoperation: 7 (6%) had screw removal for unexplained residual pain, 1 (0.8%) had lavage for deep infection, and 1 (0.8%) had evacuation to treat a hematoma. Furthermore, 3 patients (2.4%) had recurrent instability, none of whom underwent reoperation. At 3-month follow-up, all 124 shoulders showed complete radiographic graft fusion, and at 40 ± 11 months (mean ± SD; range, 24-64 months), 88% of patients had returned to sport (109/124), the Walch-Duplay score was 86 ± 14, Rowe was 84 ± 15, Subjective Shoulder Value was 88 ± 11, and visual analog scale for pain was 1 ± 1.

Conclusion

The clinical relevance of these findings is that 4.5-mm cannulated screws are safe and effective for primary Latarjet procedures and grant adequate graft healing, with low recurrence of instability and a high rate of return to sports.

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.

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).

Fixation Type Does not Affect the Learning Curve and Short-Term Radiographic Outcomes for Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibia Allograft

Purpose

The purpose of this study was to compare the learning curves and radiographic variables between screw and suture button fixation of the allograft for surgeons learning the all-arthroscopic anatomic glenoid reconstruction (AAGR) technique for anterior shoulder instability. We compared the surgical times of these two fixation techniques, as well as the graft placement in the vertical and medial-lateral directions.

Methods

This was a retrospective review of patients who underwent AAGR for recurrent anterior shoulder instability. Start and end times were recorded for each procedure, and learning was assessed through the change in operative time over successive surgeries and by variability of operative time. Graft placement, in terms of vertical positioning, medial-lateral step formation, and obliquity of fixation (alpha angle), was evaluated using 3-dimensional CT scans at approximately 6 months postoperation.

Results

A total of 43 patients were included in our study. Twenty-seven had screw fixation, and 16 had suture button fixation. The surgical duration of the button fixation technique was comparable to that of screw fixation (P = .72), with no significant difference in the variability of surgical time in either cohort (P > .05). Both groups showed similarly optimal vertical positioning of the graft onto the lower third of the glenoid (P = .89). Desired obliquity of graft fixation was identified more frequently with button fixation (P < .001). Both fixation methods provided clinically acceptable medial-lateral step formations, with suture-button fixation being significantly larger (P = .03).

Conclusions

Suture button fixation of the allograft is a potential alternative to screw fixation for the management of glenoid bone loss in recurrent anterior shoulder instability. The results of this study show that this method has a comparable learning curve, with a similar surgical duration, while not compromising the optimal accuracy of vertical and medial-lateral placement of the graft and achieves a superior alpha angle of fixation.

Level of Evidence

Level III, retrospective cohort study.

A review of bone grafting techniques for glenoid reconstruction

BACKGROUND

Traumatic anterior shoulder dislocations can cause bony defects of the anterior glenoid rim and are often associated with recurrent shoulder instability. For large glenoid defects of 20-30% without a mobile bony fragment, glenoid reconstruction with bone grafts is often recommended. This review describes two broad categories of glenoid reconstruction procedures found in literature: coracoid transfers involving the Bristow and Latarjet procedures, and free bone grafting techniques.

METHODS

An electronic search of MEDLINE and PubMed was conducted to find original articles that described glenoid reconstruction techniques or modifications to existing techniques.

RESULTS

Coracoid transfers involve the Bristow and Latarjet procedures. Modifications to these procedures such as arthroscopic execution, method of graft attachment and orientation have been described. Free bone grafts have been obtained from the iliac crest, distal tibia, acromion, distal clavicle and femoral condyle.

CONCLUSION

Both coracoid transfers and free bone grafting procedures are options for reconstructing large bony defects of the anterior glenoid rim and have had similar clinical outcomes. Free bone grafts may offer greater flexibility in graft shaping and choice of graft size depending on the bone stock chosen. Novel developments tend towards minimising invasiveness using arthroscopic approaches and examining alternative non-rigid graft fixation techniques.

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%).

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.

Non-rigid fixation of the glenoid bone block for patients with recurrent anterior instability and major glenoid bone loss: A systematic review

BACKGROUND

New types of glenoid bone block fixation, involving suture buttons, suture anchors or even implant-free impaction of the graft, have been recently introduced. In contrast to screws which allow for a rigid fixation of the bone block, these alternative procedures provide a non-rigid type of fixation.

METHODS

Two reviewers independently conducted the search in a systematic way (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms "Latarjet" OR "Eden-Hybbinette" OR "bone block" AND "anterior" AND "shoulder" AND "instability."

