Chronic Anterior Shoulder Instability Research Articles

MMP-1 and MMP-9 are Highly Expressed in the Joint Capsule of Diabetic Frozen Shoulder

BackgroundThe pathophysiology of frozen shoulder (FS) involves abnormal expressions of matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs) that lead capsular fibrosis. However, there has been little concern for why diabetic FS has more protracted fibrotic condition. The objective of this study was to compare the expression levels of MMPs and TIMPs in the joint capsule of patients with diabetic and non-diabetic FS. Materials and methodsSamples of capsular tissue were collected from 20 patients with FS (10 diabetic patients; diabetic group, and 10 non-diabetic patients; non-diabetic group) and 10 patients (control group) with chronic anterior shoulder instability. Quantitative real-time RT-PCR and Western blot analysis were performed to determine the expression levels of mRNA and protein for MMP-1, 3, 9, 13, 14, and TIMP-1, 2. ResultsThe results of quantitative real-time RT-PCR showed significantly higher expression levels of all MMPs and TIMP-1 and significantly lower expression levels of TIMP-2 in the joint capsule of patients in the diabetic or non-diabetic groups compared with the control group. Significantly higher expression levels of MMP-1, 9, 14, and TIMP-1 were detected in the diabetic group compared with the non-diabetic group. The results of Western blot analysis showed significantly higher levels of MMP-3, 13, 14, and TIMP-1 in the joint capsule of patients in the diabetic or non-diabetic groups compared with the control group. However, no significant differences of protein levels of them were observed between diabetic and non-diabetic groups. ConclusionsThe findings of this study demonstrate the potential involvement of MMP-1 and 9 in the pathophysiology of diabetic FS. These findings may be helpful in identification of therapeutic targets for development of novel treatments for this protracted chronic fibrosing condition.

Rotator Cuff Muscle Imbalance in Patients with Chronic Anterior Shoulder Instability.

(1) Background: Both intra-articular pathologies and muscle imbalance can be a cause of shoulder instability. The purpose of this study is to examine the cross-sectional areas of the rotator cuff muscle in patients with acute and chronic anterior shoulder instability and to determine the associations between imbalance and chronicity of the rotator cuff. (2) Methods: Patients with confirmed dislocation of the anterior shoulder were included. The patients were divided into two groups according to the time between the initial dislocation event and when MRI imaging was performed Measurements of the rotator cuff muscle areas were performed in the scapular Y view and glenoid face view using MRI. (3) Results: A total of 56 patients were enrolled. In the Y view, a larger area of supraspinatus muscle was observed in the chronic group compared with the acute group (17.2 ± 2.3% vs. 15.6 ± 2.2%, p = 0.006). However, a smaller area of subscapularis muscle was observed in the chronic group (47.1 ± 3.5% vs. 49.6 ± 5.3%, p = 0.044). Using the glenoid face view, a larger area of supraspinatus muscle was observed in the chronic group than in the acute group (18.5 ± 2.5% vs. 15.8 ± 2.2%, p < 0.001). However, a smaller area of subscapularis muscle was observed in the chronic group (41.6 ± 3.2% vs. 45.6 ± 4.4%, p < 0.001). (4) Conclusion: Larger areas of supraspinatus muscle compared with acute instability were observed in patients with chronic anterior shoulder instability. In contrast, a smaller area of subscapularis muscle was observed in the chronic group.

Latarjet in women for anterior shoulder instability: a case series analysis.

The Latarjet procedure is traditionally used to treat chronic anterior shoulder instability associated with glenoid bone loss. However, few series have analyzed outcomes in a female-only population. The objective of this study was to evaluate the clinical and radiological outcomes of a Latarjet bone block in this specific population. This single-center retrospective study included 15 women (mean age 35 ± 11.3; 19-60) reviewed with a minimum follow-up of 2years. The procedure was performed using the open bone block screw technique (n = 7) or by arthroscopy with cortical button (n = 8). Clinical evaluation was based on active range of motion measurements, Rowe and Walch-Duplay scores, and subjective shoulder value (SSV). Radiographic analysis explored bone block healing at the last follow-up. At a mean follow-up of 48months (32-86), no recurrence was reported. The mean Rowe score was 91 points (70-100), Walch-Duplay 90 points (60-100), and SSV 87% (70-100). The active mobilities reached 169° (± 9°) in elevation, 57° (± 15°) in external rotation at side, and 89° (± 6°) in abduction. The return-to-sport rate was 91%. Five patients experienced persistent anterior pain, with screws requiring hardware removal in 2 (p = 0.02). Radiological assessment detected one case of nonunion (7%). Women treated with the Latarjet procedure experienced satisfactory midterm clinical outcomes. The arthroscopic technique using cortical button fixation seems to avoid residual anterior pain requiring hardware removal.

