Clinical Outcomes and Graft Resorption After Metal-Free Bone Block Suture Tape Cerclage Fixation for Recurrent Anterior Shoulder Instability: A Computed Tomography Analysis.

BACKGROUND: Glenoid reconstruction with a bone block for anterior glenoid bone loss (GBL) has shown excellent outcomes. However, fixation techniques that require metal implants are associated with metal-related complications and bone graft resorption. HYPOTHESIS: Arthroscopic glenoid reconstruction using a tricortical iliac crest bone graft (ICBG) and metal-free suture tape cerclage fixation can safely and effectively restore the glenoid surface area in patients with recurrent anterior shoulder instability and anterior GBL. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Adult patients (≥18 years) of both sexes with recurrent anterior shoulder instability and anterior GBL ≥15% were enrolled. These patients underwent arthroscopic glenoid reconstruction with ICBGs and metal-free suture tape cerclage fixation. The effectiveness and clinical outcomes with this technique were evaluated at 24 months using functional scores. Resorption of the graft articular surface was assessed by computed tomography, with the graft surface divided into 6 square areas aligned in 2 columns. Descriptive analysis was conducted. RESULTS: A total of 23 consecutive patients met inclusion criteria (22 male, 1 female; mean age, 30.5 ± 7.9 years). The mean preoperative GBL was 19.7% ± 3.4%, and there were 15 allograft and 8 autograft ICBGs. All patients exhibited graft union at 3 months. The median follow-up was 38.5 months (interquartile range, 24-45 months). The Western Ontario Shoulder Instability Index, Rowe, Constant-Murley, and Subjective Shoulder Value scores improved from preoperatively (35.1%, 24.8, 83.1, and 30.9, respectively) to postoperatively (84.7%, 91.1, 96.0, and 90.9, respectively) (P < .001). No differences in clinical scores were observed between the graft types. One surgical wound infection was reported, and 2 patients (8.7% [95% CI, 2.4%-26.8%]) required a reoperation. The mean overall glenoid surface area increased from 80.3% ± 3.5% to 117.0% ± 8.3% immediately after surgery before subsequently reducing to 98.7% ± 6.2% and 95.0% ± 5.7% at 12 and 24 months, respectively (P < .001). The mean graft resorption rate was 18.1% ± 7.9% in the inner column and 80.3% ± 22.4% in the outer column. Additionally, 3 patients treated with an allograft (20.0% [95% CI, 7.1%-45.2%]), including the 2 with clinical failures, exhibited complete graft resorption at the last follow-up. CONCLUSION: Arthroscopic glenoid reconstruction using an ICBG and metal-free suture tape cerclage fixation was safe and effective, yielding excellent clinical outcomes. Resorption of the graft articular surface predominantly affected the nonloaded areas beyond the best-fit circle perimeter.

Arthroscopic Posterior Glenoid Osteotomy.

Management of posterior shoulder instability in patients with excessive glenoid retroversion can be challenging. However, a corrective posterior glenoid osteotomy is an option. Although various open techniques are available, minimally invasive and arthroscopy surgery are the most advantageous. This study describes the feasibility and safety of an arthroscopic posterior open wedge glenoid osteotomy using an autologous scapular spine graft along with additional posterior capsulolabral complex reattachment. This procedure is a viable option for patients with symptomatic posterior shoulder instability.

Arthroscopic All-Inside Remplissage Technique With Knotless Tape Bridge for Hill-Sachs Lesions.

The arthroscopic remplissage procedure has been described to successfully treat engaging Hill-Sachs lesions and improve shoulder stability. Several variations of this technique have been described, including remplissage with 1 or 2 knotted or knotless anchors, remplissage with double or triple bridging pulleys, and remplissage with or without a subacromial view. However, most techniques use anchors in combination with round sutures. This article describes an all-arthroscopic articular knotless remplissage technique using a strong, flat, double-strand suture tape bridge fixed with 2 small anchors under direct joint visualization and reduction of the capsule and infraspinatus without requiring a subacromial view.

Primary Stability and Bone Contact Loading Evaluation of Suture and Screw based Coracoid Graft Fixation for Anterior Glenoid Bone Loss.

