Coracoid Transfer Research Articles

Arthroscopic, Implant-Free Bone-Grafting for Shoulder Instability with Glenoid Bone Loss

The major steps of the procedure, which are demonstrated in the present video article, include (1) detachment of the labrocapsular ligamentous complex and preparation of the anterior aspect of the glenoid, (2) establishment of a deep anterior-inferior portal and splitting of the subscapularis tendon, (3) introduction of the "waterslide," (4) osteotomy at the scapular neck 30° relative to the glenoid surface and trial impaction, (5 and 6) harvesting and preparation of a J-shaped bicortical iliac-crest bone graft, (7) press-fit impaction of the bone graft in the prepared osteotomy over the "waterslide", and (8) capsuloligamentous repair over the graft. Coracoid transfer (Latarjet-Bristow), iliac-crest bone-grafting, and distal tibial allograft. Although widely in use, nonanatomic coracoid transfer procedures or bone-block techniques relying on hardware fixation are associated with specific complications, including nonunion, osteolysis, coracoid fractures, hardware complications, and difficult revision1. Many of these disadvantages can be avoided by the use of anatomic implant-free glenoid reconstruction with a J-shaped iliac-crest bone graft. After press-fit fixation, the graft undergoes a physiological remodeling process that follows the law of bone adaptation to mechanical stresses described by Wolff, which ultimately results in the restoration of a nearly native anterior scapular neck morphology4. The open version of this technique has been successfully used for over 3 decades. The arthroscopic, minimally invasive variation of the J-bone-graft technique presented in this video article represents a further advancement of the anatomic nature of the procedure. The arthroscopic implant-free J-bone-graft technique is an alternative to other procedures widely used for the treatment of anterior glenoid bone defects. The main advantage of this technique is the avoidance of severe complications that arise from the nonanatomic reconstruction and fixation methods found with other procedures1. Early to midterm follow-up of the arthroscopic J-bone-graft technique has revealed excellent clinical results, and the traditional open technique has been in use successfully for over 3 decades2-5. Previous patients have been able to return to a variety of occupational and athletic activities including overhead, throwing, and contact sports. Return to daily living and to moderate athletic activities is usually possible within 3 months. Return to competition is allowed after 6 months2-5. •Avoid intraoperative graft fractures by applying strictly axial force during impaction.•Reduce the risk of glenoid fractures by performing an oblique osteotomy at an angle of 20° to 30° and 5 mm medial to the glenoid surface.•The postoperative physiological remodeling process determines ultimate graft fixation and glenohumeral stability. Keep this in mind when allowing return to activities.

Outcome Analysis of 5 Patients With Recurrent Antero-Inferior Shoulder Dislocation Treated With Open Latarjet Procedure

Topic: Outcome analysis of 5 patients with recurrent antero-inferior shoulder dislocation and glenoid bone loss treated with open Latarjet procedure. Introduction: With the extreme range of movements, the shoulder joint is prone for dislocations. Selecting an optimal and efficient surgical procedure for patients with anterior glenohumeral instability and associated glenoid bone loss is a complex problem. Among the coracoid transfer procedures, open latarjet procedure offers good clinical outcomes even with glenoid bone loss. The purpose is to study the clinical outcome of Open Latarjet procedure in anterior glenohumeral instability using Carter Rowe scoring system. Aims & objectives: To evaluate the functional outcomes of 5 patinets with recurrent antero-inferior shoulder dislocation corrected by open Laterjet procedure using Carter Rowe Scoring system. Methodology: 5 patients with recurrent antero-inferior shoulder dislocation were operated by open latarjet procedure. All patients were screened clinically and confirmed on CT scan. Patients were followed up and reviewed at a mean time interval of 6 months and evaluated using Carter Rowe Score. Results: We have obtained complete bone union at 6 months in all patients with excellent to good results as scored by Carter Rowe scoring scale. In Range of motion, there was restriction in External Rotation. Patients were able to restore their daily activities by 6 months. No episode of dislocation, despite one epileptic patient having convulsed after 1 month of surgery. Conclusion: Open latarjet procedure offers a reliable surgical method of management of recurrent anterior shoulder dislocation with significant bone loss and our study showed good functional outcome as measured by Carter Rowe score.

