Postoperative Radiographic Outcomes Following Primary Open Coracoid Transfer (Bristow-Latarjet) Vary in Definition, Classification, and Imaging Modality: A Systematic Review.

PURPOSE: To analyze radiographic outcomes by conventional radiography, computed tomography (CT), or both and complication rates of open coracoid transfer at a minimum of 12-months follow-up. METHODS: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were clinical studies reporting on open Latarjet as the primary surgical procedure(revision coracoid transfer after failed prior stabilization excluded) with postoperative radiographic outcomes at a minimum mean 1-year follow-up. Patient demographics, type of postoperative imaging modality, and radiographic outcomes and complications including graft union, osteoarthritis, and osteolysis were systematically reviewed. Data were summarized as ranges of reported values for each outcome metric. Each radiographic outcome was graphically represented in a Forest plot with point estimates of the incidence of radiographic outcomes with corresponding 95% confidence intervals and I2. RESULTS: Thirty-three studies met inclusion criteria, with a total of 1,456 shoulders. The most common postoperative imaging modality was plain radiography only (n = 848 [58.2%]), both CT and radiography (n = 287 [19.7%]), and CT only (n = 321 [22.1%]). Overall, the reported graft union rate ranged from 75% to 100%, of which 79.8% (n = 395) were detected on plain radiography. The most common reported postoperative radiographic complications after the open coracoid transfer were osteoarthritis (range, 0%-100%, pooled mean 28%), graft osteolysis (range, 0%-100%, pooled mean 30%), nonunion (range, 0%-32%, pooled mean 5.1%), malpositioned graft (range, 0%-75%, pooled mean 14.75%), hardware issues (range, 0%-9.1%, pooled mean 5%), and bone block fracture (range, 0%-8%, pooled mean 2.1%). Graft healing was achieved in a majority of cases (range, 75%-100%). CONCLUSION: Postoperative radiographic outcomes after open coracoid transfer vary greatly in definition, classification, and imaging modality of choice. Greater consistency in postoperative radiographic outcomes is essential to evaluate graft healing, osteolysis, and nonunion. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

The Effect of Screw Design and Cortical Augmentation on Insertional Torque and Compression in Coracoid-Glenoid Fixation in a Sawbones Model.

PURPOSE: To compare screw insertional torque and coracoid-glenoid compression from 4 fixation techniques with different screw design parameters and cortical augmentation for the Latarjet procedure. METHODS: Simulated Latarjet procedures were performed with 4 fixation techniques using laminated polyurethane blocks with dimensions similar to the coracoid-glenoid construct. The groups included DePuy Synthes Mitek 3.5-mm partially threaded screws with top hats, Arthrex 3.75-mm fully threaded screws with a 2-hole plate, Arthrex 3.75-mm fully threaded screws, and Smith & Nephew 4.0-mm partially threaded screws. Screws were inserted using a digital torque-measuring screwdriver to determine maximum insertional torque. Pressure-sensitive film was used to measure the maximum contact pressure and the effective pressure distribution (EPD) between the coracoid and glenoid; the EPD represents the percentage of the film's surface area that experienced pressure greater than 10 MPa. One-way analysis of variance and post hoc tests were used for statistical analysis. RESULTS: Significant differences were found between the 4 fixation groups for each variable measured. The 2 cortically augmented systems produced significantly higher maximum insertional torque than the non-cortically augmented systems (P < .001 for both). The 3.75-mm screws with a 2-hole plate yielded significantly higher contact pressures than the 4.0-mm screws (P = .028). This group also had a high EPD, with a mean value more than double the values of the non-cortically augmented systems (P = .037 and P < .001). CONCLUSIONS: Cortically augmented fixation methods showed higher maximum insertional torque, maximum contact pressure, and EPD between the surfaces of the coracoid and glenoid in this Sawbones model. CLINICAL RELEVANCE: Various implants are available for the Latarjet procedure, but their biomechanical characteristics have not yet been fully elucidated. Graft fracture and nonunion represent 2 modes of failure that may be related to insertional torque and coracoid-glenoid compression. This study compared screw insertional torque and compression achieved using 4 fixation techniques with different screw design parameters and cortical augmentation in a Sawbones model.