BACKGROUND: Reconstruction techniques for anterior glenoid bone loss have seen a trend from screws to suture-based fixations. However, comparative biomechanical data, including primary fixation and glenoid-graft contact pressure mapping, are limited. HYPOTHESIS: Suture-based bone block cerclage (BBC) and suspensory suture button (SB) techniques provide similar primary fixation and cyclic stability to double-screw fixation but with higher contact loading at the bony interface. STUDY DESIGN: Controlled laboratory study. METHODS: In total, 60 cadaveric scapulae were prepared to simulate anterior glenoid bone loss with coracoid autograft reconstruction. Graft fixation was performed with 3 different techniques: (1) an interconnected all-suture BBC, (2) 2 SB suspensions, and (3) 2 screws. Initial compression was analyzed during primary fixation. Cyclic peak loading with 50 N and 100 N over 250 cycles at 1 Hz was performed with a constant valley load of 25 N. Optical recording and pressure foils allowed for spatial bone block tracking and contact pressure mapping at the glenoid-graft interface. Load-to-failure testing was performed at a rate of 1.5 mm/s with ultimate load and stiffness measured. RESULTS: Initial graft compression was higher with screw fixation (141 ± 5 N) compared with suture-based fixations (P < .001), with BBC fixation providing significantly higher compression than SB fixation (116 ± 7 N vs. 91 ± 5 N; P < .001). Spatial bone block migration and ultimate failure load were similar between the BBC and screw groups. The SB group showed significantly increased bone block translation (3.1 ± 1.0 mm; P≤ .014) and rotation (2.5°± 1.4°; P≤ .025) and significantly lower ultimate failure load (180 ± 53 N) compared with the BBC (P = .046) and screw (P = .002) groups. Both suture-based fixations provided significantly increased graft-glenoid contact loading with higher pressure amplitudes (P≤ .032) and contact pressure after cyclic loading (+13%; SB: P = .007; BBC: P = .004) compared with screw fixation. CONCLUSION: Both SB and interconnected cerclage fixation improved dynamic contact loading compared with screw fixation in a biomechanical glenoid bone loss model. Cerclage fixation was biomechanically comparable with screw fixation but with a greater variability. SB fixation showed significantly lower primary fixation strength and greater bone block rotation and migration. CLINICAL RELEVANCE: Suture-based bone block fixations improved graft-glenoid contact loading, but the overall clinical consequence on healing remains unclear.

Treatment of Symptomatic Medial Clavicle Nonunion with Intramedullary Tendon Allograft: A Case Report.

CASE: A 67-year-old patient sustained a medial clavicle fracture (MCF) treated with open reduction and fixation with cerclage sutures. A year later, he presented with symptomatic nonunion and skin prominence, which was revised with an intramedullary tendon allograft fixation including the sternoclavicular joint. At 31 months after the procedure, the patient showed no pain or clinical instability. CONCLUSION: MCF is an uncommon injury. Symptomatic nonunion after the failure of fixation is rarely described. Although the best way to treat this complication is debatable, revision fixation using an intramedullary tendon allograft can be a viable option in elderly patients.

Open Latarjet with Metal-Free Cerclage Fixation.

Despite multiple modifications, the Latarjet is still the most popular procedure for recurrent anterior shoulder instability with glenoid bone loss. Partial or subtotal resorption of the graft is common, potentially leading to hardware prominence and risk of anterior soft-tissue impingement. To minimize the technical difficulties and morbidity associated with metallic implants, a coracoid and conjoint tendon transfer with a mini-open approach using Cerclage tape suture is described, as an alternative for the Latarjet procedure typically performed with metal screws and plates.

Comprehensive management of posterior shoulder instability: diagnosis, indications, and technique for arthroscopic bone block augmentation.

Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality. Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure. A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory. Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface. Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way. An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author's preferred surgical technique for arthroscopic posterior bone block.

Latarjet Cerclage: The All-Arthroscopic Metal-Free Fixation.