The New Full Arthroscopic Revision Technic After Latarjet Procedure

Aim of the study is improve the results of revisions after coracoid transfer procedure. The Latarjet procedure is method of choice in case of glenoid bone loss and anterior inferior instability or revision procedures. However, recurrence after this procedure is possible. One of the methods for the revision after Latarjet procedure is Eden-Hybinette technique. The recurrence after this bone grafting procedure is described too. One of the reasons of recurrence is graft resorption and capsular deficiency. Long head of biceps transfer for capsular reinforcement was described by several authors and can improve the results. We describe a full arthroscopic revision technic after Latarjet procedure , which consists of transposition of the long head of the biceps together with bone block through subscapular split. Tips, tricks and step by step technic are presented. The early results of first 3 cases are described. After 3 months bone and tendon healing is confirm on MRI and CT. Full range of motion, absence of apprehension and biceps pain was reached at 6 months. The arthroscopic transposition of bone block together with long head of biceps through the subscapular split like in initial Latarjet procedure can be perspective surgical treatment option for recurrence after coracoid transfer.

Conjoint Tendon Tenotomy for Glenoid Exposure in the Setting of Previous Coracoid Transfer

Surgical exposure of the glenoid after previous coracoid process transfer is technically challenging as a result of distorted anatomy, obliterated soft-tissue planes, and adhesive scar tissue, which poses additional risk to adjacent neurovascular structures. The purpose of this article is to present a technique for glenoid exposure following coracoid transfer that involves tenotomy of the conjoint tendon to minimize the risk for neurovascular injury while leaving the well-healed coracoid bone graft in place.

Outcomes of Total Shoulder Arthroplasty for Instability Arthropathy with a Prior Coracoid Transfer Procedure: A Retrospective Review and Comparative Cohort

Outcomes of Total Shoulder Arthroplasty for Instability Arthropathy with a Prior Coracoid Transfer Procedure: A Retrospective Review and Comparative Cohort

Bone defect–induced alteration in glenoid articular surface geometry and restoration with coracoid transfer procedures: a cadaveric study

This study analyzed the alteration in glenoid articular geometry with increasing anterior bone loss, as well as its subsequent correction with 2 modifications of the Latarjet procedure. Anterior defects were simulated by creating glenoid osteotomies (10%, 20%, 30%, and 40%), and defects were reconstructed using 2 Latarjet modifications (classic and congruent arc). A total of 108 computed tomography scans were performed (1) on intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). Glenoid parameters (width, area, arc length, and version) were analyzed on computed tomography scans. Statistical analysis was used to determine significant differences between intact, deficient, and reconstructed glenoids. All parameters were reduced with every 10% defect increment (mean change in width, 2.5 mm; area, 64 mm2; version, 2.2°; and arc length, 2.2 mm). Width correction with the classic Latarjet procedure was not statistically significant in 30% and 40% defects. Area correction in 30% defects was not significant with the classic Latarjet procedure and was significantly undercorrected in 40% defects. Version correction was not significant after the classic Latarjet procedure in 20%, 30%, and 40% defects. Arc-length correction was not significant in 20% and 30% defects with the classic Latarjet procedure and was significantly undercorrected in 40% defects. The congruent-arc Latarjet procedure overcorrected glenoid parameters in all defects; however, area and arc length were not significantly different from intact glenoids in 40% defects (P < .05). Glenoid articular geometry is progressively altered with a sequential increase in anterior bone defects from 0% to 40%. The classic Latarjet procedure provided significant correction in bone defects of 10% and 20%. The congruent-arc Latarjet procedure restored and overcorrected most parameters even in 40% glenoid defects.