RESULTS

Eight out of the 325 initial studies were finally chosen according to our inclusion-exclusion criteria. In total, 750 patients were included in this review. The overall anterior instability recurrence rate for patients treated with non-rigid fixation was 2.6%, while the overall rate of non-union or graft osteolysis was 5.4%.

CONCLUSIONS

Regardless of the graft type, bone block non-rigid fixation showed satisfactory clinical and functional outcomes for the treatment of anterior shoulder instability with substantial glenoid bone deficiency. Furthermore, non-rigid fixation resulted in adequate bone graft healing and osseous incorporation. Lastly, given the relative lack of data, further prospective controlled studies are required to assess bone block non-rigid fixation procedures in comparison with the traditional rigid (with screws) fixation techniques.

LEVEL

Systematic review, IV.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up

PURPOSE

To investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability.

METHODS

Seventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed.

RESULTS

Fourteen patients [mean age 31.1 (range 18-50) years] were available after a follow-up period of 78.7 (range 60-110) months. The SSV averaged 87 (range 65-100) %, CS 94 (range 83-100) points, RS 89 (range 30-100) points, WD 87 (range 25-100) points, and WOSI 70 (range 47-87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a significant increase of the glenoid index from preoperative 0.8 ± 0.04 (range 0.7-0.8) to 1.0 ± 0.11 (range 0.8-1.2) at the final follow-up (p < 0.01).

CONCLUSION

Arthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting technique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid configuration was observed.

LEVEL OF EVIDENCE

IV.

Early Follow-Up of Arthroscopic Latarjet Procedure with Screw or Suture-Button Fixation for Recurrent Anterior Shoulder Instability

Objective

To evaluate the early clinical and radiographic results of arthroscopic Latarjet procedure using screw or suture‐button fixation in patients with recurrent anterior shoulder dislocation.

Methods

Twelve patients who underwent arthroscopic Latarjet procedure between January 2015 and December 2018 at our institution were retrospectively studied. Data of the patients' history, including age, gender, side of affected arm, body mass index (BMI), and the number of dislocations since fist dislocation were collected. Preoperative and postoperative clinical follow‐up data were evaluated using Walch–Duplay score, American Shoulder and Elbow Society (ASES) score, and modified Rowe score. Active external rotation and active internal rotation at 90° of abduction as well as active elevation were evaluated preoperatively and postoperatively. The position and healing condition of the transferred coracoid bony graft were also assessed using computed tomography (CT) and Mimics 19.0 software.

Results

Mean follow‐up was 24.9 months (range, 13 to 53 months) of all patients. At final follow‐up, the average ASES score (preoperative vs postoperative values) had improved from 68.9 ± 7.9 to 91.1 ± 6.1 in screw fixation group and 68.9 ± 8.9 to 87.5 ± 6.7 in suture‐button fixation group; the average Rowe score (preoperative vs postoperative values) had improved from 25.0 ± 8.4 to 92.5 ± 4.2 in screw fixation group and 21.7 ± 13.7 to 93.3 ± 4.1 in suture‐button fixation group; the average of Walch–Duplay score (preoperative vs postoperative values) had improved from 12.5 ± 15.1 to 91.7 ± 4.1 in screw fixation group and 18.3 ± 20.7 to 88.3 ± 7.5 in button fixation group. The forward flexion was 175.0° ± 8.4° preoperatively and 178.3° ± 4.1° postoperatively in screw fixation group while 174.8° ± 10.2° preoperatively and 175.0° ± 5.5° postoperatively in suture‐button fixation group. The active external rotation was 77.5° ± 5.2° preoperatively and 71.7° ± 4.1° postoperatively in screw fixation group while 72.5° ± 6.9° preoperatively and 68.3° ± 7.5° postoperatively in suture‐button fixation group. The average of active internal rotation was 66.7° ± 6.1° preoperatively and 67.5° ± 6.1° postoperatively in screw fixation group while 68.3° ± 11.3° preoperatively and 66.7° ± 7.5° postoperatively in suture‐button fixation group. In postoperative CT scan, 91.7% grafts midline center were located at or under the equator in the en face view; 75% of the bone blocks were flush to the glenoid face in the axial view, with only two grafts exhibiting slight medial placement in screw fixation group (33.3%) and one graft exhibiting slight lateral placement in suture‐button fixation group (16.7%). All grafts achieved bone union. Graft absorption mostly occurred outside of the “best‐fit” circle. The average bony absorption rates of the coracoid grafts were 25.2% and 10.18% in screw fixation group and suture‐button fixation group, respectively, at 6 months postoperative follow‐up.

