Arthroscopic Latarjet yields better union and prevention of instability compared to arthroscopic bony Bankart repair in shoulders with recurrent anterior instability: a systematic review.

PURPOSE: To determine whether arthroscopic Latarjet procedure or arthroscopic bony Bankart repair provide better outcomes in terms of rates of recurrent instability, non-union and complications, as well as clinical scores and range of motion. METHODS: An electronic literature search was performed using PubMed, Embase®, and Cochrane databases, applying the following keywords: "Arthroscopic bony Bankart" OR "Arthroscopic osseous Bankart" AND "Arthroscopic Latarjet" OR "Arthroscopic coracoid bone block". RESULTS: The systematic search returned 1465 records, of which 29 were included (arthroscopic bony Bankart repair, n = 16; arthroscopic Latarjet, n = 13). 37 datasets were included for data extraction, on 1483 shoulders. Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair had significantly higher instability rates (0.14; CI 0.10-0.18; vs 0.04; CI 0.02-0.06), significantly lower union rates (0.63; CI 0.28-0.91 vs 0.98; CI 0.93-1.00), and significantly lower pain on VAS (0.42; CI 0.17-0.67 vs 1.17; CI 0.96-1.38). There were no significant differences in preoperative glenoid bone loss, follow-up, complication rate, ROWE score, ASES score, external rotation, and anterior forward elevation between arthroscopic Latarjet and arthroscopic bony Bankart repair. CONCLUSION: Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on VAS (0.45 vs 1.17). There were no differences in complication rates, clinical scores, or postoperative ranges of motion. LEVEL OF EVIDENCE: IV.

Poor results after pyrocarbon interpositional shoulder arthroplasty.

BACKGROUND: This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA). METHODS: The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated. RESULTS: Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months. CONCLUSION: High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Short-term outcomes of arthroscopic partial repair vs. latissimus dorsi tendon transfer in patients with massive and partially repairable rotator cuff tears.

BACKGROUND: There is limited evidence on clinical outcomes of arthroscopic partial repair (APR) and latissimus dorsi tendon transfer (LDTT) for posterosuperior massive rotator cuff tears (mRCTs). We aimed to compare clinical outcomes of APR and LDTT for partially repairable posterosuperior mRCTs and to determine whether outcomes differ among tears that involve the teres minor. METHODS: We retrieved the records of 112 consecutive patients with mRCTs deemed partially repairable due to fatty infiltration (FI) stage ≥3 in one or more rotator cuff muscles. Of the tears, 12 involved the subscapularis, 32 were managed conservatively, 14 were treated by reverse shoulder arthroplasty, and 7 were treated by stand-alone biceps tenotomy. Of the remaining 47 shoulders, 26 underwent APR and 21 underwent LDTT. At a minimum of 12 months, we recorded complications, active forward elevation, external rotation, the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and Simple Shoulder Test (SST) score. RESULTS: No significant differences between the APR and LDTT groups were found in terms of follow-up (23.4 ± 3.5 months vs. 22.1 ± 4.1 months, P = .242), Constant-Murley score (64.8 ± 13.7 vs. 58.9 ± 20.0, P = .622), ASES score (78.3 ± 19.3 vs. 74.4 ± 14.5, P = .128), active forward elevation (158.1° ± 19.4° vs. 142.8° ± 49.1°, P = .698), or external rotation (33.3° ± 17.4° vs. 32.2° ± 20.9°, P = .752). By contrast, the APR group had a higher SSV (73.3 ± 17.5 vs. 59.5 ± 20.0, P = .010), and SST score (8.3 ± 2.4 vs. 6.4 ± 3.0, P = .024). Univariable analysis revealed that advanced FI of the teres minor compromised Constant-Murley scores (ß = -25.8, P = .001) and tended to compromise ASES scores (ß = -15.2, P = .062). Multivariable analysis corroborated that advanced FI of the teres minor compromised Constant-Murley scores (ß = -26.9, P = .001) and tended to compromise ASES scores (ß = -16.5, P = .058). CONCLUSION: Both APR and LDTT granted similar early clinical outcomes for partially repairable posterosuperior mRCTs, regardless whether the teres minor was intact or torn. Advanced FI of the teres minor was the only independent factor associated with outcomes, as it significantly compromised Constant-Murley scores and tended to compromise ASES scores.

Open Latarjet Procedures Produce Better Outcomes in Competitive Athletes Compared With Recreational Athletes: A Clinical Comparative Study of 106 Athletes Aged Under 30 Years.