Proximal-medial part in the coracoid graft demonstrates the most evident stress shielding following the Latarjet procedure: a simulation study using the 3-dimensional finite element method.

BACKGROUND: Although the osteolysis of the coracoid graft is frequently observed after the Latarjet procedure particularly in its proximal part, its pathomechanism is not well understood. METHODS: Three-dimensional finite element glenohumeral joint models were developed using CT-DICOM data of 10 normal shoulders. A 25% bony defect was created on the anterior glenoid rim, and the coracoid process was transferred flush with the glenoid cartilage using 2 half-threaded screws. In the hanging arm as well as in the 90° abducted positions, a compressive load (50 N) was applied to the greater tuberosity toward the center of the glenoid and a tensile force (20 N) was applied to the coracoid tip along the direction of the conjoint tendon. Next, elastic analysis was performed, and the distribution patterns of the equivalent stress as well as the maximum principal stress were compared among 4 parts (proximal/distal and medial/lateral) of the coracoid graft. RESULTS: Both the equivalent stress and the maximum principal stress were reduced in the proximal half of the coracoid graft. A high stress concentration was observed in the lateral aspect of the coracoid graft particularly in the 90° abducted position. The proximal-medial part demonstrated the lowest equivalent stress as well as the maximum principal stress for both arm positions, which were significantly lower than those in the distal 2 parts. CONCLUSION: In the Latarjet procedure, the proximal-medial part of the coracoid graft demonstrated the most evident stress shielding, which may play an important role in postoperative osteolysis.

Coracoid process transfer for anterior shoulder instability : a pectoralis minor sparing method.

The Latarjet procedure alters scapulothoracic motion by releasing the pectoralis minor insertion to the coracoid process and by changing the vector of the conjoint tendon. The purpose of this study is to evaluate the feasibility of retaining the pectoralis minor insertion and a part of the conjoint tendon on to the remainder of the coracoid, and to evaluate the efficiency of the procedure in avoiding scapular dyskinesis, without concessions to glenohumeral stability. Since June 2017, a modification to the Latarjet procedure has been used in the treatment of posttraumatic anterior shoulder instability. The pectoralis minor insertion and a part of the conjoint tendon is retained on its anatomical position, by harvesting only the lateral part of the coracoid. We retrospectively enrolled the first 9 consecutively treated shoulders with a minimum of 6 months follow up and recorded scapulothoracic position and scapulothoracic motion, patient satisfaction, Oxford score, and Short Form (SF)-36. All patients underwent a radiographic review at final follow up. No scapular dyskinesis was observed at final follow- up. Radiographies consistently showed a bony spur at the original osteotomy site, suggesting a functional attachment of the pectoralis minor tendon to the scapula. Harvesting only the lateral part of the coracoid is technically feasible, efficient in treating anterior shoulder instability and avoids scapular dyskinesis. Level of evidence : Level IV, Retrospective Cohort study, Treatment study.

Clinical outcomes and radiologic assessment of a modified suture button arthroscopic Latarjet procedure.