Conclusion

Both suture‐button fixation and screw fixation techniques in arthroscopic Latarjet procedure revealed excellent clinical outcomes with low complication rates in the early follow‐up. The suture‐button fixation exhibited a flexible fixation pattern that allowed for self‐correction to some extent, even slight lateralization could finally remodel over time.

Arthroscopic Latarjet for Shoulder Instability

Arthroscopic Latarjet is a relatively new, but viable option for the treatment of anterior shoulder instability. Arthroscopic Latarjet has the advantage of faster recovery, reduced stiffness, identification of additional shoulder pathology, and improved cosmesis when compared with open Latarjet. By the majority of clinical and radiographic parameters, arthroscopic Latarjet produces equivalent outcomes compared with open Latarjet. A relatively substantial learning curve for arthroscopic Latarjet exists at about 25 cases; however, multiple studies have demonstrated comparable outcomes and surgical time after the learning curve.

Cortical suture button fixation vs. bicortical screw fixation in the Latarjet procedure: a biomechanical comparison

BACKGROUND

The Latarjet procedure traditionally has been performed with 2 screws in an open manner. Recently, cortical suture button fixation for coracoid transfer has been used in hopes of mitigating complications seen with screw placement. The aim of this study was to evaluate a cortical suture button and technique currently available in the United States compared with screw fixation in the Latarjet procedure in a cadaveric model.

METHODS

We randomly assigned 9 matched pairs of fresh-frozen cadaveric shoulders (N = 18) to undergo the Latarjet procedure with either screw fixation or cortical suture button fixation. After fixation, all shoulders underwent biomechanical testing with direct loading on the graft vas a material testing system. Cyclic testing was performed for 100 cycles to determine axial displacement with time; each graft was then monotonically loaded to failure.

RESULTS

The maximum cycle displacement was significantly less for screw fixation vs. cortical suture button fixation (3.1 ± 1.3 mm vs. 8.9 ± 2.1 mm, P < .0001). The total load at failure was 481.1 ± 88.8 N for screws and 175.5 ± 95.8 N for cortical suture buttons (P < .0001). Bony damage to the surrounding anatomy was more extensive at failure in the screw-fixation group.

CONCLUSION

At time zero, the cortical button fixation and technique did not resist direct loads to the graft as much as traditional screw fixation, although bony damage to the surrounding anatomy was more extensive in screw fixation than button fixation. In the event of unanticipated loading, this could place a patient at higher risk of graft migration, which could lead to unintended early outcomes. These results support the need for implants and techniques specifically tailored to the Latarjet procedure and should bring into question the adoption of a cortical button and technique not specific to the procedure.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures

BACKGROUND

Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain.

PURPOSE/HYPOTHESIS

The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders.

RESULTS

Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment.

CONCLUSION

The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

The arthroscopic Latarjet: a multisurgeon learning curve analysis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Latarjet with cortical button fixation is associated with an increase of the risk of recurrent dislocation compared to screw fixation

PURPOSE

The purpose of this study was to compare the clinical results of the Latarjet procedure using two cortical buttons vs two screws. It was hypothesized that cortical button would result in similar rates of recurrent dislocations, but a lower rate of reoperation compared to screw fixation.

METHODS

A retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior glenohumeral instability. Patient demographics, number of dislocations prior surgery, arm dominance, shoulder hyperlaxity, level of sport, type of sport and ISIS score were collected. Shoulders were separated into two groups based on surgical fixation (screws vs cortical button). Postoperatively, shoulders were evaluated for recurrent dislocation, revision surgery, post-operative Walch-Duplay score, and the Simple shoulder test (SST). Two hundred and thirty-six patients were included in the screw fixation group (group A) and 72 in button fixation group (group B) and were evaluated at a mean follow-up of 3.4 ± 0.8 years. Demographics of the two groups were similar with the exception of operative side hand dominance, which was more common in group B [50 (69.4%) vs 128 (54.2%), p = 0.02].

RESULTS

Recurrent dislocation was significantly lower in Group A: 6 (2.5%) vs 6(8.3%) (p = 0.02). Reoperation was more common in group A [14 (5.9%) vs 0 (0%)]. At follow-up, Walch-Duplay scores and simple shoulder tests were similar in both groups.