BACKGROUND: In cases of shoulder stabilization for anterior instability, the main goals of the surgery are a rapid and efficient return to sports and excellent long-term outcomes without recurrence of dislocation, particularly in young and competitive athletes. PURPOSE: To determine whether outcomes of open Latarjet procedure (OLPs) depend on the level of sports practiced by patients and to report clinical scores and complication rates for OLP at a minimum follow-up of 2 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective comparative study was conducted for all patients who underwent OLP by the senior author (J.B.) between July 2007 and December 2012. The indication for OLP at the authors' institution was a minimum of 2 episodes of dislocation and/or subluxation, a positive apprehension test result in the cocking position, an Instability Severity Index Score more than 2, and evidence of anterior instability lesions on computed tomography arthrograms. The 106 included patients (110 shoulders) with a mean follow-up of 46 months were compared in 2 groups depending on sport activities: 57 (54%) competitive athletes and 49 (46%) recreational athletes. The principal outcome measure was evidence of recurrent instability. The secondary outcome measures were clinical scores related to anterior instability and related to sport practice: Rowe score, Oxford Shoulder Instability Score (OSIS), Western Ontario Shoulder Instability Index, and level of satisfaction. RESULTS: Of the 106 patients, 3 reported recurrence of shoulder dislocation: 2 competitive athletes (3.5%; 95% CI, 0.9%-11.2%) and 1 recreational athlete (2%; 95% CI, 0.4%-10.7%) ( P = .684). The persistent apprehension test result was positive in 7 competitive athletes (11.5%) and in 5 recreational athletes (10%) ( P = .566). The Rowe scores improved from 56.3 ± 13.2 (range, 30-80) preoperatively to 84.2 ± 16.4 (range, 30-100) postoperatively in competitive athletes and from 55.0 ± 11.0 (range, 35-80) to 69.5 ± 22.0 (range, 15-100) in recreational athletes ( P < .001). The net improvement in Rowe scores was significantly greater in competitive athletes (27.9 ± 21.7) compared with recreational athletes (14.5 ± 24.4) ( P = .006). The scores unrelated to sport activity (Oxford Shoulder Instability Score and Simple Shoulder Test) were similar for the 2 groups. All 57 (100%) competitive athletes and 34 (69.4%) recreational athletes resumed their previous sports practice, at the same level or higher than before their injury (respectively, 78.9% and 42.9%; P = .004). CONCLUSION: The OLP could be considered for primary shoulder stabilization, particularly in competitive athletes, who have high functional demands and great risks of redislocation.

Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?

BACKGROUND: Rotator cuff tears are associated with capsular contraction and stiffness that should be restored before surgical repair. Corticosteroid injections (CSIs) are frequently used as conservative treatments before surgical repair. This study aimed to determine the influence of preoperative and postoperative CSIs on clinical and anatomic outcomes after rotator cuff repair. METHODS: The authors analyzed the records of 257 patients who had arthroscopic rotator cuff repair, of whom 212 were evaluated at 3.1 ± 1.0 years (median, 2.9 years; range, 1.4-7.1 years) by clinical (Constant score) and ultrasound (Sugaya classification) examinations. Univariable and multivariable regressions were performed to determine associations between outcomes and administration of preoperative and postoperative CSIs, patient characteristics, and tendon characteristics. RESULTS: The Constant scores improved from 56.4 ± 15.1 to 80.8 ± 12.5. Multivariable regression confirmed that postoperative scores were associated with postoperative CSIs (P < .001), preoperative scores (P < .001), gender (P < .001), and fatty infiltration (P < .005). Retears (Sugaya types IV-V) were observed in 27 shoulders (13%). Multivariable regression clarified that retear rates were associated only with postoperative CSIs (P = .007) and stage 3 fatty infiltration (P = .001). Adjusting for confounders, an additional postoperative CSI would decrease scores by 4.7 points and double retear risks. DISCUSSION: Preoperative CSIs had no influence on clinical scores and retear rates, whereas postoperative CSIs were associated with lower scores and more retears. Although we can infer that preoperative CSIs do not affect outcomes, we cannot determine whether postoperative CSIs compromised outcomes or were administered in patients who had already poor outcomes. Our findings may resolve controversies about the administration of preoperative CSIs.

Is the two-dimensional computed tomography scan analysis reliable for coracoid graft positioning in Latarjet procedures?