BACKGROUND: As several neurologic and hardware complications have been reported with screw fixation. Suture buttons are used to serve as an alternative to screw fixation to obtain better outcome and to reduce the complication. The purpose of this study was to observe the clinical outcomes and make the radiologic assessment of a modified suture button (MSB) arthroscopic Latarjet procedure. METHODS: A total of ninty-one patients with recurrent shoulder joint dislocation who underwent MSB arthroscopic Latarjet procedure was retrospectively reviewed. Fifty cases identified from the chart review met the inclusion criteria. The clinical outcomes and position of the grafts, glenohumeral degeneration, and graft healing condition were assessed postoperatively in a follow-up with at least one and half of a year. RESULTS: All the fifty patients were satisfied with their clinical outcome. The overall complication rate was 4% in this study. The mean visual analog scale score, the affected shoulder active mobility in Ers(external rotation at the side), Era(external rotation in abduction) decreased significantly; the ASES score, Rowe score, Walch-Duplay score improved significantly. CT scans in the sagittal view showed that grafts in 88% of cases were in good position, grafts in 12% of cases were fixed too superiorly and inferiorly. In the axial view grafts in forty cases were flush with the glenoid rim, ten were considered as too lateral. The ten grafts became remodeled and were more flush with the glenoid rim in the follow-up. CONCLUSIONS: The MSB arthroscopic Latarjet procedure provides excellent outcome with few complications, and no degenerative changes were observed in the follow-up. Moreover, the graft fixed too laterally presented a phenomenon of remodeling and became flush with the glenoid rim over time.

Monocortical fixation of the coracoid in the Latarjet procedure is significantly weaker than bicortical fixation.

PURPOSE: A crucial step of the Latarjet procedure is the fixation of the coracoid process onto the glenoid. Multiple problems associated with the fixation have been described, including lesions of the suprascapular nerve due to prominence of the screw or bicortical drilling. The purpose of the present study was to evaluate whether monocortical fixation, without perforating the posterior glenoid cortex, would provide sufficient graft stability. METHODS: Coracoid transfer was performed in 14 scapula models (Sawbones®, Composite Scapula, 4th generation). Two groups were assigned: in one group, fixation was achieved with two screws that did not perforate the posterior cortex of the glenoid neck (monocortical fixation), in the other group, fixation was achieved with perforation of the posterior cortex (bicortical fixation). The ultimate failure load and mode of failure were evaluated biomechanically. RESULTS: Monocortical fixation was a significantly weaker construct than bicortical fixation (median failure load 221 N, interquartile range 211-297 vs. median failure load 423 N, interquartile range 273-497; p = 0.017). Failure was either due to a pullout of the screws from the socket or a fracture of the glenoid. There was no significant difference in the mode of failure between the two groups (n.s.). CONCLUSION: Monocortical fixation was significantly weaker than bicortical fixation. However, bicortical drilling and overly long screws may jeopardize the suprascapular nerve. Thus, anatomic knowledge about the safe zone at the posterior rim of the glenoid is crucial. Until further research has evaluated, if the inferior stability is clinically relevant, clinicians should be cautious to use a monocortical fixation technique for the coracoid graft.

Intraoperative and anatomic dimensions of the coracoid graft as they pertain to the Latarjet-Walch procedure.

BACKGROUND: Our objective was to study the anatomic and intraoperative coracoid measurements with an aim to closely replicate the Latarjet-Walch technique and find the similarities and dissimilarities in our population. METHODS: In the cadaveric study, 20 shoulders in 10 fresh cadavers were dissected, and the coracoid length, width, and thickness were measured. In the intraoperative study, 10 patients underwent the classic Latarjet procedure according to the Walch technique. The harvested coracoid graft was analyzed for the length of the coracoid, the distance of the inferior hole from the lateral margin of the coracoid graft, and the width of the coracoid graft at the inferior and superior hole. RESULT: The average distance from the tip of the coracoid to the trapezoid insertion was 25.4 mm (standard deviation [SD], 1.7 mm). The mean width of the undersurface of the coracoid was 14.2 mm. The average length of the graft after harvesting was 25.1 mm (SD, 1 mm). The average distance between the lateral border and the inferior hole was 5.5 mm (SD, 1.1 mm). We used 25-mm malleolar screws in 3 shoulders and 30-mm malleolar screws in 7 shoulders. CONCLUSION: The"7-mm" rule of Walch could be followed in our population. The medial surface width of the coracoid in our Indian morphology was an average of 7 mm; hence, malleolar screws of 30 and 25 mm were used to fix the graft on the glenoid.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Neer Award 2019: Latarjet procedure vs. iliac crest bone graft transfer for treatment of anterior shoulder instability with glenoid bone loss: a prospective randomized trial.