Arthroscopic Xenograft With Cerclage Fixation: A Method for Glenoid Bone Loss Reconstruction With Cerclage Fixation Using a Specific Posterior Guide

Large glenoid bone defects are closely associated with high failure rates after arthroscopic Bankart repair in chronic anterior shoulder instability; therefore nowadays the glenoid bone grafting reconstruction procedure is strictly recommended. On the contrary, the optimal grafting procedure is still controversial because there is considerable concern about the resorption rate of allografts, donor site morbidity of the autografts, and sequelae caused by the use of metal fixation devices in proximity of the shoulder joint. We describe an all-arthroscopic technique for anatomic reconstruction of the glenoid that uses a previously shaped xenograft assembled with a metal-free fixation device using 2 ultra-high-strength sutures (FiberTape Cerclage System; Arthrex, Naples, FL), using a specific posterior guide (Arthrex, Naples, FL) in combination with upper third subscapularis augmentation.

Pectoralis Major Tendon Transfer for Subscapularis Insufficiency: An Operative Technique

Background: Pectoralis major tendon (PMT) transfer is an effective surgical treatment for addressing subscapularis insufficiency in younger, active patients. Indications: The primary indication for a PMT transfer is subscapularis insufficiency or irreparable tear in an active, young patient that is not a candidate for reverse shoulder arthroplasty. In addition, patients should have an intact posterosuperior rotator cuff. In this case, the patient is a 41-year-old male with chronic anterior shoulder instability after failed open Bankart stabilization with subscapularis incompetency. Technique Description: The patient was placed in the beach-chair position and a standard deltopectoral approach was utilized. The conjoint tendon and adjacent musculocutaneous nerve were identified and retracted. Subsequently, the sternal head of the PMT was isolated from the clavicular head at the humeral insertion. It was then released, mobilized and passed inferior to the conjoined tendon for reapproximation at the lesser tuberosity with a suture anchor. Results: A previous systematic review demonstrated that patients with isolated subscapularis insufficiency who undergo PMT transfer have significant increase in Constant Score, range of motion, and internal rotation strength. Additionally, a retrospective case series evaluating 22 patients at a 10-year follow-up revealed maintained improvements in Constant Score, Simple Shoulder test, and Visual Analog scale for Pain. However, they found that strength on internal rotation and range of motion significantly regressed to baseline, preoperative levels. Discussion/Conclusion: PMT transfer for subscapularis insufficiency is a viable treatment option for symptomatic subscapularis tendon tears not amenable to repair. It allows for excellent long-term improvements in strength, range of motion and patient reported outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

All-Arthroscopic Glenoid Bone Augmentation Using Iliac Crest Autograft Procedure for Recurrent Anterior Shoulder Instability: Button Fixation Is a Feasible and Satisfactory Alternative to Screw Fixation

To investigate the efficacy of all-arthroscopic glenoid bone augmentation surgery using the iliac crest autograft procedure. Furthermore, we sought to compare the clinical and radiographic outcomes of using screw versus button fixation, in patients with recurrent anterior shoulder instability. Between 2015 and 2019, 134 shoulders with persistent instability were surgically treated with an arthroscopically placed autologous iliac crest bone graft transfer procedure. Preoperative and postoperative clinical follow-up data were evaluated using the range of motion, and the Walch-Duplay, American Shoulder and Elbow Society, and Rowe scores. Radiologic assessment on 3-dimensional computed tomography scans was performed preoperatively, immediately after surgery, as well as postoperatively, at 3months, 6 months, 1 year, and at the final follow-up stage. Graft positions, healing, and resorption were evaluated from postoperative images. This study included 102 patients who underwent arthroscopic iliac crest bone grafting procedure with 2 screws fixation (n= 37; group 1) and 2 button fixation (n= 65; group 2). The mean follow-up period was 37 months. There were no significant differences between groups in terms of clinical scores, shoulder motion range, graft healing, or graft positions on computed tomography scans (P>.05). In group 1, 1 patient showed mechanical irritation and persistent pain around the screw insertion site, being treated through the arthroscopic removal of the screws. The average postoperative bony resorption percentages were 20.3% and 11.2% at 6 months, and 32.4% and 19.3% at 12 months, in group 1 and group 2, respectively. A statistically significant difference was detected between the two groups (P<.05). In the arthroscopic iliac crest bone grafting procedure for the treatment of chronic osseous anterior shoulder instability, excellent functional results were obtained after both button fixation and screw fixation techniques. In addition, less graft resorption and no hardware-related complications were detected with suture button fixation technique. Level III, retrospective comparative therapeutic trial.

