Risk of suprascapular nerve injury in open Trillat procedure: an anatomical study

PURPOSE

The open Trillat Procedure described to treat recurrent shoulder instability, has a renewed interest with the advent of arthroscopy. The suprascapular nerve (SSN) is theoretically at risk during the drilling of the scapula near the spinoglenoid notch. The purpose of this study was to assess the relationship between the screw securing the coracoid transfer and the SSN during open Trillat Procedure and define a safe zone for the SSN.

METHODS

In this anatomical study, an open Trillat Procedure was performed on ten shoulders specimens. The coracoid was fixed by a screw after partial osteotomy and antero-posterior drilling of the scapular neck. The SSN was dissected with identification of the screw. We measured the distances SSN-screw (distance 1) and SSN-glenoid rim (distance 2). In axial plane, we measured the angles between the glenoid plane and the screw (α angle) and between the glenoid plane and the SSN (β angle).

RESULTS

The mean distance SSN-screw was 8.8 mm +/-5.4 (0-15). Mean α angle was 11°+/-2.4 (8-15). Mean β angle was 22°+/-6.7 (12-30). No macroscopic lesion of the SSN was recorded but in 20% (2 cases), the screw was in contact with the nerve. In both cases, the β angle was measured at 12°.

CONCLUSION

During the open Trillat Procedure, the SSN can be injured due to its anatomical location. Placement of the screw should be within 10° of the glenoid plane to minimize the risk of SSN injury and could require the use of a specific guide or arthroscopic-assisted surgery.

Neglected and locked anterior shoulder dislocation: functional outcomes and complications after open reduction and preservation of humeral head

Background

Neglected and locked anterior shoulder dislocation is a rare problem that presents several treatment challenges. Our study aimed to evaluate the functional outcomes and postoperative complications after open reduction and head preservation surgery in patients with neglected and locked anterior shoulder dislocation.

Methods

Ten patients (age 51 ± 22 years) with a follow-up of 27 months ± 7 months (range 24-40 months) were included in the study. The anteriorly dislocated humeral heads were open and reduced after an average neglect of 10 ± 15 months. The neglected dislocation was classified into two types by the severity of the injury. (1) Type 1: There were no associated severe injuries, and the humeral head was reduced in the glenoid cavity without take-down of the subscapularis (type 1a) (n = 5) or via take-down of the upper half of the subscapularis (type 1b) (n = 2). (2) Type 2: There were associated factors such as a greater tuberosity fracture (n = 2) or a grade 3/4 fatty infiltrated supraspinatus and infraspinatus muscles (n = 1). Complete removal of the subscapularis was necessary to reduce the humeral head.

Results

The pain scores improved from a baseline value of 8 ± 1 to a final value of 1 ± 1 (P < .001), the absolute Constant score improved from a baseline value of 13 ± 8 to a final value of 69 ± 21 (P < .001), elevation range of motion (ROM) improved from a baseline value of 44° ± 43° to a final value of 123° ± 30° (P < .001), external rotation ROM improved from 0° ± 13° to 49° ± 12° (P < .001), and internal rotation ROM improved from sacroiliac joint ± 2 vertebra level to thoracic T11 ± 3 vertebrae level (P < .0001). The final shoulder subjective value was 77 ± 20 and was excellent in 3 patients, good in 5 patients, fair in 1, and poor in 1 patient. Major complications were observed in 30% (n = 3) of patients: persistent humeral head anterior subluxation in 20% (n = 2) of patients and superior migration of the humeral head in 10% (n = 1) of patients.

Conclusion

Open reduction and head preservation in patients with neglected anterior dislocation led to good functional outcomes in 70% (as per Constant score) to 80% (as per shoulder subjective value) of the patients. However, we observed major complications such as persistent anterior subluxation (n = 2) and superior head migration (n = 1), leading to suboptimal functional outcomes in cases with associated factors such as a greater tuberosity fracture or severe fatty infiltrated cuff muscles.

Treatment of Chronic Anterior Shoulder Dislocation by Coracoid Osteotomy with or without Bristow-Latarjet Procedure

Objective

To investigate the clinical efficacy and outcomes of the coracoid osteotomy with or without Bristow–Latarjet procedures in the treatment of chronic anterior shoulder dislocation (CASD).

Methods

Between January 2013 and January 2019, 20 shoulders of 18 patients who were diagnosed with chronic anterior dislocation and underwent open reduction in our trauma center were retrospectively studied. Open coracoid osteotomy with Bristow–Latarjet procedures were performed on 16 shoulders and open coracoid osteotomy without Bristow–Latarjet procedures were performed on four shoulders. Open coracoid osteotomy with or without Bristow–Latarjet procedures were chosen on the basis of the stability of the shoulder after reduction. Outcomes were assessed preoperatively and postoperatively with the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the University of California Los Angeles (UCLA) shoulder rating scale, and the range of motion (ROM) for shoulder activity.

Results

There were three males and 15 females with an average age of 60.94 ± 2.69 years. The time between dislocation and treatment ranged from 21 to 240 days with an average of 73.3 ± 14.4 days. All patients were available for a mean follow‐up of 15.2 ± 4.3 months. No procedure‐related death or incision‐related superficial or deep tissue infection was identified in all cases. No iatrogenic neurovascular injuries or fractures were found in this study. At the time of 12 months follow‐up, the range of motion and the shoulder functional evaluation (VAS [P < 0.001], ASES [P < 0.001], and UCLA score [P < 0.001]) in patients who underwent Bristow–Latarjet procedures were significantly improved. Subluxation after surgical procedure was found and confirmed in one patient and this patient refused to undergo revision surgery. According to the Samilson and Prieto classification system, 16 shoulders were assessed as grade 0, three shoulders were grade 1, one shoulder was grade 2.

Conclusions

Coracoid osteotomy with or without Bristow–Latarjet procedure yielded an acceptable clinical result in this study. This method has the advantages of enlarging the exposure of surgical field, assisting reduction of shoulder, and convenient conversion to Bristow–Latarjet procedure. It is an efficient and reliable method for treatment of chronic anterior shoulder dislocation.

A 69‐year‐old woman diagnosed with right chronic anterior shoulder dislocation with large Hill–Sachs lesion. The latarjet procedure with remplissage technique was applied for this patient.