Return to Sport After Coracoid Transfer in Athletes With Anterior Shoulder Instability: A Systematic Review.

Recurrent shoulder instability in young athletes can lead to a spectrum of soft tissue and bony lesions that can be bothersome and/or disabling. Coracoid transfer is a treatment option for athletes with recurrent instability. To report the rate of return to sport for athletes after coracoid transfer. An electronic search of the literature was performed using the PubMed (MEDLINE) and Cochrane Databases (1966-2018). Studies were included if they evaluated return to sport after treatment with coracoid transfer at a minimum 1-year follow-up. Systematic review. Level 4. Data were extracted by 2 authors and included study design, level of evidence, patient demographics (number, age, sex), procedure performed, duration of clinical follow-up, rate of return to sport, patient-reported outcome measures, reoperations, and complications. Fourteen studies met the inclusion criteria. The rate of return to sport at any level ranged from 80% to 100% in all but 1 study (38%), and the rate of return to the previous level of play ranged from 56% to 95% in all but 1 study (16%). Patients returned to sport at an average of 3.2 to 8.1 months. The average patient-reported outcome scores ranged from 78% to 94% (Rowe), 223.6 to 534.3 (Western Ontario Shoulder Instability Index), and 75% to 90% (subjective shoulder value). The rate of postoperative dislocation ranged from 0% to 14%, and the reoperation rate ranged from 1.4% to 13%. There was a high early rate of return to sport in patients who underwent coracoid transfer for anterior shoulder instability, although patients did not reliably return to the same level of play. The procedure had very favorable outcomes for treatment of instability, with low rates of recurrent dislocation and reoperation.

Functional outcome of latarjet’s procedure for recurrent shoulder dislocation

Background: Recurrence of anterior shoulder instability is disabling condition for which treatment options have been insufficiently studied. Our patients don’t seek definitive treatment initially, hence they tend to have engaging hill sacks with or without bony bank arts defect. Coracoid transfer as described by Latar jet and modified by Joe De Beer is one surgery which is suited for recurrent shoulder dislocations. There are various papers mentioning different results. Hence the purpose of this study was to know the functional outcome at two years duration in our set of patients with variable age and occupation.Methods: A cohort formed the basis of retrospective series study was done in tertiary care medical college hospital in Mangalore, Karnataka, India involving twenty-seven patients who underwent Latar jet procedure with congruent ark modification for recurrent anterior glen humeral instability by a single Orthopaedic surgeon in our Institute during July 2015 and Jan 2018. Twenty-four patients were available for follow-up. Clinical outcomes at a mean of three, twelve and twenty-four months postoperatively assessed by the Rowe and SPADI (Shoulder Pain and Disability Index) scores. Standardized anteroposterior and axial radiographs were used to assess the graft position and union.Results: No shoulder dislocations or subluxations observed post-surgery. Unspecified shoulder symptoms of pain were present in two patients. We noticed that there was significant increase in the functional outcome between the 3rd, 12th and the 24th month follow up. At the end of 24months follow up sixteen patients had excellent and remaining eight had good results in terms of Rowe scoring.Conclusions: Later jet procedure with congruent arc modification and adequate rehab can effectively restore anterior glen humeral shoulder stability with good functional results.

Arthroscopic Soft Tissue Stabilization for Traumatic Anterior Shoulder Instability in Elite Collision Athletes: Is it Sufficient?