The Bristow-Latarjet procedure has been one of the most recognized procedures for the treatment of recurrent shoulder dislocation with anterior glenoid bone loss, revision surgery after failed Bankart repair, contact and collision sport injuries, and patients with a high risk of recurrence. Open and arthroscopic approaches have recently shown similar outcomes by several authors. However, complications related to metal implants, despite being low, are still a matter of concern. We describe an all-arthroscopic Latarjet technique with a metal-free fixation method using 2 ultra-high-strength sutures, creating a cerclage construct through 2.4mm glenoid and coracoid tunnels with a final capsulolabral complex reconstruction.

Arthroscopic Knotless Subscapularis Bridge Technique for Reverse Hill-Sachs Lesion With Posterior Shoulder Instability.

Posterior shoulder dislocations are an uncommon cause of glenohumeral instability; they are frequently missed and are associated with humeral head defects and capsulolabral lesions. Despite surgical treatment often being mandatory, there is still no standardized treatment for anterior impaction fractures of the humeral head (reverse Hill-Sachs lesions). Arthroscopic surgery is typically indicated, with a tendency toward resorting to knotless techniques in recent years. We present a method for the treatment of posterior shoulder dislocations with engaging reverse Hill-Sachs lesions that achieves full defect coverage using an arthroscopic all-in-the-box knotless subscapularis bridge technique with 2 anchors-with one crossing the subscapularis tendon and the other embracing it-along with posterior capsulolabral complex restoration. This promising technique is a potentially superior alternative for the treatment of these lesions that can also be used in the presence of concomitant partial subscapularis tears.

Footprint preparation with nanofractures in a supraspinatus repair cuts in half the retear rate at 1-year follow-up. A randomized controlled trial.

PURPOSE: To evaluate if adding nanofractures to the footprint of a supraspinatus tear repair would have any effect in the outcomes at one-year follow-up. METHODS: Multicentric, triple-blinded, randomized trial with 12-months follow-up. Subjects with isolated symptomatic reparable supraspinatus tears smaller than 3 cm and without grade 4 fatty infiltration were included. These were randomized to two groups: In the Control group an arthroscopic supraspinatus repair was performed; in the Nanofracture group the footprint was additionally prepared with nanofractures (1 mm wide, 9 mm deep microfractures). Clinical evaluation was done with Constant score, EQ-5D-3L, and Brief Pain Inventory. The primary outcome was the retear rate in MRI at 12-months follow-up. Secondary outcomes were: characteristics of the retear (at the footprint or at the musculotendinous junction) and clinical outcomes. RESULTS: Seventy-one subjects were randomized. Two were lost to follow-up, leaving 69 participants available for assessment at 12-months follow-up (33 in the Control group and 36 in the Nanofracture Group). The Nanofracture group had lower retear rates than the Control group (7/36 [19.4%] vs 14/33 [42.4%], differences significant, p = 0.038). Retear rates at the musculotendinous junction were similar but the Nanofracture group had better tendon healing rates to the bone (34/36 [94.4%] vs. 24/33 [66.71%], p = 0.014). Clinically both groups had significant improvements, but no differences were found between groups. CONCLUSION: Adding nanofractures at the footprint during an isolated supraspinatus repair lowers in half the retear rate at 12-months follow-up. This is due to improved healing at the footprint. LEVEL OF EVIDENCE: Level I.

Arthroscopically Assisted Comprehensive Double Cerclage Suture Fixation Technique for Acute Acromioclavicular Joint Separation.

Acromioclavicular dislocations are some of the most frequently recorded and controversial injuries in the athletic population. These injuries have historically been a matter of disagreement between surgeons, particularly when it comes to the surgical technique used to treat them, its approach, or its timing. Consensus over the "gold standard" procedure to treat them is yet to be established. Even though numerous surgical techniques have already been described, the number of complications and loss of reduction remains a matter of concern for treating physicians. Here, we present an arthroscopically assisted coracoclavicular and horizontal acromioclavicular fixation technique in a modified figure-of-eight configuration using 2 strong FiberTape Cerclage sutures, with measurable tension, for the comprehensive treatment of acromioclavicular joint dislocations.

Latarjet Cerclage: The Metal-Free Fixation.

