Significant Glenoid Bone Loss Research Articles

Case Report of Arthroscopic Anatomical Bone Glenoid Augmentation with Subscapularis Tendon Protection with A 24 Months Follow-Up and Literature Review of The Current Concepts of Glenoid Bone Augmentation

Recurrent shoulder instability is known to be a challenge in terms of the success rate of surgical stabilization of the shoulder joint. According to the latest literature the choice of the glenohumeral stabilization surgical treatment is guided by the degree of bone loss. Among the techniques dedicated to significant glenoid bone loss, one will find many already reported, but each has its drawbacks. As we observe currently popular techniques, we conclude that we should continue to look for techniques or some modifications to those already available that are laden with as few complications as possible. In 2019, a new technique called bone block cerclage has been described. It is a new approach, using when metal implants are not used while providing benefits such as maintenance and integrity and function of structures like coracobrachialis, short head of biceps, pectoralis minor and preservation of subscapularis tendon. Currently, there are not many reported cases in the literature after BBC with a longer follow-up time. In this paper, we present the case of our patient operated on 24 months ago with this technique with good results. The patient is still under our observation. Due to the relatively new technique and the small number of described follow- ups, we feel it is relevant to describe our case.

Distal clavicle autograft for large glenoid defects during revision reverse total shoulder arthroplasty

IntroductionRevision reverse total shoulder arthroplasty (rTSA) can be complicated by significant glenoid bone loss and require augmented baseplates or structural bone grafts to fill the defect while optimizing glenosphere lateralization. Distal clavicle autografting is a newly described type of structural graft that has shown promising outcomes in revision reverse rTSA to address severe glenoid bone loss. Additionally, distal clavicle autografts are an option that is proposed to be more cost effective and have low morbidity in addressing glenoid bone defects. The technique for distal clavicle autografting during revision rTSA and the outcomes of a series of cases are contained within this report. Materials and MethodsA retrospective chart review was conducted for 9 patients who underwent revision rTSA with a distal clavicle autograft for glenoid bone loss between January 2013 to January 2022. The primary outcome was component survivorship at two years postoperatively. Patient charts were reviewed for clinical and radiographic information, and any complications were recorded. Postoperative radiographs were assessed for evidence of component loosening or failure. Distal clavicle and glenoid defect dimensions were measured using preoperative CT scans and compared. Results9 patients were identified who underwent revision rTSA with distal clavicle autograft to address glenoid bone loss. All patients had clinical and radiographic data available two years postoperatively. There was significant improvement in active forward flexion and abduction, and no-significant change in external rotation compared to preoperative measurements. Patient-reported QuickDASH score improved significantly with non-significant improvements in VAS function, SANE, and ASES scores. 8 of 9 (88.9%) of patients had stable prostheses with no evidence of loosening or failure at two years. One patient experienced component failure and graft osteolysis requiring conversion to hemiarthroplasty. No other complications were noted. Dimensions of the distal clavicle are similar to the dimensions of contained glenoid vault defects and glenoid defects with minimal loss of containment. ConclusionUsing a distal clavicle autograft during revision rTSA is an effective technique that can address severe glenoid bone loss. This technique has excellent radiographic outcomes at short-term follow-up and is a fortuitous autograft option in revision rTSA due to its location, dimensions, and low cost.

Revision reverse shoulder arthroplasty for the management of baseplate failure: an analysis of 676 revision reverse shoulder arthroplasty procedures

Baseplate failure in reverse shoulder arthroplasty (RSA) is a rare but potentially catastrophic complication owing to poor patient outcomes and significant glenoid bone loss. The purpose of this study was to report on the prevalence, causes, and outcomes of revision RSA (rRSA) for baseplate failure or loosening. A retrospective review of our institutional database was performed to identify all patients treated for a failed RSA from 2006 to 2021 who required revision to another RSA (rRSA) performed by a single surgeon. A total of 676 failed RSA procedures were identified, and further analysis identified 46 patients (6.8%) who underwent rRSA for baseplate failure with a confirmed loose baseplate at the time of rRSA. The primary outcome was repeated failure of the reimplanted baseplate following rRSA. The mode of failure associated with baseplate failure was stratified into 1 of 3 groups: aseptic, septic, or traumatic. Twenty-four patients underwent primary revision, and 22 had undergone >1 previous arthroplasty prior to undergoing re-revision. Five patients underwent previous rRSA for baseplate failure performed by an outside surgeon. The criteria for secondary outcome analysis of final American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and range of motion were met by 32 patients and 23 patients at 1- and 2-year follow-up, respectively. Three patients (6.5%) had repeated baseplate failure requiring re-revision; 2 had baseplate failure at <1year with associated periprosthetic infections and underwent conversion to hemiarthroplasty. The third patient experienced traumatic failure at 10 years and underwent successful rRSA. The mean American Shoulder and Elbow Surgeons scores at 1 and 2 years were 62.3 and 61.7, respectively. There was no significant difference in outcomes based on mode of baseplate failure (P=.232) or total arthroplasty burden (P=.305) at 1 year. There were 13 total complications in 11 patients, 5 of which required reoperation for reasons other than baseplate failure. In this study, rRSA for baseplate failure constituted 6.8% of all revisions performed over a period of 15 years. Re-revision for recurrent baseplate failure was required in 3 of 46 patients (6.5%). Complications and reoperation rates were higher than those for primary RSA but outcomes were comparable for revision of failed anatomic shoulder arthroplasty.