Current concepts in chronic traumatic anterior shoulder instability.

Chronic traumatic anterior shoulder instability can be defined as recurrent trauma-associated shoulder instability requiring the assessment of three anatomic lesions: a capsuloligamentous and/or labral lesion; anterior glenoid bone loss and a Hill-Sachs lesion. Surgical treatment is generally indicated. It remains controversial how risk factors should be evaluated to decide between a soft-tissue, free bone-block or Latarjet-type procedure. Patient risk factors for recurrence are age; hyperlaxity; competitive, contact and overhead sports. Trauma-related factors are soft tissue lesions and most importantly bone loss with implications for treatment. Different treatment options are discussed and compared for complications, return to sports parameters, short- and long-term outcomes and osteoarthritis. Arthroscopic Bankart and open Latarjet procedures have a serious learning curve. Osteoarthritis is associated with the number of previous dislocations as well as surgical techniques. Latarjet-type procedures have the lowest rate of dislocation recurrence and if performed correctly, do not seem to increase the risk of osteoarthritis.

Poster 166: Biomechanical Evaluation of Open Bankart and Soft Tissue Bristow Procedures with 10% Glenoid Bone Loss

Objectives:Chronic anterior shoulder instability can be debilitating for a wide number of individuals from the general populations, high level and recreational athletes, laborers and the members of the military. Glenoid bone loss presents a more difficult problem to treat as it negates the positive results that can be achieved with arthroscopic labral repair alone. The optimal procedure for subcritical bone loss of 10% or less is undetermined. In young competitive contact athletes, there is still a high failure rate with arthroscopic procedures. Therefore, the purpose of this study was to biomechanically characterize the effects of soft tissue Bristow (conjoint tendon transfer) and open Bankart repair in a 10% glenoid defect model.Methods:Eight fresh cadavers were studied using a custom shoulder testing system. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Range of motion, anterior-inferior translation at 60° of external rotation with 20, 30 and 40N of force were tested in scapular and coronal planes. Stiffness and the force required to dislocate in the anterior-inferior direction were also quantified in the coronal plane. 4 different states were examined including: (1) intact capsule (2) Bankart lesion with 10% bone loss, (3) soft tissue Bristow (conjoint tendon transfer), and (4) open Bankart repair. Repeated measures ANOVA with Bonferroni correction was used for statistical analysis.Results:The bony Bankart (injury model) increased range of motion in both the scapular and coronal planes. The conjoint tendon transfer had little effect on range of motion, and the Bankart repair decreased the range of motion to a similar state with that of the pre-injury model. The injury state showed increased translation which was decreased with both the conjoint tendon transfer and the Bankart repair (Figure 1A). The conjoint tendon transfer shifts the humeral head posteriorly in 0° and 30° of external rotation in the scapular plane. There was no difference in stiffness during dislocation between conjoint tendon transfer and Bankart repair (Figure 1B).Conclusions:Both the soft tissue Bristow and the open Bankart repair were noted to decrease anterior translation in this shoulder instability model. Both open repair models significantly decreased anterior translation and are valid surgical options for the treatment of instability with 10% glenoid bone loss. Surgically, an open Bankart repair is more anatomic and may be the preferred technique.

Arthroscopic Trillat technique for chronic post-traumatic anterior shoulder instability: outcomes at 2 years of follow-up.