The Latarjet technique is a widely used technique for anterior shoulder instability with glenoid bone defects, irreparable capsuloligamentous lesion, or in patients at greater risk of recurrence. The use of this technique has been reported to obtain satisfactory clinical and biomechanical results. Although other methods exist, the coracoid process is typically fixed with 2 metal screws. Complications related to metal fixation are very frequently reported. In an attempt to avoid these complications, we developed this arthroscopically assisted metal-free Latarjet technique in which we fix a coracoid graft using four cerclage tapes to achieve a strong, stable fixation, thus mimicking a plate.

Arthroscopic "Bone Block Cerclage" Technique for Posterior Shoulder Instability.

Many open and arthroscopic techniques have been described to treat posterior glenohumeral instability. Multifactorial features of posterior shoulder instability pathoanatomy and varied patient characteristics have challenged the understanding of this condition and have led to dissimilar results, without a strong consensus for the most adequate technique to treat it. We describe an arthroscopic anatomical metal-free posterior glenoid reconstruction technique, using a tricortical iliac crest allograft with 2 ultra-high strength sutures (FiberTape Cerclage System; Arthrex, Naples, FL) with concomitant posterior capsulolabral complex reconstruction procedure.

Low prevalence of relevant associated articular lesions in patients with acute III-VI acromioclavicular joint injuries.

PURPOSE: To define the prevalence of associated articular injuries in patients with severe (Rockwood's III-VI) acute acromioclavicular joint injuries and to find out how many of these were associated with the traumatic event and required surgical treatment. METHODS: Retrospective observational multicentric study performed in ten centres included patients who required surgery for acute acromioclavicular joint injuries between 2010 and 2017. The inclusion criteria were: presence of an acute acromioclavicular joint injury (grades III-IV-V-VI) and surgical treatment within 3 weeks of injury that included a full arthroscopic evaluation of the shoulder. Basic epidemiological data, severity of the original injury, prelesional sport level and prelesional work site requirements were recorded. The presence of intraarticular glenohumeral lesions and information of their characteristics, treatment, and whether each lesion was considered acute or pre-existing was also recorded. RESULTS: Two-hundred one subjects [mean (SD) age 36.7 (11.7) years] with acute acromioclavicular joint injuries (110 Rockwood type III, 34 type IV, 56 type V and 1 type VI) fulfilled the inclusion criteria. A total of 28 (13.9%) associated articular lesions were found. These lesions were more often found in grade IV injuries (26.5% in grade IV vs 11.4% in grade III, p = 0.037) and presented in males (18.7% in males vs 4% in females, p = 0.015). Age, laterality, sport level or work requirements did not affect the prevalence of associated lesions. Twelve were rotator cuff tears (6 PASTA lesions, 3 partial supscapularis tears, 2 bursal supraspinatus tears and 1 full-thickness supraspinatus tear), 16 were labral tears (9 anterior, 1 posteroinferior and 6 SLAP). Only 14 (50% of lesions, 7% of total subjects) were considered acute and all but one (an SLAP type 2 tear) required further surgical attention. Most pre-existing lesions were left untreated (n = 7) or managed with minimal debridement (n = 6), and only two required further surgery. The prevalence of associated lesions that required surgical management was 7.46%. CONCLUSIONS: The prevalence of relevant associated lesions in subjects with acute grade III to VI ACJI is relatively low. Only 14% of subjects have an associated lesion and only half of these required further surgical attention. LEVEL OF EVIDENCE: Retrospective case series, level IV.

Arthroscopic Bone Block Cerclage: A Fixation Method for Glenoid Bone Loss Reconstruction Without Metal Implants.

Large glenoid bone loss defects are associated with higher failure rates after arthroscopic Bankart repair in cases of glenohumeral anterior instability, further necessitating bone graft reconstruction. Because most techniques use strong initial fixation using metal devices, bone graft resorption considered to be closely related to the presence of metal components is a potential shortcoming of these techniques. We describe an arthroscopic technique for anatomical reconstruction of the glenoid that uses a tricortical iliac crest with a metal-free fixation method using 2 ultra-high-strength sutures (FiberTape Cerclage System; Arthrex, Naples, FL), which provide substantial stability to the graft, and finishing with a capsulolabral reconstruction.