Surgical Technique for the Latarjet Procedure Using Non-Cannulated Screws

Background: The Latarjet procedure is effective for patients with anterior glenohumeral instability with substantial glenoid bone loss due to its triple blocking effect. Indications: Indications include high-risk patients with recurrent anterior glenohumeral instability with any glenoid bone loss or low-risk patients with 15% to 30% glenoid bone loss. Technique Description: An incision is made lateral to the coracoid and the deltopectoral interval is established. The pectoralis minor is released medially off the coracoid and the coracoacromial (CA) ligament is released close to the acromion. The coracoid is cut with a right-angle saw and the inferior coracoid is decorticated with a burr. Two holes are pre-drilled in the coracoid. The subscapularis is split between the upper two-thirds and lower one-third with the arm in external rotation. The capsule is split vertically at the joint line and the humeral head is retracted. The anterior glenoid is decorticated with a burr, and a hole is drilled inferiorly. The depth is measured and added to the depth of the inferior bone block hole. A fully threaded 3.5-mm solid stainless steel screw is placed in the inferior hole. Care is taken to ensure that the lateral border of the bone block is flush with the articular margin. This is repeated for the superior hole. A 1.8-mm knotless suture anchor is placed between the screws. The repair stitch is passed through the capsule and loaded onto the anchor and tensioned. The CA ligament is laid over the capsule and repaired. The subscapularis split is repaired side to side and the wound is closed in layers. Results: High return-to-sport rates, including at the same level of play, have been observed among young competitive athletes with significant glenoid bone loss who underwent a Latarjet, with similarly favorable results in older patients. Ninety-day complication rates have been reported around 9%, 5% of which constituted graft or hardware failures. Discussion/Conclusion: The Latarjet procedure is an effective option for indicated patients with anterior glenohumeral instability and may be enhanced with solid screws, proper anatomic technique, and capsulolabral repair augmentation. 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.

Pediatric and Adolescent Shoulder Instability.

Traumatic and atraumatic shoulder instability is common in pediatric and adolescent patients. It is well-established that young patients with anterior shoulder dislocation are at high risk of recurrent instability. This review assesses the current literature pertaining to management of both anterior instability and MDI in the pediatric and adolescent populations. Current research suggests that pediatric and adolescent patients with shoulder instability have excellent outcomes following arthroscopic Bankart repair; however, higher rates of recurrent instability requiring revision surgical management have been identified in patients with more than one dislocation episode pre-operatively, those with Hill-Sachs lesions and those under age 16. The addition of the remplissage procedure to an arthroscopic Bankart repair may be useful in preventing recurrent instability for patients with large Hill-Sachs lesions. Open procedures with bony glenoid augmentation may be indicated in patients with significant glenoid bone loss, or those who have failed primary surgical management, with promising outcomes reported following the Latarjet coracoid process transfer procedure in the adolescent population. Pediatric and adolescent patients with hyperlaxity, and those participating in swimming or gymnastics are more likely to have multidirectional instability (MDI). Non-surgical management with physical therapy is the mainstay of treatment for MDI with positive outcomes reported overall. In young patients with MDI who continue to have symptoms of instability and pain that effects daily activities or sports despite an adequate and appropriate course of rehabilitation, surgical management with capsulorrhaphy may be considered, with promising outcomes reported for both open and arthroscopic techniques. Attentive selection of timing and surgical procedure for pediatric and adolescent patients with anterior shoulder instability may help to prevent recurrent instability following shoulder stabilization. Although most pediatric and adolescent patients with MDI do well following non-surgical management alone, those that fail conservative management have good outcomes following arthroscopic or open capsulorrhaphy.