CONCLUSION

Button fixation for Latarjet showed higher rates of recurrent dislocation compared to screw fixation. However, the increased stability afforded by screw fixation needs to be weighed against the increased risk of reoperation for hardware prominence.

LEVEL OF EVIDENCE

III.

Modified Arthroscopic Latarjet Procedure: Suture-Button Fixation Achieves Excellent Remodeling at 3-Year Follow-up

BACKGROUND

Some studies have advocated the use of suture-button fixation during the Latarjet procedure to reduce complications associated with screw fixation. However, the sample size of these studies is relatively small, and their follow-up period is short.

PURPOSE

To investigate the efficacy of the suture-button Latarjet procedure with at least 3 years of follow-up and remodeling of the coracoid graft.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 152 patients who underwent the suture-button Latarjet procedure between February 2013 and February 2016 were selected, and 128 patients who met the inclusion criteria were enrolled in this study. Preoperative and postoperative clinical results were assessed. The position and healing condition of the coracoid graft and arthropathy of the glenoid and humeral head were also assessed using radiography and 3-dimensional computed tomography (CT).

RESULTS

The mean follow-up time was 40.3 ± 5.8 months. There were 102 patients included in this study. The mean visual analog scale score for pain during motion, the American Shoulder and Elbow Surgeons score, the Rowe score, and the Walch-Duplay score were improved considerably. A total of 100 grafts achieved bone union. The overall absorption rate was 12.6% ± 4.3%. Graft absorption mostly occurred on the edge and outside the "best-fit" circle of the glenoid. A vertical position was achieved in 98 grafts (96% of all cases) immediately postoperatively, with the mean graft midline center at the 4 o'clock position. In the axial view, CT showed that 89 grafts were flush to the glenoid, whereas 2 and 11 grafts were fixed medially and laterally, respectively. In all cases, the bone graft and glenoid tended to extend toward each other to form concentric circles during the remodeling process. During follow-up observations, the height of the 11 grafts that were positioned laterally (ie, above the glenoid level) exhibited a wave-curved change. No arthropathy was observed in any patient.

CONCLUSION

Patient outcomes were satisfactory after the modified arthroscopic suture-button Latarjet technique. Graft absorption mostly occurred on the edge and outside the "best-fit" circle of the glenoid. The graft exhibited the phenomenon of ectatic growing when it fused with the glenoid and finally remodeled to a new concentric circle with the humeral head analogous to the original glenoid. Grafts positioned laterally did not cause arthropathy of the joints within the period of the study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III. Therapeutic study: case-control study.

Editorial Commentary: Arthroscopic Latarjet: An Analysis of Outcomes and Complications Through its Learning Curve

The arthroscopic Latarjet has been proposed in the past decade to reduce the rate of bone block malpositioning, decrease soft-tissue damage associated with open approach, and possibly decrease intraoperative complications. Several recent studies have reported similar or even superior results with arthroscopic Latarjet compared with those achieved with open technique. However, arthroscopic Latarjet is known to be more technically demanding and some feel that it should be performed by expert shoulder surgeons with advanced arthroscopic skills. Surgical innovations should be adopted when they have potential advantages for patients. Despite the initial challenges and learning curve of arthroscopic Latarjet, experience and technical skills may reduce the rate of intraoperative complications for this technically demanding procedure.

All-arthroscopic, guided Eden-Hybbinette procedure using suture-button fixation for revision of failed Latarjet

PURPOSE

To report the results of a guided arthroscopic Eden-Hybbinette procedure, using suture button for iliac crest bone graft fixation, in a series of patients with a prior failed Latarjet and persistent glenoid bone loss.

METHODS

Seven consecutive patients (5 males, 2 females, mean age: 30.7 years [range, 17-47 years]) with recurrent anterior dislocations and glenoid deficiency greater than 20% underwent the all-arthroscopic revision procedure. The iliac crest bone graft and suture-button device (Bone-Link) were shuttled through the rotator interval. Specific drill guides were used and a suture tensioning device allowed bone graft compression. Previous broken screw shafts (3 patients) were left in situ. Graft placement and healing was assessed postoperatively with computed tomography imaging.