BACKGROUND: The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are competing treatment options for anterior shoulder instability with glenoid bone loss. METHODS: In this bicentric prospective randomized study, 60 patients with anterior shoulder instability and glenoid bone loss were included and randomized to either an open Latarjet or open ICBGT (J-bone graft) procedure. Clinical evaluation was completed before surgery and 6, 12, and 24 months after surgery, including the Western Ontario Shoulder Instability index, Rowe score, Subjective Shoulder Value, pain level, satisfaction level, and work and sports impairment, as well as assessment of instability, range of motion, and strength. Adverse events were prospectively recorded. Radiographic evaluation included preoperative, postoperative, and follow-up computed tomography analysis. RESULTS: None of the clinical scores showed a significant difference between the 2 groups (P > .05). Strength and range of motion showed no significant differences except for diminished internal rotation capacity in the Latarjet group at every follow-up time point (P < .05). A single postoperative traumatic subluxation event occurred in 2 ICBGT patients and 1 Latarjet patient. The type and severity of other adverse events were heterogeneous. Donor-site sensory disturbances were observed in 27% of the ICBGT patients. Computed tomography scans revealed a larger glenoid augmentation effect of the ICBGTs; this, however, was attenuated at follow-up. CONCLUSION: The Latarjet and ICBGT procedures for the treatment of anterior shoulder instability with glenoid bone loss showed no difference in clinical and radiologic outcomes except for significantly worse internal rotation capacity in the Latarjet group and frequently noted donor-site sensory disturbances in the ICBGT group.

Analysis of failures after the Bristow-Latarjet procedure for recurrent shoulder instability.

PURPOSE: Despite good clinical results and low recurrence rates, post-operative complications of coracoid process transfer procedures are not well understood. This study aims to evaluate the underlying failure mechanism in cases requiring major open revision surgery after prior Bristow or Latarjet stabilization. METHODS: Between January 2006 and January 2017, 26 patients underwent major open revision after primary Bristow or Latarjet procedure. Clinical notes and radiographic images were retrospectively reviewed for all cases to determine underlying pathology. Choice of treatment and clinical and radiographic outcome were similarly reported for all cases. RESULTS: The underlying failure mechanism was associated with non-union in 42.3%, resorption in 23.1%, graft malpositioning in 15.4%, and trauma or graft fracture in 19.2% of cases. Although none of the patients reported any dislocations, mean subjective shoulder score was 60.2% and WOSI scores averaged 709.3 points at final follow-up. Radiographic signs of deteriorating degenerative arthritis were seen in 34.6%. CONCLUSION: Graft non-union resulting in recurrent instability was the main indication for open revision surgery after Bristow or Latarjet procedure, followed by resorption, malpositioning, and graft fracture in this retrospective case series. Revision surgery consisted of a structural iliac crest bone graft in the majority of cases. Clinical and radiographic outcomes are predictably variable in this population of multioperated patients.

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

BACKGROUND: 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. METHODS: In this study 38 patients (4 females, 34 males, mean age 27 years) were included of whom 29 patients were available for follow-up after a mean of 27 months. Previous shoulder stabilization procedures were predominantly arthroscopic (n = 25). Complications were divided according to their timely appearance into early (< 3 months) and late (> 3 months) 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. RESULTS: In this patient cohort, the overall complication rate was 27.6%, all of them occurred > 3 months 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)]. CONCLUSION: 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.

Fate of coracoid grafts after the Latarjet procedure: will be analogous to the original glenoid by remodelling.