Objectives: Surgical options for shoulder instability in collision athletes remain controversial. Although arthroscopic soft tissue stabilization is widely accepted treatment for shoulder instability, many surgeons prefer coracoid transfer for collision athletes with or without glenoid defect due to potential high recurrence rate after arthroscopic soft tissue Bankart repair (ABR). In the meantime, Hill-Sacks remplissage (HSR) has been gaining popularity as an effective arthroscopic augmentation procedure. Since 2002, we performed rotator interval closure (RIC) as an augmentation in addition to ABR or arthroscopic bony Bankart repair (ABBR) for collision athletes and obtained satisfactory outcome. However, teen players demonstrated higher recurrence rate compared to twenties and thirties. Therefore, from 2012, we performed HSR as an additional augmentation for teen players besides ABR/ABBR and RIC. The purpose of this study was to assess the outcomes after arthroscopic stabilization in collision athletes who underwent shoulder stabilization under our treatment strategy. Methods: Between 2012 through 2015, 95 consecutive collision athletes underwent shoulder stabilization. Among those, only 2 patients (2%) underwent arthroscopic bony procedure for poor capsular integrity. Among the remaining 93 patients who underwent soft tissue stabilization, 65 were available for minimum 2 year follow-up (70%). Therefore, subjects consisted of 65 players including 54 rugby and 11 American football players (Table 1). There were 13 national top league, 24 collegeate, 21 junior or senior high school, and 7 recreational players. The mean age at surgery was 20 years (range, 16-36). The mean follow-up was 37 months (range, 24-64). We retrospectively reviewed intraoperative findings and surgical procedures using patient records including surgical reports and videos. We also investigated the mean time for sports return, functional outcome and recurrence rate. Pre- and postoperative Rowe scores were compared using paired t test. Results: Preoperative 3DCT of the glenoid demonstrated bony Bankart (fragment type) in 43 players (66%), attritional type in 16 (25%), and normal glenoid in 6 (9%). Mean glenoid bone loss was 15% (range, 0-25) and all of the glenoid with more than 10% bone loss retained bony fragment (Table 2). All 65 players demonstrated Bankart lesion and 15 had concomitant SLAP lesion (23%) which required repair. In addition, 5 players demonstrated capsule tear (8%), which were also repaired. Twenty four players (36%) underwent ABR or ABBR with RIC and forty one players (64%) underwent ABR or ABBR combined with HSR (Table 1).The mean time for sports return was 7 months (range, 4-13) after surgery. The mean Rowe score significantly improved after surgery from 65 (range, 55-75) to 92 (range, 65-100) (P &lt; .001). Recurrence appeared in 2 cases (3%), both of which were junior or senior high school players who underwent ABR with HSR. Conclusion: Soft tissue stabilization combined with selective augmentation procedures for shoulder instability in collision athletes demonstrated satisfactory outcomes with low recurrence rate. Since the incidence of having bony Bankart lesion in collision athletes was very high, arthroscopic bony Bankart repair worked in many patients even with significant glenoid bone loss. Further, HSR seemed to be effective additional augmentation especially in young collision athletes. [Table: see text][Table: see text]

Analysis of complication after open coracoid transfer as a revision surgery for failed soft tissue stabilization in recurrent anterior shoulder instability

The coracoid transfer represents a treatment option for patients with recurrent shoulder instability. Only a few studies exist about the complication rate of the coracoid transfer as a revision surgery following failed soft tissue stabilization. The purpose of this study was to analyze the results and complication rate after coracoid transfer as a revision surgery. In this study 38 patients (4 females, 34 males, mean age 27years) were included of whom 29 patients were available for follow-up after a mean of 27months. Previous shoulder stabilization procedures were predominantly arthroscopic (n = 25). Complications were divided according to their timely appearance into early (< 3months) and late (> 3months) postoperatively as well as need for revision. Clinical scores [Constant Score (CS), Rowe Score (RS), Walch-Duplay-Score (WDS), WOSI and Subjective-Shoulder-Value (SSV)] were evaluated preoperatively and at final follow-up. In this patient cohort, the overall complication rate was 27.6%, all of them occurred > 3months postoperatively. In seven of eight cases (24.1%) a repeat surgical procedure was conducted. Recurrent instability occurred in three patients (10.3%) of which two received a revision surgery (n = 1 iliac-crest bone graft, n = 1 labral repair). Due to persistent pain five patients underwent an arthroscopic implant removal. The complication rate was with 40% higher in patients with two or more previous surgeries (n = 4 out of 10 patients) compared to patients with one previous surgery (21%, n = 4 out of 19 patients). The scores increased significantly comparing pre- to postoperative [CS 74-90 points, RS 27-91 points, WDS 16-89 points, WOSI 40-76% and SSV 41-82% (p < 0.05)]. The open coracoid transfer as a revision surgery after failed soft tissue stabilization leads to satisfying clinical results. However, the complication rate is high though comparable to data in the literature when used as a primary surgery. The indication for a coracoid transfer should be judged carefully and possible alternatives should be considered.