Survivorship of Allologous Structural Bone Graft at a Minimum of 2 Years When Used to Address Significant Glenoid Bone Loss in Revision Shoulder Arthroplasty: A Computed Tomographic and Clinical Review.

This study assesses outcomes in revision shoulder replacements where the glenoid bone loss was managed using a structural allograft (donated femoral head) in combination with a trabecular titanium (TT) implant. We contacted patients who had undergone revision shoulder arthroplasty using the Lima Axioma TT metal-backed glenoid with an allologous bone graft as a composite who were over 2 years since surgery. Patients underwent computerd tomography evaluation, clinical review, and scoring preoperatively, at 6 months and the latest follow-up. Fifteen patients were included with a mean age of 59 (33-76). The average follow-up period was 40.5 months (24-51). 80% showed satisfactory bone graft incorporation and peg integration at the latest follow-up. Three had signs of significant bone graft resorption, although in 2 patients the pegs were still soundly fixed in the host bone. Clinically all patients showed a statistically significant improvement in pain relief, movement, and function. No unusual complications were reported. Results show femoral head structural allograft in combination with TT metal-backed glenoid baseplate is a viable option for revision total shoulder replacement in the context of massive glenoid bone loss. We do, however, acknowledge that this resorption rate is higher than in other reported series where autograft is used.

Classic Versus Congruent-Arc Latarjet Procedures

Glenohumeral instability remains a frequent pathology, specifically in athletes and active patients. As such, several treatment options have been described. In the setting of significant glenoid bone loss (i.e., >20%), off-track Hill–Sachs lesions, and failed previous soft-tissue–based repairs, glenoid bone–augmentation techniques must be considered. These techniques restore stability by a triple blocking effect of the bony graft, the capsulolabral complex repair, and the dynamic sling effect of the conjoined tendon. The classic Latarjet procedure consists in performing a coracoid osteotomy along with the conjoined tendon attachment followed by transfer and fixation to the anterior glenoid, positioning the lateral surface of the coracoid to be flush with the articular side. Then, a modification of this technique defined as “congruent-arc Latarjet” (CAL) was described. This approach involves rotating the coracoid process 90° along its longitudinal axis using the inferior surface to recreate the native glenoid arc. Biomechanical studies have discussed advantages and disadvantages of these techniques. The CAL allows a greater glenoid surface area, which may be relevant in patients with increased glenoid bone loss. However, the bone contact area is reduced, which increases the technical difficulty of screw positioning with an increased risk of graft fragmentation. The classic Latarjet technique has a greater initial fixation strength between the graft and the glenoid and a greater potential for bone consolidation due to the broader contact bone area. Excellent clinical and sports outcomes with low recurrence rates have been observed in both techniques. Imaging findings have exhibited high bone block healing and no difference in graft placement, but CAL demonstrated a greater incidence of fibrous or nonunion rates and errors in screw fixation. Finally, while similar early complications have been reported, long-term outcomes are still needed in CAL for comparing osteoarthritis progression. These results emphasize that either technique can be considered to manage glenohumeral instability when appropriately indicated.

Arthroscopic Anterior Glenoid Bone Grafting for Shoulder Instability Using an Interconnected Suture Anchor Technique

Anterior bone grafting is an established and frequently used treatment option for recurrent anterior shoulder instability in combination with significant glenoid bone loss. Several open and arthroscopic fixation techniques have been presented to this field in recent years. Some of these techniques are associated with different peri- and postoperative problems or complications. Therefore, the technical gold standard for anterior bone grafting has not been determined, resulting in an ongoing evolvement of bone-grafting techniques. Arthroscopic, metal-free fixation procedures were introduced to the field bone grafting to overcome previous problems of screw fixation. These metal-free techniques frequently include surgically challenging transglenoidal drilling and are placing anterior soft tissues and neurovascular structures at risk. We therefore present an arthroscopic anterior, PEEK (polyether ether ketone)–anchor based, interconnecting bone-grafting technique bypassing previous challenges to restore the anterior glenoid bone stock with adequate positioning and fixation of the bone graft.

Long-Term Results of Arthroscopic Bankart Repair for Anterior Glenohumeral Instability: Does Associated Postero-inferior Capsulolabral Repair Still Have a Role?