PURPOSE: To evaluate the location, magnitude, and change over time of osteolysis of coracoid grafts after Latarjet procedure. METHODS: This is a retrospective study of 54 patients (55 shoulders) who underwent the Latarjet procedure. Three-dimensional computed tomography (CT) scans were performed preoperatively, immediately postoperatively, and at follow-up (mean 7.7 and 31.7 months postoperative). "En face" views of the glenoid, size of glenoid defect and changes in the glenoid surface area postoperatively were measured relative to the area of an assumed outer-fitting circle. On the oblique sagittal planes, location and subsequent severity of osteolysis of the graft at follow-up were documented. RESULTS: The mean glenoid surface area increased significantly from 79.7 ± 4.8% of the original circle preoperatively to 111.3 ± 8.0% immediately postoperatively. At 7.7 and 31.7 months of follow-up, glenoid surface area decreased to 102.2 ± 6.0% and 100.3 ± 5.3%, respectively. Osteolysis occurred on the outer side of the graft in all cases, but did not occur on the inner side. Maximum osteolysis was observed in the superior third of the graft (78.5 ± 17.1%), followed by the middle third (15.8 ± 10.4%), and the inferior third (8.0 ± 5.1%). No significant difference in magnitude of osteolysis was observed between 7.7 and 31.7 months of follow-up. CONCLUSION: Osteolysis of the grafted coracoid mainly occurred on the outer side of the superior portion, resulting in reshaping of the rectangular shape of graft coracoids after Latarjet procedure. Coracoid graft remodelling was almost completed approximately 8 months postoperatively to reach the original glenoid dish with no further changes thereafter. These results may help surgeons to understand changes of grafts after the surgery. LEVEL OF EVIDENCE: IV.

Coracoid graft union: a quantitative assessment by computed tomography in primary and revision Latarjet procedure.

BACKGROUND: The goal of the Latarjet procedure is restoration of shoulder stability enabled by accurate graft positioning and union. This study aimed to establish a reproducible method of quantitatively assessing coracoid graft osseous union percentage (OUP) using computed tomography (CT) scans and to determine the effect of other factors on the OUP. MATERIALS AND METHODS: Postoperative CT scans of 41 consecutive patients treated with the open Latarjet procedure (37% primary, 63% revision) for anterior glenohumeral instability were analyzed for the OUP, position of the graft, and screw type and angle. Two musculoskeletal radiologists independently examined the images 2 times, and intraobserver and interobserver reliability was calculated using intraclass correlation coefficient (ICC). RESULTS: Mean OUP was 66% (range, 0%-94%) using quantitate methods, with good intraobserver reliability (ICC = 0.795) and interobserver reliability (ICC = 0.797). Nonunion and significant graft resorption was found in 2 patients. No significant difference was found in the mean OUP in the primary (63%) vs. revision Latarjet procedure (67%). Grafts were flush in 39%, medial in 36%, and lateral in 8%. The medial and neutral graft position was associated with slightly higher OUP (72% and 69%) compared with lateral (65%). OUP was higher when the superior screw angle was less than 17° and the inferior screw angle was less than 24°. This difference did not reach statistical significance. Screw type was not associated with significant difference in OUP. CONCLUSION: Quantitative assessment of osseous union of the graft using a reproducible method that we introduced showed similar OUP in the primary and revision Latarjet procedure.

Treatment of recurrent anterior shoulder instability with the Latarjet or Bristow procedure in older patients.

BACKGROUND: The coracoid transfer procedure is commonly and successfully used to treat shoulder instability in young patients. However, there is concern that the outcome of this procedure might be inferior in older patients because of decreased bone graft quality and the potential concomitant presence of irreparable rotator cuff tears (RCTs). METHODS: All patients older than 40 years treated with a coracoid transfer procedure between 1998 and 2013 because of anterior shoulder instability were included. Surgical indication criteria were anterior glenoid bone defects and/or the presence of an irreparable yet functionally compensated RCT. Of 27 consecutive patients, 25 (93%) were followed up after an average of 9 years (2-15 years) clinically as well as by means of computed tomography scans. Mean age at surgery was 62 years (40-85 years). RESULTS: Nine patients (36%) were revised during the follow-up period. The average Western Ontario Shoulder Instability Index of the nonrevised patients was 556; Rowe score, 77; American Shoulder and Elbow Surgeons score, 75; Constant score, 65; and subjective shoulder value, 70%. The average preoperative instability arthropathy score of 0.7 increased to 2.0 (P < .001). An irreparable RCT showed no significant effect on the clinical outcome scores or revision rate but was associated with the development of cuff arthropathy (R = 0.89; P = .01). An increased grade of preoperative cuff arthropathy was associated with a higher revision rate (R = 0.55; P = .04). CONCLUSION: The coracoid transfer procedure represents a joint-preserving treatment option for anterior shoulder instability in older patients with glenoid bone defects or concomitant irreparable yet functionally compensated RCTs. However, bone graft- and hardware-related complications as well as required revision operations are frequent.