RESULTS

No neurologic injury or hardware problems occurred, and no patient required further surgery. On computed tomography scan, optimal positioning (flush and under the equator) and healing of the bone graft was observed in all patients. At a mean follow-up of 21 months (range, 12-39 months), all but one patient were satisfied and had a stable shoulder; 5 returned to sports. The Constant score increased from 32 to 81 points, and the subjective shoulder value from 31% to 87% (P < .001). The Walch-Duplay and Rowe scores averaged 85.7 (range, 65-100) points and 86.4 (range, 70-100) points, respectively.

CONCLUSION

Recurrence of anterior shoulder instability after a failed Latarjet procedure can be successfully treated by an all-arthroscopic Eden-Hybbinette procedure. Suture-button fixation is reliable and permits optimal positioning and predictable healing of the new bone graft; in addition, it is an appropriate fixation option in the setting of retained broken hardware.

Learning Curves in the Arthroscopic Latarjet Procedure: A Multicenter Analysis of the First 25 Cases of 5 International Surgeons

PURPOSE

To analyze the learning curves of 5 experienced, fellowship-trained shoulder surgeons and their respective 25 first arthroscopic Latarjet cases in regard to surgical time, graft placement, complication rates, and recurrent instability.

METHODS

The first 25 arthroscopic Latarjet procedures of 5 surgeons were retrospectively analyzed in an international multicenter setting, and thus 125 patients were included in this study. The surgical time, intraoperative and postoperative events out of the ordinary, and graft positioning were examined.

RESULTS

The 125 patients consisted of 16 women (12.8%) and 109 men (87.2%). In 81.6% (n = 102), surgery was undertaken as a first-line procedure, whereas 18.4% (n = 23) were revisions. Surgical time decreased significantly from an average of 123.8 minutes (range 70 to 210) to 92.6 minutes (range 50 to 160) from the first 5 cases to the last 5 cases of each surgeon within a period of <2 years. Overall, 22 events in 21 patients requiring additional treatment were reported (17.6%). Five (4%) were unlikely to affect final outcome and did not require revision surgery. Twelve (9.6%) required revision surgery that was not trauma related yet was prone to affect outcomes. Five events were trauma-related (4%), 4 requiring revision surgery and 1 treated conservatively. Overall, 6 patients (4.8%) had recurrent shoulder instability, 3 as a result of a traumatic event. Conventional radiology showed the bone-block in ideal positioning in 93 cases (74.4%), flush with the glenoid in a true anteroposterior view. In 3 cases (2.4%), it was considered too high, 15 too low (12%), 5 too lateral (4%), and 15 too medial (12%). Some patients had combinations of the above.

CONCLUSION

This analysis shows that surgical time in arthroscopic Latarjet can be significantly reduced after only 20 cases. However, complication rates did not decrease over this time. The authors believe that the arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

[Research progress of surgical treatment for anterior shoulder dislocation and combined injuries]

Objective

To summarize the research progress of surgical treatment for anterior shoulder dislocation and combined injuries.

Methods

The related literature was reviewed, and the surgical treatment options for the anterior shoulder dislocation and its combined injuries were summarized.

Results

Anterior shoulder dislocation can combine with anteroinferior capsular ligament complex injury (Bankart injury), bony Bankart defect, and Hill-Sachs lesion. For Bankart and bony Bankart injuries, arthroscopic repair or coracoid osteotomy combined with bony graft reconstruction can be performed. For Hill-Sachs lesion, conservative treatment, soft tissue repair, or bony reconstruction should be selected based on the extent of the bone defect. For bipolar injury, the Bankart repair, Remplissage, or arthroplasty should be selected based on the extent of the glenoid defect.

Conclusion

With the development of arthroscopy and the improvement of the surgical concept, there is a complete set of surgical options for various injuries of the anterior shoulder dislocation. When choosing a surgical procedure, the patient's specific injury and age, exercise level, and other relating factors should be comprehensively assessed in order to achieve the best results.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mid-term clinical results of an arthroscopic glenoid rim reconstruction technique for recurrent anterior shoulder instability

INTRODUCTION

Glenoid bone loss in recurrent anterior instability of the shoulder needs to be addressed to restore joint stability. Over the last years, several arthroscopic methods have been described to treat this condition. However, no clinical mid-term results have been presented for arthroscopic iliac crest bone grafting procedures.

METHODS

We included 32 patients with significant glenoid bone loss and repetitive dislocations of the shoulder who were treated in our shoulder unit with a previously described all-arthroscopic reconstruction technique. All patients filled out a questionnaire evaluating repetitive dislocations, consumption of pain medicine, Constant Score (CS, adapted to age and gender), activities of daily living (ADL), visual analogue scale for pain (VAS) as well as the Western Ontario Shoulder Instability Index (WOSI). Additionally, all complications were recorded.