The purpose of this study was to assess the outcomes of a new arthroscopic Trillat technique at a 2-year follow-up. Our current hypothesis was that this technique could be used for the effective treatment of chronic post-traumatic unidirectional anterior shoulder instability, and that the recurrence and complication rates, external rotation, and functional outcomes would be as good as those of the reference technique. Between April 2012 and August 2016, all patients older than 16 years who underwent the arthroscopic Trillat technique for unidirectional chronic post-traumatic anterior shoulder instability at the Dijon University Hospital (France), after the failure of well-conducted medical and rehabilitation treatment with at least 24 months of follow-up, were included. Criteria for noninclusion were association with posterior and/or inferior instabilities, voluntary instabilities, and glenoid bone loss greater than 20%. Patients attended follow-up with their surgeon before the intervention, in the immediate postoperative period, at 6 weeks, 3 and 6 months, and then by an independent observer for the last evaluation. Patients were then examined clinically with scores such as Constant, Rowe and Walch-Duplay scores, and subjective shoulder value, for shoulder range of motion, and radiographically (anteroposterior and Lamy's lateral x-rays of the operated shoulder). Forty-nine patients and 52 shoulders were included, with a mean follow-up of 40 months (range, 24-71 months). The recurrence rate of instability was 3.8% (2 of 52). No conversion to arthrotomy was necessary. No intraoperative complications, postoperative neurological lesions, or sepsis were observed. The mean Constant score was 92.1 (77.5-100) points, Walch-Duplay 82.9 (40-100), Rowe 81.73 (5-100), and subjective shoulder value 86.1 (50-100) at the last follow-up. The arm at side external rotation limitation averaged 8.4° (-25° to 40°) and the external rotation with 90° arm abduction limitation 0.34° (-5° to 15°). Forty-one patients (79%) resumed their sports activity at the same level. Fifty patients (96%) were satisfied to very satisfied. One patient developed nonunion of the coracoid process and subsequently underwent a Latarjet procedure with a good outcome. The arthroscopic Trillat procedure offers good outcomes as a first-line treatment for chronic anterior post-traumatic glenohumeral instability. It should be excluded in cases of glenoid loss greater than 20%.

Long head of biceps transfer to augment Bankart repair in chronic anterior shoulder instability with and without subcritical bone loss: a biomechanical study.

Treating recurrent anterior shoulder instability in participants in collision sports, patients with capsulolabral defects, and patients with bipolar bone loss remains challenging. The study purpose was to investigate the effect of long head of the biceps transfer (LHBT) on load-to-dislocation biomechanics in a repetitive serial shoulder dislocation cadaveric model comparing LHBT with the Latarjet and Bankart procedures-the first-line treatment methods for chronic traumatic anterior shoulder instability with and without anterior glenoid bone loss, respectively. In this controlled laboratory study, 8 fresh-frozen cadaveric shoulders with different conditions were dislocated in sequence using a custom test frame. The muscle loading configuration simulated the arm in the apprehension position, and biceps loads of 20 N and 40 N were used for the static glenohumeral position analysis to evaluate the sling effect. Sequential experimental conditions consisted of the intact state, second and third dislocations, chronic instability, Bankart repair, first LHBT, subcritical glenoid bone loss, second LHBT, and Latarjet procedure. The pectoralis major and joint reaction loads to dislocation sequentially decreased with serial dislocations in all specimens, with the lowest value in the subcritical glenoid bone defect condition. In the setting of chronic instability, the pectoralis load to dislocation was significantly higher with the Bankart repair (P = .031) and LHBT (P < .001), at 71% and 85% of the intact value, respectively. Direct comparison of the pectoralis load to dislocation favored LHBT over Bankart repair (P = .015). In the subcritical defect scenario, LHBT did not significantly increase the load to dislocate, and the Latarjet procedure demonstrated a higher load to dislocate than LHBT (P < .001). All 3 surgical procedures tested significantly increased the angle of horizontal abduction at the time of dislocation and restored the glenohumeral position to closer to the intact state. Doubling the biceps load leveraged the sling effect, pulling the humeral head farther posterior-superiorly, but this was not enough to overcome the effect of a 20% subcritical glenoid bone defect. In a serial dislocation model, LHBT effectively stabilized the glenohumeral joint in a simulated chronic instability scenario, increasing the pectoralis major load-to-dislocate and glenohumeral joint reaction force components at the time of dislocation and restoring relative glenohumeral positioning to close to the intact state. The Latarjet procedure outperformed LHBT in stabilizing shoulders in the 20% subcritical glenoid bone defect condition.