Predictors of safety margin for coracoid transfer: a cadaveric morphometric analysis

BackgroundThe purpose of this study was to investigate the relationship between the bone length available for coracoid transfer without coracoclavicular ligament injury and the distance from the coracoid tip to the attachments of the coracoacromial ligament or pectoralis minor. We hypothesized that cadaver height and the soft tissue attachments on the coracoid process were predictive factors for sufficient bone length for coracoid transfer.MethodsThis study included 28 shoulders from Japanese cadavers: 19 male and 9 female. The distance from the coracoid tip to the distal attachment of the coracoclavicular ligament and the anterior and posterior margins of the coracoacromial ligament or pectoralis minor on the coracoid process were measured.ResultsThe mean available length for coracoid transfer was 24.8 ± 3.4 mm. There was a significant difference in length between male and female subjects, being 26.0 ± 2.9 mm and 22.2 ± 3.0 mm, respectively (p = 0.004). High positive correlations were found between the length of the coracoid transfer and cadaver’s height (r = 0.48, p = 0.009) and the distance from the coracoid tip to the anterior coracoacromial ligament attachment (r = 0.63, p < 0.001). The receiver operating characteristic curve area under the curve for cadaver height was 0.72 while that for distance from coracoid tip to anterior coracoacromial ligament was 0.88 when predicted for a sufficient length for coracoid transfer > 25 mm.ConclusionsOur findings will aid surgeons in preoperative planning and performing of osteotomy of the coracoid safely by predicting the available length of coracoid bone graft.

Arthroscopic Surgical Stabilization of Glenohumeral Dislocations with Clavicular Graft and Remplissage.

Surgical repair of the unstable shoulder begins with reattachment of the detached capsulolabral complex. The degree of damage to the glenohumeral articulation can be variable and is often related to the degree of trauma, duration of dislocation, and the number of instability events. There have been many surgical procedures proposed for the treatment of shoulder instability in the athlete, ranging from soft-tissue repair to coracoid transfer or the addition of a bone graft. The arthroscope provides an opportunity to visualize and repair the injured structures, returning the shoulder to maximal range of motion and permitting functional improvement. Indications for arthroscopic anterior stabilization include a first-time dislocation, patients with apprehension following dislocation, and recurrent dislocation and subluxation prior to creating advanced bone loss. If there is advanced bone loss, an augmented repair or a procedure other than arthroscopic stabilization has been recommended. Mobilization of the anterior capsule and fixation to recreate the proper anterior tension will limit translation and potential recurrence of instability. The steps of the arthroscopic anterior stabilization include:Perform examination under anesthesia to identify the directions and degree of humeral translation relative to the glenoid.Position the patient with the shoulder 30° abducted and 20° flexed.Create proper portals, including a posterior viewing portal, dual anterior portals, and accessory portals for suture anchor placement.Perform a diagnostic arthroscopy to determine the damaged structures and how they relate to shoulder positions that may invite future dislocations.Perform capsule and labrum mobilization to permit anatomic relocation of the injured ligament.Place a series of suture anchors along the anterior and inferior glenoid margin.Utilize suture hooks to retrieve the sutures placed through the capsule to advance the capsule superiorly to the glenoid margin.Assess glenoid deficiency and place an autograft anterior to the damaged glenoid rim in selected cases.Tenodese the posterior capsule and infraspinatus to a large Hill-Sachs lesion on the posterosuperior aspect of the humeral head in selected cases.Repair additional labral structures superiorly and posteriorly if they contribute to glenohumeral instability. The anticipated outcome is a return to sport and high-demand activities. Bracing is available, but the internal repair is the most reliable technique to protect the glenohumeral articulation. Additional techniques can be implemented when added trauma has resulted in severe bone loss of the glenoid, humeral head, or anterior capsular structures. A return to high-risk activities can be anticipated in 4 to 7 months.