To compare the outcomes of arthroscopic anterior Bankart repair with and without associated postero-inferior capsulolabral repair as treatment of anterior glenohumeral instabiliy at minimun 10year follow-up. A retrospective comparative study including patients who underwent arthroscopic anterior Bankart repair to treat anterior glenohumeral instability with glenoid bone-loss < 15% between January 2000 and February 2010 was performed. Outcomes were reported as recurrence rate, type of recurrence (dislocation or subluxation), need for revision surgery, range of motion, complications, and functional status. Outcomes were compared depending on whether a postero-inferior capsulolabral repair was added to the anterior Bankart repair. 70 shoulders [59 males, mean age 28.2 (range 14-56), mean follow-up 146.1 (range 120-208) months] were included. Recurrence occurred in 9 cases (12.8%), including 3 dislocations and 6 subluxations. Revision surgery was needed in 8 (11.4%). Mean Rowe score improved from 29.7 (11.6) preoperatively to 87.1 (12.3) postoperatively. 83.3% returned to previous sports activities. Mean forward flexion changed from 173.5° (19.2) to 168.4º(10.4) (P < 0.01), external rotation from 81.4° (18) to 75.7° (10.5) (P < 0.01), and internal rotation decreased from 66.2% reaching T12 to 14.1% (P < 0.01). Addition of postero-inferior capsulolabral repair did not influence any of the outcomes significantly. Postero-inferior capsulolabral repair added to anterior Bankart repair as treatment of anterior glenohumeral instability in abscence of significant glenoid bone-loss did not influence the outcomes in terms of recurrence, range of motion, return to sports, or functional status, compared to isolated anterior Bankart repair at 12.2year follow-up. Level III.

Poster 151: Latarjet Treatment of Anterior Shoulder Instability: The Effect of Pre-Operative MRI Coracoid Dimensions on Post-Operative Outcomes

Objectives:While pre-operative coracoid dimensions have been previously evaluated utilizing CT, no studies have utilized MRI to evaluate coracoid dimensions before Latarjet surgery. Also, no studies have evaluated post-operative outcomes based on pre-operative coracoid dimensions in Latarjet patients. Therefore, the purpose is to determine the effect of coracoid length and width as measured on pre-operative imaging (MRI) on outcomes following Latarjet treatment of anterior shoulder instability. We hypothesized that patients with longer and wider coracoid dimensions would have improved post-operative outcomes after Latarjet treatment for anterior shoulder instability.Methods:Patients who underwent primary Latarjet surgery between 2009-2019 were identified. Inclusion criteria were an available pre-operative MRI and minimum of 2-year post-operative follow-up. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Width measurements were obtained perpendicular to length at three locations – the coracoid base, midpoint and tip – and then averaged. Inter-rater reliability was good for measuring both coracoid length (ICC=0.75) and coracoid width (ICC=0.76). The primary outcomes of interest were recurrent instability, re-operation, complications, rate of and time until return-to-sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Comparisons were made between shorter vs. longer coracoid length, narrower vs. wider coracoid width, and male vs. female coracoid dimensions.Results:56 patients were included with an average age of 28.4 years and 16% were female. There were no statistically significant demographic differences between coracoid length and coracoid width groups. Coracoid length averaged 21.6 ± 2.4 mm (range: 16.7-26.9 mm), coracoid width 10.0 ± 1.0 mm (range: 8.3-13.2 mm), and glenoid bone loss 13.7% ± 8.2% (range: 0.0%-32.4%). There were 41 patients (73.2%) with harvestable coracoid length ≥ 20 mm. 55 patients received two coracoid screws for fixation, and only one patient was limited to one screw. Patients with a smaller coracoid length (<22 mm, n=30) had similar rate of recurrent instability (smaller length 6.7% vs. longer length 3.8%), complication (10.0% vs. 15.4%), re-operation (3.3% vs. 7.7%), rate of RTS (76.5% vs. 58.8%), and post-operative ASES scores (85.0 vs. 81.6) (all p>0.05), relative to patients with a larger coracoid length (>22 mm, n=26). Likewise, patients with a smaller coracoid width (<10 mm, n=29) had similar prevalence of recurrent instability (smaller width 6.9% vs. larger width 3.7%), complication (17.2% vs. 7.4%), re-operation (3.5% vs. 7.4%), rate of RTS (66.7% vs. 68.4%), and post-operative ASES scores (87.1 vs. 80.0) (all p>0.05), relative to patients with a larger coracoid length (>10 mm, n=27). Finally, male patients had a larger average coracoid width (10.1 ± 1.0 mm) than female patients (9.3 ± 0.5 mm) (p=0.001).Conclusions:This MRI protocol closely accounts for the specific landmarks utilized during the Latarjet osteotomy by focusing on identification of the CC ligament insertion. A minimum pre-operative coracoid length of 25 mm is not needed as previously stated, as anterior shoulder instability patients experience favorable post-operative outcomes after Latarjet surgery regardless of pre-operative coracoid dimensions based on our findings. Surgeons who are treating patients with significant glenoid bone loss may utilize this MRI protocol if they are concerned about the anatomy of the coracoid pre-operatively.Figure 1.Demonstration of coracoid width measurements. (Figure 2A) First, on the coronal T1 weighted oblique sequence the coracoclavicular ligaments were identified (between the red arrows), outlined by fat, including the more medial trapezoid ligament and lateral conoid ligament. (Figure 2B) Using scout localizers, the insertion of the coracoclavicular ligaments on the fluid sensitive axial sequence was identified (red arrow). A line from this point to the anterior margin of the glenoid was drawn (yellow dotted line) denoting the width of the coracoid base. Coracoid width measurements were then collected at three locations: 5 mm anteriorly from the coracoid base, midpoint, and 5 mm posteriorly from the coracoid tip. A straight line from the midpoint of the base to tip (not shown) was drawn to approximate coracoid length.Figure 2.Difference between mean pre-operative coracoid length (on left) and width (on right) between female (dark) and male (not dark) patients as measured on MRI. UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/d06d5b2e-8ec8-40b2-a9b0-fd58358533b7/1/Table_2_Coracoid_Dimensions.doc Table 1.Comparison of post-operative complications, recurrent instability, and re-operation between smaller (<22 mm) and larger (≥22 mm) coracoid length, and between smaller (<10 mm) and larger (≥10 mm) coracoid width. Categorical data presented as n (%), continuous data presented as mean ± standard deviation.Table 2.Comparison of post-operative American Shoulder and Elbow Surgeons (ASES) scores, return to play (RTP) rates, and RTP time between smaller (<22 mm) and larger (≥22 mm) coracoid length, and between smaller (<10 mm) and larger (≥10 mm) coracoid width. Categorical data presented as n (%), continuous data presented as mean ± standard deviation.

