Abstract
BackgroundArthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure.Questions/purposesWe determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout.MethodsBetween July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed.ResultsAt latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion.ConclusionsThe arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Highlights
Multiple recurrent shoulder subluxations or dislocations may be responsible for both erosion of the anterior glenoid rim and irreversible stretching of the anteroinferior capsule [7, 51]
The decision to perform an arthroscopic Bristow-LatarjetBankart procedure was based on two criteria: (1) an Instability Severity Index Score (ISIS) of greater than 3 points, which predicts a high risk of failure with an arthroscopic Bankart repair alone [2], and (2) the presence of a severe glenoid bone defect ([ 20% of the glenoid surface as measured on preoperative CT scan according to Sugaya et al [45] and confirmed at arthroscopy, according to Burkhart et al [11])
When we compared the 51 patients whose bone block had healed with the 14 patients whose bone block was either nonunited or migrated (Fig. 7), we found that use of a unicortical screw (p\0.01) and/or an overangulated screw ([ 25°) (p \ 0.01) relative to the glenoid surface was associated with poor bone block fixation and healing
Summary
Multiple recurrent shoulder subluxations or dislocations may be responsible for both erosion of the anterior glenoid rim and irreversible stretching of the anteroinferior capsule [7, 51]. The surgical treatment of recurrent anterior shoulder instability associated with severe glenoid defects and capsular deficiency remains challenging [8, 13, 32, 38, 39]. The Bristow-Latarjet procedure, transferring the coracoid and attached conjoined tendon to the anterior glenoid, is currently used to treat recurrent anterior instability in patients with severe glenoid bone loss and capsular deficiency [1, 10, 14, 16, 19, 20, 22, 23, 30, 31, 42, 47, 49]. Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research
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