Résultats cliniques et reprise de l’activité sportive après un traitement chirurgical de l’instabilité antérieure récidivante de l’épaule par Latarjet modifiée

IntroductionThe Latarjet procedure is an attractive surgical option for the management of chronic anterior shoulder instability. The original surgical approach involves the vertical tenotomy of the subscapularis tendon. Alternatively, the subscapularis muscle is split longitudinally and the tendon left attached at the lesser tuberosity. HypothesisThe hypothesis is that the longitudinal split is of functional advantage and may lead to better functional results and earlier return to sports activities compared to the vertical tenotomy. Material and methodsIn all, 32 patients were included in this retrospective cohort study. In 14 patients, the subscapularis tendon was vertically incised (group A), whereas in 18 patients, the subscapularis muscle was split longitudinally (group B). Patients were evaluated at 1 year (FU1) and 2 years (FU2) after the Latarjet procedure. Results at follow-up were correlated with patient-specific data and compared with the preoperative status. Primary outcomes were the functional assessment based on Western Ontario Shoulder Instability (WOSI) index and Constant Score (CS) and the assessment of the return to sports activity. Patients’ demographics, duration of surgery, and the rate of recurrent dislocations were recorded as secondary variables. ResultsAll patients started their sports activities with a mean±SD of 12.41±1.24 weeks. Interestingly, the time from surgery to full recovery of sports activities was significantly longer for group A (mean±SD of 30.17±10.36 weeks) compared to group B (mean±SD of 20.71±3.67 weeks). There is a statistically significant decrease of the WOSI score from the preoperative level compared to FU1 and FU2, indicating a decrease in instability related symptoms during the entire follow up period with no statistically significant difference between group A and B. There is an increase in shoulder function during the entire follow up period based on the CS. Most interestingly, there is a statistically significant difference between group A and B at FU1, indicating a significantly better shoulder function for group B at the early follow up timepoint (FU1). At the later follow up timepoint (FU2), no difference exists in the individual items. However, a significantly better total CS remains in group B, indicating an overall improved function compared to group A. Discussion/ConclusionThe longitudinal split of subscapularis muscle is a safe approach which leads to quicker functional recovery and return to sports activity compared to the vertical tenotomy, which is a benefit especially for active individuals. It is therefore recommended as the standard surgical approach. Level of evidenceIII; retrospective cohort study.

Clinical outcome and return to sports activity after surgical treatment for recurrent shoulder instability with a modified Latarjet procedure

IntroductionThe Latarjet procedure is an attractive surgical option for the management of chronic anterior shoulder instability. The original surgical approach involves the vertical tenotomy of the subscapularis tendon. Alternatively, the subscapularis muscle is split longitudinally and the tendon left attached at the lesser tuberosity. HypothesisThe hypothesis is that the longitudinal split is of functional advantage and may lead to better functional results and earlier return to sports activities compared to the vertical tenotomy. Material and methodsThirty-two patients were included in this retrospective cohort study. In 14 patients, the subscapularis tendon was vertically incised (group A), whereas in 18 patients, the subscapularis muscle was split longitudinally (group B). Patients were evaluated at 1 year (FU1) and 2 years (FU2) after the Latarjet procedure. Results at follow-up were correlated with patient-specific data and compared with the preoperative status. Primary outcomes were the functional assessment based on Western Ontario Shoulder Instability (WOSI) index and Constant Score (CS) and the assessment of the return to sports activity. Patients’ demographics, duration of surgery, and the rate of recurrent dislocations were recorded as secondary variables. ResultsAll patients started their sports activities with a mean±SD of 12.41±1.24 weeks. Interestingly, the time from surgery to full recovery of sports activities was significantly longer for group A (mean±SD of 30.17±10.36 weeks) compared to group B (mean±SD of 20.71±3.67 weeks). There is a statistically significant decrease of the WOSI score from the preoperative level compared to FU1 and FU2, indicating a decrease in instability related symptoms during the entire follow up period with no statistically significant difference between group A and B. There is an increase in shoulder function during the entire follow up period based on the CS. Most interestingly, there is a statistically significant difference between group A and B at FU1, indicating a significantly better shoulder function for group B at the early follow up timepoint (FU1). At the later follow up timepoint (FU2), no difference exists in the individual items. However, a significantly better total CS remains in group B, indicating an overall improved function compared to group A. Discussion/ConclusionThe longitudinal split of subscapularis muscle is a safe approach which leads to quicker functional recovery and return to sports activity compared to the vertical tenotomy, which is a benefit especially for active individuals. It is therefore recommended as the standard surgical approach. Level of evidenceIII; Retrospective cohort study.

Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity

The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity. In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL) < 15%. Exclusion criteria were GBL > 15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results. Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test > 85°) metall inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P= .037), and the ASES score rose from 71.5 to 97.4 (P= .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position). The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (<15%) and hyperlaxity, without compromising external rotation. Level IV, case series.

What did we learn from our first arthroscopic Trillat procedures? Results, complications and failures in a series of 100 anterior shoulder stabilizations

Objectives:Arthroscopic adaptation of the Trillat procedure has become a part of the armamentarium for anterior shoulder instability. As the first team to have described a surgical technique, we present the results of our first 100 patients.Methods:This is a cohort study on a prospective database, descriptive of patients who had undergone surgery for chronic anterior shoulder instability between March 2011 the date our technique was developed, and October 2019. Patients were clinically and radiologically evaluated preoperatively (standard radiographs, CT scan) and postoperatively (standard radiographs) at 1, 3, 6 and 12 months and by CT scan 6 months postoperatively to evaluate the consolidation of the coracoid fracture and subscapularis muscle trophicity. Functional results were evaluated by Constant, SSV, Walch/Duplay and Rowe scores and recurrences of accidents due to instability and complications were collated.Results:100 patients, mean follow-up of 25 months (6-96), mean age, 29 years (15-73), 71% sportspeople, mean age at first episode, 20 years (7-59), 20% hyperlaxity. 67% notches, 22% bony Bankart, 15% glenoid wear and 2% rotator cuff tear. The surgical technique was identical, there were 3 operators, average operating time was 50 min (26-145), 70% were ambulatory, there were 13 fractures and no conversion to an open technique. At the last follow-up there were 3 recurrences of luxation and 4 recurrences of subluxation and in 4 cases failure to recover muscle tone was noted. 95% of the sportspersons resumed their activity, 81% at the previous level. One year postoperatively, the Walsh-Duplay score was 88 (40-100) and the Rowe score was 92 (40-100). There were 4 cases of pseudoarthrosis, 3 of which were due to a technical defect, 2 coracoid fractures, 1 case of resolving sepsis and no neurological complications. There was no damage to the subscapularis. 97% of the patients were satisfied or very satisfied.Conclusion:This is the largest available series on the arthroscopic Trillat procedure. The results are identical to those in the preliminary series and as good as those for the reference techniques. Failures and complications were few and often the result of technical errors. The recovery of muscle tone in the limb on which surgery was performed seemed to influence the effectiveness of stabilization.

Mid-term outcomes of arthroscopic Latarjet procedure in chronic anterior shoulder instability after failed Bankart surgery or with significant glenoid bone loss.

Arthroscopic Latarjet surgery is a technique developed to minimize invasive surgical treatment of anterior shoulder instability. However, compared to an open Latarjet operation, it is considered more technically demanding. The aim of our study was to assess its mid-term success rate in the hands of a surgeon with sufficient experience. We included 32 patients with recurrent anterior shoulder instability in the analysed cohort who had undergone arthroscopic intervention according to Latarjet as a revision after a previous failed Bankart operation or in the case of the significant bone loss of the glenoid. Patients were followed-up according to a defined protocol for an average of 30.2 months (range 12‒60 months). In this study, we present clinical and radiological results of a long-term follow-up evaluated using Rowe, UCLA, and SST scoring systems, comparing ranges of motion, and thorough analysis of CT examinations performed no earlier than 6 months after surgery. Rowe, UCLA and SST scores were determined pre- and postoperatively; the range of motion was compared to the contralateral side. The postoperative score was significantly improved in accordance with the clinical finding in the followed-up group (Rowe: preOP 22.1 points ‒ postOP 97.6 points, UCLA: preOP 19.50 points ‒ postOP 33.30 points, SST: preOP 8.2 points ‒ postOP 11.5). However, the postoperative external rotation remains significantly smaller as compared to the contralateral side. The feared neurovascular damage did not occur in our cohort; one patient (3 %) had an infection in the access portal, which was managed conservatively; one patient (3 %) required revision surgery. Our results demonstrated that when in the hands of experienced surgeon, the arthroscopic Latarjet surgery is an effective surgical method with a low incidence of complications and excellent mid-term clinical outcomes (Fig. 17, Ref. 25).