Fresh Distal Tibial Allograft: An Updated Graft Preparation Technique for Anterior Shoulder Instability

Fresh distal tibia allograft (DTA) has been gaining popularity among surgeons as an anatomic reconstruction option for the treatment of significant glenoid bone loss. Fresh DTA results in a clinically stable joint with excellent clinical outcomes and minimal graft resorption, and it has similar outcomes as the Latarjet procedure. Proper graft preparation and fixation are critical to ensuring optimal outcomes. The purpose of this Technical Note is, therefore, to describe our updated technique for DTA preparation that highlights precise cutting anatomy, sizing options, and use of orthobiologics to optimize distal tibia graft union to the native glenoid surface.

Open Shoulder Stabilization for Anterior Glenohumeral Instability: The Latarjet Procedure

Background: Traumatic anterior glenohumeral instability is a commonly encountered shoulder pathology among young active patients. Nonoperative management and arthroscopic techniques are associated with high rates of reoccurrence, particularly in patient populations with known major risk factors. Indications: The coracoid process transfer (Latarjet procedure) is typically reserved for cases of anterior glenohumeral instability where glenoid deficiency exceeds 20% to 25% or when soft tissue stabilization techniques have failed. Technique Description: We use a standard open deltopectoral approach. The coracoid process is exposed and released from the pectoralis minor and coracoacromial ligament. An osteotomy is performed using an oscillating saw and completed with an osteotome to harvest the bone block, leaving the conjoint tendon intact. Soft tissue is cleared from the graft, and it is predrilled/measured. We use a subscapularis splitting technique to access the joint and expose the anterior glenoid. All bony surfaces are prepared. We drill into the glenoid at the premeasured offset. The graft is provisionally fixed into place with K wires, then secured with 2 parallel cannulated screws. The capsule is repaired to make the graft extraarticular. The subscapularis split is repaired in addition to standard closure. Results: The Latarjet procedure is very successful for restoring stability. Rates of recurrent dislocation range from 0% to 10% across various studies, and revision rates are as small as 3%. This is much lower than those seen following soft tissue stabilization, particularly in high-risk patient populations. Patient reported outcomes show good function and high rates of return to sport. Complication rates are generally higher, with some studies reporting up to 25% incidence. Musculocutaneous and axillary nerve injuries may occur, and graft overhang can lead to glenohumeral arthritis. Certain complications are unique to the procedure, including graft lysis, coracoid fracture, nonunion, and hardware issues. Discussion/Conclusion: The Latarjet procedure is very useful in cases of anterior glenohumeral instability with significant glenoid bone loss or following failed soft tissue stabilization. Its utilization may continue to grow in future years as technique innovations develop and surgical indications expand.