Open Distal Tibial Allograft Augmentation

Isolated soft tissue stabilization procedures for treatment of recurrent shoulder instability are often not appropriate when the patient demonstrates bone loss of greater than 15% and in situations where there is recurrent instability after multiple attempts at arthroscopic stabilization. Current techniques for glenoid reconstruction include autografts with coracoid transfers, both Latarjet and Bristow techniques, autografts from the iliac crest, and allografts. Recent focus is on the use of distal tibial allografts for glenoid reconstruction. Distal tibial allografts provide a nearly identical radius of curvature to the glenoid with the addition of a thick cartilaginous surface that helps to restore the natural arc of the glenoid, ultimately leading to improved contact pressures by increasing the contact area. Additionally, these grafts are readily available and offer exceptional bone strength for fixation with a screw. This article discusses the surgical technique of distal tibial allograft augmentation for recurrent shoulder instability as well as the pre- and postoperative management of these patients.

The Glenojet Procedure: A Bone Preserving Alternative

Bone loss in the setting of shoulder instability increases the likelihood of recurrent instability and increases the failure rate of arthroscopic interventions. Bone loss of the anteroinferior glenoid can be addressed via autograft (coracoid transfer or iliac crest bone graft) or allograft (iliac crest or osteochondral). We describe a technique for managing glenoid bone loss with a preshaped allograft. The Glenojet (Arthrosurface Inc.) is an allograft cortical bone augment for the glenoid. It is placed with a standard deltopectoral approach. The graft is predrilled and has a disposable targeting guide that fits 2 3.5 mm cortical screws. It offers an easy solution for addressing anteroinferior glenoid bone loss that preserves normal patient anatomy. It is particularly appealing for revision procedures of failed coracoid transfers.

Open Latarjet Reconstruction: Tips for Success

The Latarjet coracoid transfer is a key procedure for reducing anterior shoulder instability in patients with glenoid bone loss. New evidence suggests that subcritical glenoid bone loss, particularly in revision situations, portends an increased risk of recurrent instability. High recurrent instability rates associated with nonoperative management and revision soft tissue stabilization make the Latarjet and other bony stability procedures a must in an orthopaedic surgeons repertoire of recurrent anterior instability management. The long-term outcomes of the Latarjet surpass revision stabilization by soft-tissue correction in those with significant glenoid loss. Despite the promising outcomes of the Latarjet, the complication rate remains high. We present a practical guide to the open Latarjet procedure, addressing many of technical challenges to aid the reader in future decision-making regarding indications, approach, exposure, surgical technique, and rehabilitation.

Arthroscopic Soft Tissue Stabilization for Traumatic Anterior Shoulder Instability in Elite Collision Athletes