Comparative study of open and arthroscopic coracoid transfer for shoulder anterior instability (Latarjet)-computed tomography evaluation at a short term follow-up. Part II.

PURPOSE AND HYPOTHESIS: The aim of this study was to evaluate and to compare the radiological parameters after arthroscopic and open Latarjet technique via evaluation of computed tomography (CT) scans. Our hypothesis was that the radiological results after arthroscopic stabilisation remained in the proximity of those results achieved after open stabilisation. MATERIAL AND METHODS: CT scan evaluation results of patients after primary Latarjet procedure were analysed. Patients operated on between 2006 and 2011 using an open technique composed the OPEN group and patients operated on arthroscopically between 2011 and 2013 composed the ARTHRO group. Forty-three out of 55 shoulders (78.2%) in OPEN and 62 out of 64 shoulders (95.3%) in ARTHRO were available for CT scan evaluation. The average age at surgery was 28 years in OPEN and 26 years in ARTHRO. The mean follow-up was 54.2 months in OPEN and 23.4 months in ARTHRO. CT scan evaluation was used to assess graft fusion and osteolysis. Bone block position and screw orientation were assessed in the axial and the sagittal views. The subscapularis muscle fatty infiltration was evaluated according to Goutallier classification. RESULTS: The non-union rate was significantly higher in OPEN than in ARTHRO: 5 (11.9%) versus 1 (1.7%) (p < 0.05). The total graft osteolysis was significantly higher in the OPEN group: five cases (11.9%) versus zero in ARTHRO (p < 0.05). Graft fracture incidence was comparable in both groups: in two patients in ARTHRO (3.3%) and one case (2.4%) in the OPEN group (p > 0.05). These results should be evaluated very carefully due to significant difference in the follow-up of both groups. A significantly higher rate of partial graft osteolysis at the level of the superior screw was reported in ARTHRO with 32 patients (53.3%) versus 10 (23.8%) in OPEN (p < 0.05). In the axial view, 78.4% of patients in ARTHRO and 80.5% in OPEN had the coracoid bone block in an acceptable position (between 4 mm medially and 2 mm laterally). In the sagittal plane, the bone block was in an acceptable position between 2 and 5 o'clock in 86.7% of patients in ARTHRO and 90.2% in OPEN (p > 0.05). However, in the position between 3 and 5 o'clock there were 56.7% of the grafts in ARTHRO versus 87.8% in OPEN (p < 0.05). The screws were more parallel to the glenoid surface in ARTHRO-the angles were 12.3° for the inferior screw and 12.6° for the superior one. These angles in the OPEN group were respectively 15° and 17° (p < 0.05 and for the superior screw). There was no significant difference in the presence of fatty infiltration of the subscapularis muscle. CONCLUSIONS: Arthroscopic Latarjet stabilisation showed satisfactory radiographic results, comparable to the open procedure, however the short-term follow-up can bias this evaluation. Graft healing rate was very high in the arthroscopic technique, but yet osteolysis of the superior part of the graft and more superior graft position in the sagittal view were significantly different when compared to the open technique. The screw position was slightly more parallel to the glenoid via the arthroscopic technique. We recommend both further investigation and development of the arthroscopic technique. LEVEL OF EVIDENCE: III.

Biomechanical Analysis of Latarjet Screw Fixation: Comparison of Screw Types and Fixation Methods.