Management of Complex and Revision Anterior Shoulder Instability

Treatment of recurrent anterior shoulder instability has gained significant interest in recent years and involves evaluation of both glenoid and humeral sided bone loss. Decision making is more complex in patients with significant humeral or glenoid bone defects or in those who underwent previous instability surgery. Appropriate assessment of the glenoid track is necessary as “off track” lesions typically require treatments beyond arthroscopic labral repair alone. In those with significant humeral or glenoid sided bone loss, the authors recommend three-dimensional computed tomography in addition to magnetic resonance imaging for accurate evaluation. The Glenoid Track Instability Management Score is a useful guide to help direct treatment by using the glenoid track as well as other known risk factors for recurrence. In circumstances with significant glenoid bone loss, typically over 20%, a coracoid transfer such as the Latarjet is recommended. In patients that previously failed a coracoid transfer, the authors recommend a distal tibia allograft; however, distal clavicle and iliac crest autograft have also been reported to have high success rates. In those with large Hill-Sachs lesions, remplissage or bone grafting are recommended. An estimation of the postoperative glenoid track after glenoid bone augmentation is required for appropriate Hill-Sachs lesion treatment. The authors typically recommend against revision instability surgical treatment with arthroscopic repair alone.

Patient Factors Associated With Increased Risk for Complications After the Latarjet Procedure.

Background:The open Latarjet has become the most common method of addressing significant glenoid bone loss in patients with recurrent glenohumeral instability.Purpose:To describe national trends in Latarjet procedures and risk factors for complications associated with this procedure.Study Design:Cohort study; Level of evidence, 3.Methods:Eligible patients were identified through the National Surgical Quality Improvement Program (NSQIP) data set over the years 2014 to 2018 by using the Current Procedural Terminology (CPT) code for “capsulorrhaphy anterior with coracoid process transfer” (CPT 23462). Patient and surgical outcome variables were extracted and analyzed from the NSQIP database. Logistic regression analysis and odds ratios (ORs) were performed to evaluate the relative risk of complications.Results:The authors identified 458 patients (399 men and 59 women) from the data set. The mean body mass index was 27.4 kg/m2, and mean operative time was 130.2 minutes. Statistically significant variables included smoking status and sex, which were further stratified. Smokers were 2.19 times more likely to experience at least 1 adverse outcome, including deep vein thrombosis (DVT), pulmonary embolism, reoperation, wound infection, unplanned readmission, or readmission (95% CI, 0.62-7.82). Specifically, smokers were 7.8 times more likely to have a DVT (95% CI, 0.58-105.96), 1.4 times more likely to undergo reoperation (95% CI, 0.14-5.73), and 2.4 times more likely to have an unplanned readmission (95% CI, 0.19-28.68). Women were 2.2 times more likely to experience at least 1 adverse outcome. Specifically, women were found to be 6.4 times more likely to have a DVT (95% CI, 0.76-54.87), 4.1 times more likely to have an unplanned readmission (95% CI, 0.00-106.21), and 4.7 times more likely to have a readmission (95% CI, 0.00-13.92).Conclusion:The results indicate that smokers and female patients are at a higher risk of experiencing adverse outcomes and may require additional pre- and postprocedural precautions when undergoing the Latarjet procedure. With the increase in frequency, providers should be aware of patient-related factors that may lead to adverse outcomes.

Arthroscopic Anatomic Glenoid Reconstruction With Distal Tibial Allograft and Hybrid Fixation

Glenoid grafting is the standard surgical treatment for recurrent shoulder instability with significant glenoid bone loss. Arthroscopic anatomic glenoid reconstruction using a distal tibial allograft for anatomic glenoid reconstruction has recently been gaining attention. This article describes the use of a hybrid graft fixation technique with 1 suture-EndoButton device and 1 compression screw in arthroscopic anatomic glenoid reconstruction using distal tibial allograft.

Determining the Minimal Clinically Important Difference on the Oxford Shoulder Instability Score in Patients Undergoing Arthroscopic Bankart Repair for Shoulder Instability.