Objectives: Surgical options for shoulder instability in collision athletes remain controversial. Although arthroscopic soft tissue stabilization is widely accepted treatment for traumatic anterior shoulder instability, many surgeons prefer coracoid transfer such as Latarjet procedure for collision athletes with or without glenoid defect due to potential high recurrence rate after arthroscopic soft tissue Bankart repair (ABR). In the meantime, Hill-Sachs remplissage (HSR) has been gaining popularity as an effective arthroscopic augmentation procedure. Since 2002, we performed rotator interval closure (RIC) as an augmentation in addition to ABR or arthroscopic bony Bankart repair (ABBR) for collision athletes and obtained satisfactory outcome. However, teen players demonstrated higher recurrence rate compared to twenties and thirties. Therefore, from 2012, we performed HSR as an additional augmentation for teen players besides ABR/ABBR and RIC. The purpose of this study was to assess the outcomes after arthroscopic stabilization in collision athletes who underwent shoulder stabilization under our treatment strategy. Methods: Between 2012 through 2015, 95 consecutive collision athletes underwent shoulder stabilization. Among those, only 2 patients (2%) underwent arthroscopic bony procedure for poor capsular integrity. Among the remaining 93 patients who underwent soft tissue stabilization, 65 were available for minimum 2-year follow-up (70%). Therefore, subjects consisted of 65 players including 54 rugby and 11 American football players (Table 1). There were 13 national top league, 24 collegiate, 21 junior or senior high school, and 7 recreational players. The mean age at surgery was 20 years (range, 16-36). The mean follow-up was 37 months (range, 24-64). We retrospectively reviewed intraoperative findings and surgical procedures using patient records including surgical reports and videos. We also investigated functional outcome and recurrence rate. Pre- and postoperative Rowe scores were compared using paired t test. Results: Preoperative 3DCT of the glenoid demonstrated bony Bankart (fragment type) in 43 players (66%), attritional type in 16 (25%), and normal glenoid in 6 (9%). Mean glenoid bone loss was 15% (range, 0-25) and all of the glenoid with more than 10% bone loss retained bony fragment. All 65 players demonstrated Bankart lesion and 15 had concomitant SLAP lesion (23%) which required to be repaired. In addition, 5 players demonstrated capsule tear (8%), which were also repaired. Twenty-four players (36%) underwent ABR or ABBR with RIC and forty one players (64%) underwent ABR or ABBR combined with HSR (Table 1). The mean Rowe score significantly improved after surgery from 65 (range, 55-75) to 92 (range, 65-100) (P &lt; .001). Recurrence appeared in 2 cases (3%), both of which were junior or senior high school players who underwent ABR with HSR. Ten national top league players who underwent ABR with RIC had no recurrence. Conclusion: Soft tissue stabilization combined with selective augmentation procedures for traumatic shoulder instability in collision athletes demonstrated satisfactory outcomes with extremely low recurrence rate. Since the incidence of having bony Bankart lesion in collision athletes was very high, arthroscopic bony Bankart repair worked in many patients even with significant glenoid bone loss. Further, Hill-Sachs remplissage seemed to be effective additional augmentation especially in young collision athletes. [Table: see text]

The coracoid process is supplied by a direct branch of the 2nd part of the axillary artery permitting use of the coracoid as a vascularised bone flap, and improving it's viability in Latarjet or Bristow procedures

A comprehensive understanding of the anatomy of the vascular supply of the coracoid is needed to ensure that the coracoid remains vascularised in order to optimize bone union during any coracoid transfer procedures. It is the purpose of this study to present an anatomical overview of the blood supply of the coracoid process, describing a previously unidentified vessel that arises directly from the axillary artery and nourishes the coracoid process, permitting the coracoid to be used as a free bone flap. An anatomical study examining the blood supply to the coracoid process of the scapula was performed in 14 shoulders from 7 fresh frozen (unembalmed) adult cadavers. In addition, the vascular supply to the coracoid was studied in 22 shoulders in patients during operations around the anterior shoulder. In all the cadaveric shoulders studied there was a single consistent direct branch of the second part of the axillary artery that supplied the distal 2-3cm of the coracoid process with a corresponding vein. The mean pedicle length for the artery was 4.46cm (range 3.1-5.6cm). This artery originated from the axillary artery from the antero-lateral position in 6, lateral position in 3 and posterolateral position in 5 shoulders. The mean pedicle length for the vein was 5.8cm (range 4.5-7.8cm). The vein joined directly to the axillary vein in 3 shoulders and via another tributary (parallel to the axillary vein) in 9 shoulders. The diameter of the artery and vein averaged 1-1.5mm. The clinical study confirmed the findings of the cadaveric study. Our anatomical cadaveric and clinical studies demonstrate the presence of a previously unidentified direct arterial branch from the second part of the axillary artery supplying the anterior 2-3cm of the coracoid process of the scapula. This consistent vessel and accompanying vein should be preserved for any surgical procedure that involves transfer of the coracoid process, such as the Laterjet and Bristow procedures for shoulder dislocation and can be used for free transfer of the coracoid where a small vascularised bone flap may be required.