BACKGROUND: The aim of the study was to develop a computed tomography (CT)-based measurement protocol for coracoid graft (CG) placement in both axial and sagittal planes after a Latarjet procedure and to test its intraobserver and interobserver reliability. METHODS: Fifteen postoperative CT scans were included to assess the intraobserver and interobserver reproducibility of a standardized protocol among 3 senior and 3 junior shoulder surgeons. The evaluation sequence included CG positioning, its contact area with the glenoid, and the angle of its screws in the axial plane. The percentage of CG positioned under the glenoid equator was also analyzed in the sagittal plane. The intraobserver and interobserver agreement was measured by the intraclass correlation coefficient (ICC), and the values were interpreted according to the Landis and Koch classification. RESULTS: The ICC was substantial to almost perfect for intraobserver agreement and fair to almost perfect for interobserver agreement in measuring the angle of screws in the axial plane. The intraobserver agreement was slight to almost perfect and the interobserver agreement slight to substantial regarding CG positioning in the same plane. The intraobserver agreement and interobserver agreement were both fair to almost perfect concerning the contact area. The ICC was moderate to almost perfect for intraobserver agreement and slight to almost perfect for interobserver agreement in analyzing the percentage of CG under the glenoid equator. CONCLUSION: The variability of ICC values observed implies that caution should be taken in interpreting results regarding the CG position on 2-dimensional CT scans. This discrepancy is mainly explained by the difficulty in orienting the glenoid in the sagittal plane before any other parameter is measured.

Arthroscopic-assisted Acromioclavicular and Coracoclavicular Ligaments Reconstruction for Chronic Acromioclavicular Dislocations: Surgical Technique.

Chronic acromioclavicular (AC) instability is a rare posttraumatic shoulder condition that can lead to undesirable symptoms like persistent pain, muscle fatigue, loss of strength, or even scapular dyskinesis. It is well known that in these cases the superior functional results depend on the restoration of the anatomy and stability of the AC joint in both vertical and horizontal planes. Considering the ligaments degeneration and atrophy in chronic AC joint dislocations, we present an arthroscopic-assisted reconstruction of both the coracoclavicular and AC ligaments using autograft augmentation. In details the coracoclavicular ligaments component is reconstructed using the Tightrope suspension device augmented with a palmaris longus autograft and by the nonanatomic coracoacromial ligament transfer (modified Weaver-Dunn). The AC part is restored by suturing the remainder palmaris longus autograft on the acromion and on the deltotrapezial fascia. Using the construct provided by this technique all the possible ruptured ligaments are reconstructed, optimizing the vertical and horizontal stability of the area, and promising excellent long-term radiologic and functional results.

Tibial slope correction combined with second revision ACL produces good knee stability and prevents graft rupture.

PURPOSE: Revision ACL reconstruction requires careful analysis of failure causes particularly in cases of two previous graft ruptures. Intrinsic factors as excessive tibial slope or narrow femoral notch increase failure risks but are rarely addressed in revision surgery. The authors report outcomes, at minimum follow-up of 2 years, for second revision ACL reconstructions combined with tibial deflexion osteotomy for correction of excessive slope (>12°). METHODS: Nine patients that underwent second revision ACL reconstruction combined with tibial deflexion osteotomy were retrospectively studied. The mean age was 30.3 ± 4.4 years (median 28; range 26-37), and mean follow-up was 4.0 ± 2.0 years (median 3.6; range 2.0-7.6). Autografts were harvested from the quadriceps tendon (n = 8) or hamstrings (n = 1), and tibial osteotomy was done by anterior closing wedge, without detachment of the patellar tendon, to obtain a slope of 3° to 5°. RESULTS: All patients had fused osteotomies, stable knees, and there were no intraoperative or postoperative complications. The mean posterior tibial slope decreased from 13.2° ± 2.6° (median 13°; range 12°-18°) preoperatively to 4.4° ± 2.3° (median 4°; range 2°-8°) postoperatively. The mean Lysholm score was 73.8 ± 5.8 (median 74; range 65-82), and the IKDC-SKF was 71.6 ± 6.1 (median 72.8; range 62.2-78.5). CONCLUSION: The satisfactory results of second revision ACL reconstruction combined with tibial deflexion osteotomy at minimum follow-up of 2 years suggest that tibia slope correction protects reconstructed ACL from fatigue failure in this study. The authors stress the importance of careful analysis failure causes prior to revision ACL reconstruction, and recommend correction of tibial slope if it exceeds 12°, to reduce the risks of graft retear. LEVEL OF EVIDENCE: III.