Background:The literature on minimal clinically important differences (MCIDs) for patient-reported outcome measures assessing shoulder instability is limited, with none addressing the Oxford Shoulder Instability Score (OSIS). The OSIS was developed to provide a standardized method for assessing shoulder function after surgery for shoulder instability, and previous studies have demonstrated its high reliability, low interrater variability, and ease of administration.Purpose:To identify the MCID for the OSIS after arthroscopic Bankart repair for recurrent shoulder instability.Study Design:Case series; Level of evidence, 4.Methods:A longitudinally maintained institutional registry was queried for patients who underwent arthroscopic Bankart repair from 2010 to 2016 for recurrent shoulder instability secondary to a Bankart lesion without significant glenoid bone loss. The OSIS was completed preoperatively and at 1 year postoperatively. Patients were categorized into “expectations met” and “expectations unmet” groups using a questionnaire evaluating expectation fulfilment. The MCID of the OSIS at 1 year was calculated using 3 anchor-based approaches and a distribution-based approach. The 3 anchor-based approaches comprised (1) simple linear regression analysis, (2) receiver operating characteristic curve analysis, and (3) calculation of mean differences in change for the OSIS between the “expectations met” and “expectations unmet” groups.Results:The study cohort comprised 68 men and 11 women aged 29.9 ± 12.7 years (mean ± SD). Duration of follow-up for all patients exceeded 1 year. The MCIDs for the OSIS based on the 4 calculation approaches yielded a narrow range of values, ranging from 7.7 to 8.5 for the anchor-based methods and 8.6 for the distribution-based method.Conclusion:Study results indicated that patients with recurrent shoulder instability without significant bone loss who undergo primary arthroscopic Bankart repair and have at least 8.6 points of improvement on their OSIS experience a clinically significant change at 1 year postoperatively.

Clinical Outcomes of Revision Arthroscopic Capsulolabral Repair for Recurrent Anterior Shoulder Instability With Moderate Glenoid Bone Defects: A Comparison With Primary Surgery.

Background:The optimal revision surgery for failed primary arthroscopic capsulolabral repair (ACR) has yet to be determined. Revision ACR has shown promising results.Purpose:To compare the functional, strength, and radiological outcomes of revision ACR and primary ACR for anterior shoulder instability.Study Design:Cohort study; Level of evidence, 3.Methods:Between March 2007 and April 2017, a total of 85 patients underwent ACR (revision: n = 23; primary: n = 62). Functional outcome scores and positive apprehension signs were evaluated preoperatively, at 1 year, and then annually. Isokinetic internal and external rotation strengths were evaluated preoperatively and at 1 year after surgery.Results:The mean follow-up was 36.5 ± 10.2 months (range, 24-105 months). There was no significant difference between the revision and primary groups in the glenoid bone defect size at the time of surgery (17.3% ± 4.8% vs 15.4% ± 5.1%, respectively; P = .197). At the final follow-up, no significant differences were found in the American Shoulder and Elbow Surgeons score (97.6 ± 3.1 vs 98.0 ± 6.2, respectively; P = .573), Western Ontario Shoulder Instability Index score (636.7 ± 278.1 vs 551.1 ± 305.4, respectively; P = .584), or patients with a positive apprehension sign (17.4% [4/23] vs 11.3% [7/62], respectively; P = .479) between the revision and primary groups. There was no significant difference between the revision and primary groups for returning to sports at the same preoperative level (65.2% vs 80.6%, respectively; P = .136) and anatomic healing failure at 1 year after surgery (13.0% vs 3.2%, respectively; P = .120). Both groups recovered external rotation strength at 1 year after surgery (vs before surgery), although the strength was weaker than in the uninvolved shoulder. In the revision group, a larger glenoid bone defect was significantly related to a positive apprehension sign (22.0% ± 3.8%) vs a negative apprehension sign (16.0% ± 3.2%; cutoff = 20.5%; P = .003).Conclusion:In patients with moderate glenoid bone defect sizes (10%-25%), clinical outcomes after revision ACR were comparable to those after primary ACR. However, significant glenoid bone loss was related to a positive remaining apprehension sign in the revision group. Surgeons should consider these findings when selecting their revision strategy for patients with failed anterior shoulder stabilization.

Arthroscopic “Double-Inlay” Eden-Hybinette Procedure with Modified Suture Button Fixation for the Revision of Failed Bristow-Latarjet

Bristow-Latarjet procedure has been widely regarded as a reliable and satisfactory operation for recurrent anterior glenohumeral instability, especially for patients with significant glenoid bone loss or high sports demand. Once failed, however, the subsequent revision surgery could be challenging. Eden-Hybinette procedure is the most common operation for revision of failed Bristow-Latarjet. It can perfectly restore the bone defect of the failed Bristow-Latarjet by harvesting a proper size of iliac bone block. Furthermore, several studies have shown the advantages of using suture button fixation in the revision surgery for failed Bristow-Latarjet procedure. However, the potential inferior biomechanical strength of suture button fixation is still a concern. This Technical Note introduced an arthroscopic “double-inlay” Eden-Hybinette procedure with modified suture button fixation for the revision of failed Bristow-Latarjet. With its “quadruple” reinforcement effect, this procedure can achieve an excellent biomechanical strength of fixation.