PURPOSE: To compare the initial fixation stability, failure strength, and mode of failure of 5 different screw types and fixation methods commonly used for the classic Latarjet procedure. METHODS: Thirty-five fresh-frozen cadaveric shoulder specimens were allocated into 5 groups. A 25% anteroinferior glenoid defect was created, and a classic Latarjet coracoid transfer procedure was performed. All grafts were fixed with 2 screws, differing by screw type and/or fixation method. The groups included partially threaded solid 4.0-mm cancellous screws with bicortical fixation, partially threaded solid 4.0-mm cancellous screws with unicortical fixation, fully threaded solid 3.5-mm cortical screws with bicortical fixation, partially threaded cannulated 4.0-mm cancellous screws with bicortical fixation, and partially threaded cannulated 4.0-mm captured screws with bicortical fixation. All screws were stainless steel. Outcomes included cyclic creep and secant stiffness during cyclic loading, as well as load and work to failure during the failure test. Intergroup comparisons were made by a 1-way analysis of variance. RESULTS: There were no significant differences among different screw types or fixation methods in cyclic creep or secant stiffness after cyclic loading or in load to failure or work to failure during the failure test. Post-failure radiographs showed evidence of screw bending in only 1 specimen that underwent the Latarjet procedure with partially threaded solid cancellous screws with bicortical fixation. The mode of failure for all specimens analyzed was screw cutout. CONCLUSIONS: In this biomechanical study, screw type and fixation method did not significantly influence biomechanical performance in a classic Latarjet procedure. When performing this procedure, surgeons may continue to select the screw type and method of fixation (unicortical or bicortical) based on preference; however, further studies are required to determine the optimal method of treatment. CLINICAL RELEVANCE: Surgeons may choose the screw type and fixation method based on preference when performing the Latarjet procedure.

A Prospective Comparative Study of Arthroscopic Versus Mini-Open Latarjet Procedure With a Minimum 2-Year Follow-up.

PURPOSE: To compare postoperative pain during the first postoperative week and the position of the coracoid bone block at the anterior aspect of the glenoid after the arthroscopic and the mini-open Latarjet procedure. The secondary purpose was to assess functional results and recurrence after at least 2 years of follow-up. METHODS: This comparative prospective study included patients who underwent a Latarjet-Bristow procedure for anterior shoulder instability in 2012. The Latarjet procedure was performed by a mini-open approach (G1) in one center and by an arthroscopic approach (G2) in the other. The main evaluation criterion was average shoulder pain during the first postoperative week assessed by the patient on a standard 10-cm visual analog scale (0-10). Secondary criteria were consumption of analgesics during the first week, the position of the coracoid bone block on radiograph and computed tomography scan at the 3-month follow-up and clinical outcomes (Western Ontario Score Index and new surgery) after at least 2 years of follow-up. RESULTS: Fifty-eight patients were included, 22 G1 and 36 G2, 13 women and 45 men, mean age 26.9 ± 7.7 years. The mean follow-up was 29.8 ± 4.4 months. There was significantly less pain in the arthroscopic Latarjet group than in the mini-open group during the first postoperative week (2.5 ± 1.4 vs 1.2 ± 1.2, P = .002) with comparable consumption of analgesics (P > .05). The arthroscopic Latarjet procedure resulted in a more lateral coracoid bone block (P = .04) and a better equatorial position than the mini-open technique (P = .02). Three patients underwent revision surgery (1 recurrence [2.8%], 1 block fracture, 1 screw ablation) in the arthroscopic group, none in the mini-open group (P = .54). At the final follow-up, the Western Ontario Score Index score was good in all patients (G1: 78.5 ± 7.5% vs G2: 82.3 ± 7%, P = .03). CONCLUSIONS: This prospective comparative study showed that the arthroscopic Latarjet procedure was significantly less painful than the mini-open procedure during the first postoperative week. The clinical outcomes were comparable after at least 2 years of follow-up. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Identification of a Remodeled Neo-tendon After Arthroscopic Latarjet Procedure.