RESULTS

After a mean follow-up of 42 months, three traumatic dislocations had been observed. With an ADL of 25 points (95% CI 24-27), a WOSI of 71% (95% CI 65-76) and CS of 87 points (95% CI 82-92), our patients showed good functional results. The VAS result for pain was 2.1 (95% CI 1.5-2.6). No patient reported the regular usage of pain medicine related to the shoulder instability at final follow-up.

CONCLUSION

The all-arthroscopic glenoid reconstruction using iliac crest grafts shows good functional results with a recurrence rate of 9%. At final follow-up 42 months after surgery, our patients showed low pain levels and acceptable complications.

ARTHROSCOPIC LATARJET TECHNIQUE COMBINED WITH ENDOBUTTONS: FUNCTIONAL OUTCOMES IN 26 CASES

Objective

The cause of anterior shoulder instability is not fully understood and surgical management remains controversial. The objective of this study was to evaluate the results of patients undergoing arthroscopic Latarjet procedure with endobuttons.

Methods

A retrospective study of 26 patients undergoing arthroscopic Latarjet procedure with endobuttons to treat anterior shoulder instability. Patients with previous glenohumeral instability, failure of Bankart procedure or Instability Severity Index Score (ISIS) greater than or equal to 6, were included. Patients were assessed by: DASH, UCLA, Rowe, Visual Analog Scale (VAS) of pain and Short-Form 36 (SF36) scores. Correct position and consolidation of the graft were evaluated.

Results

Mean age was 31.5 years (16 to 46). Preoperative duration of symptoms was 1.7 years (1 month to 10 years). Mean follow-up was 14.3 (6 to 24) months. Mean postoperative scores were: 10 points in DASH; 1.6 in VAS, where 23 (88%) patients experienced mild pain and 3 (12%) moderate pain; 89 in Rowe; 32 in UCLA and 78 in SF-36. Positioning of the graft was correct in 25 (96%) cases, and was consolidated in 23 (88%). We had two cases of graft fracture (7%) and postoperative migration (7%).

Conclusion

Surgical treatment using arthroscopic Latarjet with endobuttons is safe and effective, producing good functional outcomes in patients. Level of Evidence IV, Case Series.

Biomechanical Comparison of Screw Fixation Versus a Cortical Button and Self-tensioning Suture for the Latarjet Procedure

Background

Metal screws are traditionally used to fix the coracoid process to the glenoid. Despite stable fixation, metal screws have been associated with hardware complications. Therefore, some studies have advocated for suture button fixation during the Latarjet procedure to reduce the complications associated with screw fixation.

Purpose

To biomechanically evaluate the ultimate failure load of a cortical button and self-tensioning suture versus metal screws for coracoid graft fixation during the Latarjet procedure.

Study Design

Controlled laboratory study.

Methods

Eight matched pairs of fresh-frozen, male cadaveric shoulders (N = 16) underwent the Latarjet procedure. The shoulders of each pair were randomly assigned to 1 of 2 groups: fixation using two 3.75-mm cannulated, fully threaded metal screws or fixation using a double suture button construct. Specimens were secured in a dynamic testing machine and cyclically preconditioned from 2 to 10 N at 0.1 Hz for 10 cycles. After preconditioning, specimens were pulled to failure at a normalized displacement rate of 400% of the measured gauge length per minute. The ultimate failure load and mechanism of failure were recorded for each specimen.

Results

The mean ultimate load to failure for screw fixation (226 ± 114 N; 95% CI, 147-305 N) was not significantly different from that for suture button fixation (266 ± 73 N; 95% CI, 216-317 N) (P = .257). The mean strain at failure for screw fixation (63% ± 21%; 95% CI, 48%-77%) was not significantly different from that for suture button fixation (86% ± 26%; 95% CI, 69%-104%) (P = .060). The most common mechanism of failure for the screw fixation method was at the bone block drill holes, while an intramuscular rupture at the clamp-muscle interface occurred for the suture button construct.

Conclusion

The screw and suture button fixation techniques exhibited comparable biomechanical strength for coracoid bone block fixation of the Latarjet procedure.

Clinical Relevance

Metal screws have been reported to be a large contributor to intraoperative and postoperative complications. Therefore, given the results of the current study, a suture button construct may be an alternative to metal screw fixation during the Latarjet procedure. However, further clinical studies are warranted.