Early outcomes of the arthroscopic Latarjet procedure in a series of 37 patients with shoulder instability

BackgroundAnterior shoulder dislocation remains a clinical challenge. This study aimed to assess the graft position and clinical outcomes of the arthroscopic Latarjet procedure and capsular repair for the treatment of recurrent anterior shoulder dislocation with significant glenoid bone loss in 37 patients.MethodsBetween 2017 and 2017, 37 patients underwent arthroscopic Latarjet plus capsular repair procedure for recurrent anterior shoulder dislocation combined with significant glenoid bone loss. In follow-up examinations, Walch-Duplay scores, subjective shoulder value (SSV) scores, Rowe scores, and active range of motion (AROM) were assessed. Three-dimensional computed tomography (CT) was used to evaluate coracoid graft position and bone resorption. A new method of evaluating the position of the coracoid bone block after Latarjet (H-Z method) was developed.ResultsThirty-seven patients were included in this study. Follow-up ranged from 6 to 36 months postoperatively (with an average of 13 months). No recurrent dislocation occurred at the final follow-up, and there was no significant effect on the AROM (all p > 0.05). Rowe (from 42.2 ± 5.6 to 91.1 ± 3.3), Walch-Duplay (from 31.5 ± 8.0 to 92.6 ± 3.7), and SSV (from 63.9 ± 6.1 to 79.3% ± 5.0%) scores were improved significantly after surgery (all p < 0.001). CT showed that the 29 patients had varying degrees of bone resorption, and 23 recovered to the preinjury level of motional function within 6–12 months after surgery.ConclusionsIn active patients with recurrent anterior shoulder dislocations and significant glenoid bone loss, the arthroscopic Latarjet procedure plus capsular repair could restore shoulder stability satisfactory.

Arthroscopic Iliac Bone Grafting for Traumatic Anterior Shoulder Instability With Significant Glenoid Bone Loss Yields Low Recurrence and Good Outcome at a Minimum of Five-Year Follow-Up

The purpose of this study was to investigate the clinical and radiographic outcomes of arthroscopic iliac bone grafting with capsulolabral reconstruction for severe glenoid bone loss with a minimum of 5 years' follow-up. The inclusion criterion was shoulders that underwent arthroscopic iliac bone grafting for >20%-25% glenoid defect between January 2007 and April 2014, and the exclusion criterion was <5 years' follow-up. Iliac crest bone grafts of approximately 2.0 cm length and 0.8 cm height were arthroscopically fixed to the anterior glenoid using 2 cannulated screws followed by capsulolabral repair. Rowe score, Western Ontario Shoulder Instability Index (WOSI), and passive range of motion were evaluated. Radiographic findings including the Kellgren and Lawrence osteoarthritis grade and graft integration on 3-dimensional computed tomography at the final follow-up were also evaluated. Forty-eight shoulders met the inclusion criteria, and 24 shoulders with ≥5 years' follow-up were included (1 died; 23 were lost follow-up): 22 males, 2 females; a mean age at surgery, 30 years (range, 18-52 years); a mean follow-up of 8 years (range, 5-11 years). The mean preoperative glenoid bone defect was 22% (range, 20%-28%). All shoulders had a Hill-Sachs lesion including 4 on-track lesions. One shoulder experienced traumatic redislocation at 5 years after surgery. The scores significantly improved: Rowe score, 19 ± 8 to 94 ± 8 (P < .001); WOSI, 1547 ± 241 to 439 ± 318 (P < .001). Postoperative flexion showed significant improvement from 158 ± 18 to 169 ± 11 (P= .008), whereas internal rotation deteriorated from T8 ± 3 to T10 ± 3 (P= .005). Graft integration showed remodeling in 54% and excessive absorption in 13%. Osteoarthritis grades progressed significantly (P < .001), but only grade 1 osteoarthritic changes were seen, except for 4 shoulders with grade 2 osteoarthritis. Arthroscopic iliac bone grafting for traumatic anterior shoulder instability with severe glenoid bone loss yielded satisfactory outcomes with mid-term follow-up. Arthritic changes progressed in half of the shoulders; however, most shoulders only demonstrated grade 1 osteoarthritis. Level IV, therapeutic case series.