Repair integrity and functional outcomes of arthroscopic repair in chronic anterior shoulder instability: single-loaded versus double-loaded single-row repair.

This study compared the clinical outcome and repair integrity of single-loaded and double-loaded single-row arthroscopic repair of chronic anterior shoulder instability. Fifty consecutive chronic anterior shoulder instability cases treated by arthroscopic labral repair were included. A single-loaded single-row technique was used in the first 25 consecutive shoulders, and a double-loaded single-row technique was used in the next 25 consecutive shoulders. The number of suture anchors was 4 in the shoulders that underwent single-loaded repair and 3 in the shoulders that underwent double-loaded repair. 42 shoulders (84.0%) followed up clinical outcomes were evaluated a minimum 2years (mean 28.5months; range 24-46) postoperatively. The postoperative labral repair integrity was evaluated by MDCT-arthrogram at a minimum 6months postoperatively. At the final follow-up, the average UCLA, ASES, Constant, Rowe score, VAS pain score, and VAS for instability scores improved significantly, to 33.05, 92.33, 89.05, 94.86, 0.90 and 0.52, respectively, in the single-loaded group and to 32.19, 90.10, 89.05, 94.52, 0.90, and 0.86, respectively, in the double-loaded group. The clinical scores improved in both groups postoperatively (all P < 0.05); however, there was no significant difference between the two groups at final follow-up (P = 0.414, 0.508, 1.000, 0.917, 1.000, and 0.470, respectively). The re-tear rate was 2 (9.5%) in the shoulders that underwent single-loaded repair and 3 (14.3%) in the shoulders that underwent double-loaded repair; this difference was statistically not significant (P = 0.634). The double-loaded single-row technique resulted in comparable clinical outcomes, and re-tear rate compared with the single-loaded single-row technique in chronic anterior shoulder instability at short-term follow-up. Number of used suture anchor in double-loaded single-row technique was fewer than that of single-loaded single-row technique. Comparative retrospective study, level III.

Reconstruction of the Coracoacromial Ligament during a Modified Latarjet Procedure for the Treatment of Shoulder Instability: Clinical Outcome at Minimum 5 Years Follow-Up.

The function of the coracoacromial ligament (CAL) in superior shoulder stability has been well established, and the release of the CAL with the Latarjet procedure leads to increased superior humeral translation. A surgical technique was developed recently to reconstruct the CAL during a modified Latarjet procedure, and the clinical outcome of this technique at medium-term follow-up is yet to be determined. Twenty-six patients with chronic post-traumatic anterior shoulder instability were included in this retrospective case-control study. Patients in group 1 (n = 12) were surgically treated with the classic congruent-arc Latarjet, where the CAL is sacrificed. In group 2 (n = 14), the CAL was reconstructed using a pectoralis minor fascia flap (PMFF). Primary outcomes were the return to sports activity and functional assessment based on the Western Ontario Shoulder Instability Index (WOSI) and the Constant Score (CS) at minimum 5 years follow-up. Patient's demographics, sport activities, duration of surgery, the rate of recurrent dislocations, and specific complications related to the surgical technique were recorded as secondary variables. There was a decrease of the WOSI in both groups, indicating a decrease of symptoms at follow-up compared to the preoperative level. There was no statistically significant difference between groups 1 and 2 for the total WOSI as well as for all subscales. There was an increase of the CS in both groups in all four items at follow-up compared to preoperatively, indicating an increase in shoulder function at follow-up. There was a statistically significant difference between groups 1 and 2 for the total CS, as well as for the items power, mobility, and activity, but not for pain. Most patients (n = 20) returned to their preoperative sports activity, 13 at the same level. However, seven patients who used to perform their sports competitively chose to perform their activity at a noncompetitive level after the Latarjet procedure. All were younger than 35 years of age. Six patients did not return to their preoperative sports activity. All except one were over 35 years of age. The duration of surgery ranged from 75 to 125 minutes with a mean ± SD of 94.23 ± 15.06 minutes for both groups with no significant difference between the groups (p = 0.117). None of the patients had intra- or postoperative complications related to the surgical procedure. Especially, no patient had recurrent dislocations of the affected shoulder following the Latarjet procedure. The use of a PMFF is a safe technique for reconstruction of the CAL, which does not result in a longer surgery time or higher rate of complications. The reconstruction of the CAL during the modified Latarjet procedure may lead to better functional results in medium-term follow-up.

Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability Using Two Different Types of Fixation: Cortical Buttons Versus Screws

Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability Using Two Different Types of Fixation: Cortical Buttons Versus Screws

Relationship between the Thickness of the Coracoid Process and Latarjet Graft Positioning-An Anatomical Study on 70 Embalmed Scapulae.

Background: The Latarjet procedure is a popular technique with the aim of the reconstruction of glenoid cavity bone defects in patients with chronic anterior shoulder instability. Studies have shown that the Congruent arc Latarjet procedure is better able to reconstruct larger defects than the Classic Latarjet, but there is a lack of information on the limitations of both methods. Methods: The dimensions of the glenoid width and the native coracoid process of two groups with 35 Formol-Carbol embalmed scapulae each were measured using a digital caliper. The relationship between the coracoid graft and the anterior-posterior diameter of the glenoid cavity was calculated to determine the maximum defect size of the glenoid cavity width, which can be treated by both Latarjet techniques. Results: The average restorable defect size of the anterior segment of the glenoid cavity was 28.4% ± 4.6% (range 19.2%–38.8%) in the Classic Latarjet group, and 45.6% ± 5.2% (range 35.7%–57.1%) in the Congruent arc Latarjet group. Based on our results, the feasibility of the Classic Latarjet procedure to reconstitute the anatomical width of the glenoid cavity was 86% in a 25% bone loss scenario, and only 40% in a 30% bone loss scenario. Conclusion: Based on our results we are unable to define a clear threshold for the optimal Latarjet graft position. In glenoid cavity defects <20%, the Classic Latarjet technique usually provides enough bone stock for anatomical reconstruction. Defects ≥35% of the glenoid cavity width should only be treated with a coracoid graft in the Congruent arc position. In the critical area between 20% and 35% of bone loss, we suggest the preoperative assessment of coracoid dimensions, based on which the graft position can be planned to restore the anatomical anterior-posterior diameter of the glenoid cavity.

Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability: Patients With Prior Arthroscopic Bankart Repair Versus Primary Cases

Background: It remains unclear whether results differ between a Latarjet procedure performed after a failed arthroscopic Bankart repair and one performed as the primary operation. Purpose: To compare the postoperative outcomes of the Latarjet procedure when performed as primary surgery and as revision for a failed arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior shoulder instability. Patients were separated into 2 groups depending on if the Latarjet procedure was performed after a failed arthroscopic Bankart repair (group 1) or as the first operation (group 2). Outcome measures included recurrent instability, reoperation rates, complications, pain, Walch-Duplay scores, and Simple Shoulder Test. Results: A total of 308 patients were eligible for participation in the study; 72 (23.4%) did not answer and were considered lost to follow-up, leaving 236 patients available for analysis. Mean follow-up was 3.4 ± 0.8 years. There were 20 patients in group 1 and 216 in group 2. Despite similar rates of recurrent instability (5.0% in group 1 vs 2.3% in group 2; P = .5) and revision surgery (0% in group 1 vs 6.5% in group 2; P = .3), group 1 demonstrated significantly worse pain scores (2.56 ± 2.7 vs 1.2 ± 1.7; P = .01) and patient-reported outcomes (Walch-Duplay: 52 ± 25.1 vs 72.2 ± 25.0; P = .0007; Simple Shoulder Test: 9.3 ± 2.4 vs 10.7 ± 1.9; P = .001) when compared with those patients undergoing primary Latarjet procedures. Conclusion: Functional outcome scores and postoperative pain are significantly worse in patients undergoing a Latarjet procedure after a failed arthroscopic Bankart repair when compared with patients undergoing primary Latarjet. The assumption that a failed a Bankart repair can be revised by a Latarjet with a similar result to a primary Latarjet appears to be incorrect. Surgeons should consider these findings when deciding on the optimal surgical procedure for recurrent shoulder instability.