PURPOSE: To macroscopically, histologically, and radiologically describe a time-dependent remodeling process of a neo-tendon or -ligament in the shoulder after the arthroscopic Latarjet procedure. METHODS: During follow-up surgery after the arthroscopic Latarjet procedure, 17 shoulders in 16 patients were evaluated for a remodeled tendon-like structure. The mean overall follow-up period was 27.4 months. The mean time between the arthroscopic Latarjet procedure and revision was 11.6 months. All shoulders were evaluated with magnetic resonance imaging, and seven histologic specimens were obtained during revision surgery. RESULTS: A distinct, oriented strand of tissue was found in 16 of 17 shoulders on revision surgery. Postoperative magnetic resonance imaging analyses showed a signal-free, longitudinal tendon-like structure originating at the tip of the acromion, traversing the space of the former subcoracoid bursa to attach in the course of the transposed conjoint tendon or the proximal short head of the biceps. Histologic analysis of seven specimens showed a characteristic timeline of remodeling. CONCLUSIONS: A tendon- or ligament-like structure is remodeled between the anterior bottom tip of the acromion and the transposed coracoid process in a time-dependent manner after the arthroscopic Latarjet procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Three-dimensional volume measurement of coracoid graft osteolysis after arthroscopic Latarjet procedure.

BACKGROUND AND HYPOTHESIS: The Latarjet procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability. Coracoid bone graft osteolysis is a potential catastrophic complication and can lead to recurrent instability. The purpose of our study is to present a novel quantitative method to measure the amount of coracoid bone osteolysis using 3-dimensional (3D) computed tomography (CT) scan imaging. MATERIALS AND METHODS: This is a prospective study with 15 patients (16 shoulders) who underwent an arthroscopic Latarjet procedure. Three-dimensional CT scans were obtained at 6 weeks and 6 months. Using volumetric analysis, we quantified the amount of bone loss using our described method. Interobserver reliability and intraobserver reliability were calculated. RESULTS: On the basis of our new volumetric analysis of the arthroscopic Latarjet procedure using 3D CT scans, we found that the superior half of the coracoid bone graft undergoes a significant amount of osteolysis at 6 months postoperatively. The interobserver reliability and intraobserver reliability were excellent. DISCUSSION: This study presents a reproducible method to quantify and compare coracoid bone graft osteolysis after an arthroscopic Latarjet procedure. We also developed a description system that may be used for comparison studies. To our knowledge, this is the first method that quantifies the amount of coracoid bone graft osteolysis using more accurate 3D CT scanning. CONCLUSION: The 3D analysis we propose is a valid method to measure the amount of coracoid bone graft osteolysis after an arthroscopic Latarjet procedure. Our description system may guide the surgeon regarding possible revision surgery when faced with significant osteolysis of the coracoid bone graft.

The Latarjet Procedure For Anterior Shoulder Instability : A Consecutive Prospective Series Of 50 Cases.

The Latarjet is a successful primary and revision option for anterior shoulder instability. However, recent reports have highlighted varying complication rates. Our study prospectively collected clinical, functional and radiological outcomes of patients undergoing the procedure. Forty-eight consecutive patients (fifty shoulders) underwent the Latarjet procedure in a single UK centre. Clinical, radiological and functional follow-up was performed. Mean clinical follow-up was 32 months and radiological follow-up 20 months. 95% shoulders were subjectively graded "excellent" or "good" and 5% "fair". Mean Rowe, Oxford Shoulder Instability Score, American Shoulder and Elbow selfassessment Score and Subjective Shoulder Value Score all improved post-operatively (p<0.001). No infections, dislocations, revisions or metalworkrelated complications occurred. There was one intra-operative coracoid fracture and five transient neurological injuries, resolving within three months. The long-term complication rate was 2%. The Latarjet procedure is safe and reliable for treating anterior shoulder instability with a very low long-term complication rate providing excellent clinical and functional outcomes.