Arthroscopic All–Intra-articular Revision Eden-Hybinette Procedure for Recurrent Instability After Coracoid Transfer

Failure, in the form of recurrent shoulder instability, following a coracoid transfer procedure presents a challenging problem. Successful treatment with a revision Eden-Hybinette procedure, by both an open and arthroscopic approach using screws to secure the bone graft, has previously been reported. However, both the open and arthroscopic approach have required careful dissection through the distorted soft-tissue anatomy in the anterior compartment in front of subscapularis to gain access to the front of the glenoid through a muscle split. In this article, we describe a modification of an arthroscopic Eden-Hybinette technique that is undertaken intra-articularly and only requires portals through the rotator interval. This technique avoids having to undertake any extra-articular dissection in the anterior compartment and can address potential problems with retained metalwork and pre-existing anchor voids within the glenoid. In this Technical Note, we describe and highlight the pearls and pitfalls of an all–intra-articular arthroscopic revision Eden-Hybinette procedure.

Arthroscopic Anatomic Glenoid Reconstruction in Lateral Decubitus Position Using Allograft With Nonrigid Fixation

Recurrent shoulder instability is highly associated with glenoid bone loss. Traditionally, bony procedures to address this bone loss have described nonanatomic, coracoid transfer procedures. More recently, anatomic glenoid reconstruction procedures have been described. These were first described as open procedures, and subsequently there have been several arthroscopic procedures described. We provide a description of an arthroscopic anatomic glenoid reconstruction approach with allograft.

Arthroplasty for glenohumeral arthritis in shoulders with a previous Bristow or Latarjet procedure

Coracoid transfer has become increasingly popular for recurrent anterior shoulder instability. Despite the success, glenohumeral arthropathy develops in some patients. Arthroplasty in this population is complicated by altered anatomy, scarring, and retained hardware. This study evaluated shoulder arthroplasty in patients with a previous Latarjet or Bristow procedure. Between 1980 and 2014, 33 patients underwent shoulder arthroplasty after coracoid transfer. Of these, 17 men and 13 women were monitored for a minimum of 2 years or until reoperation. Arthroplasty procedures included hemiarthroplasty (HA) in 5, total shoulder arthroplasty (TSA) in 14, and reverse shoulder arthroplasty (RTSA) in 11. Outcome measures included pain, range of motion, complications, and reoperations. At the most recent follow-up, pain had significantly improved in all arthroplasty groups. Elevation and external rotation also improved significantly (P < .001). Overall, 9 shoulders (30%) underwent revision for instability (1 TSA and 1 HA), glenoid loosening (1 TSA), instability and glenoid loosening (3 TSA), late cuff failure (1 TSA), and painful glenoid erosion (2 HA). Revision rates were significantly different between HA and RTSA (P = .0058) and between TSA and RTSA (P = .015). Radiographically, 2 additional anatomic glenoid components were considered loose, progressive medial erosion was seen in 1 HA, and grade 1 to 2 notching was observed in 2 RTSAs. Shoulder arthroplasty in patients after prior coracoid transfer is technically challenging, yet improvements in pain and function are predictable. Instability and glenoid loosening are common reasons for revision surgery, likely related to difficulties in achieving a good soft tissue balance.