Variation in technique and postoperative management of the Latarjet procedure among orthopedic surgeons.

BACKGROUND: The Latarjet procedure has become a treatment of choice for glenohumeral instability in the setting of large glenoid osseous defects (>20%) and for prior failed soft tissue repairs. However, surgical techniques and postoperative rehabilitation protocols vary among expert shoulder surgeons. The purpose of this survey study was to characterize the variation in current practice patterns among fellowship-trained orthopedic shoulder surgeons and identify factors related to variation. METHODS: A 9-question survey was created (SurveyMonkey, San Mateo, CA, USA) and distributed to orthopedic surgeons who are active members of the American Shoulder and Elbow Surgeons or American Orthopaedic Society for Sports Medicine. The survey asked questions regarding surgeon experience with the Latarjet procedure, fellowship training, open vs. arthroscopic approach, method of coracoid-to-glenoid fixation, period of sling use postoperatively, and time before clearance to return to sport. Subgroup analysis was performed to determine whether further variation was evident between surgeons who completed sports medicine vs. shoulder and elbow fellowship training. RESULTS: In total, 242 surgeons completed the survey. Of these, 55% indicated performing a sports medicine fellowship and 39% indicated completing a shoulder and elbow fellowship. Among all surgeons, the classic open Latarjet procedure was the strongly preferred technique (79%), followed by the open congruent-arc (17%) and all-arthroscopic (3%) techniques. With respect to fixation, 98% used screw fixation and only 1% indicated cortical button use. With respect to the postoperative course, >85% of surgeons preferred immobilization for 3-6 weeks after the procedure and 42% of respondents stated they waited ≥6 months prior to clearing their patients to return to sport. Subgroup analysis revealed that surgeons who completed a shoulder and elbow fellowship performed the classic open technique 89% of the time compared with 63% of those who completed a sports medicine fellowship (P < .001). CONCLUSION: The results of our survey study indicate an overall strong preference for the open classic Latarjet technique as well as an overall strong preference for screw fixation of the coracoid graft to the glenoid among all surgeons. Shoulder and elbow fellowship-trained surgeons are significantly more likely to perform open surgery with a classic technique compared with sports medicine fellowship-trained surgeons. Furthermore, the significant variation in postoperative sling use and return to sport suggests that further research is needed to develop an evidence-based postoperative Latarjet rehabilitation protocol.

Early radiographic failure of reverse total shoulder arthroplasty with structural bone graft for glenoid bone loss.

INTRODUCTION: Structural glenoid bone grafting in reverse total shoulder arthroplasty (RSA) has previously been reported to have good functional outcomes and low complication rates. We have observed different complication rates and hypothesized that baseplate fixation and severity of deformity may be predictors of early failure. METHODS: We retrospectively identified 44 patients who underwent RSA with structural bone grafting for glenoid bone defects. All patients had preoperative and postoperative (Grashey and axillary) radiographs at a minimum of 1 year after surgery and within 3 months of surgery for evaluation of implant and graft positioning. Clinical data and outcome scores were collected at the same intervals. RESULTS: There were 61% females and 39% males, with an average age of 74 ± 8 years at the time of surgery. The median final radiographic follow-up was 20 months, with 37 primary RSA and 7 revision RSA. Graft resorption was found in 11 of 44 patients (25%), and radiographic failure was found in 11 of 44 patients (25%) at a median of 8 months (range 3-51 months). Forward elevation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores all significantly improved postoperatively (P < .0001). Radiographic baseplate failure was associated with graft resorption (P = .002), more retroversion correction (P = .02), and worse SANE scores at final follow-up (P = .01). DISCUSSION/CONCLUSION: RSA with structural bone graft improved range of motion and function, but there was a larger than previously reported baseplate loosening rate. This early radiographic loosening appeared to be associated with graft resorption, retroversion correction, and worse outcome scores.

Management of glenoid bone defects with reverse shoulder arthroplasty-surgical technique and clinical outcomes.

BACKGROUND: Management of significant glenoid bone loss in patients undergoing a reverse shoulder arthroplasty (RSA) poses a significant treatment challenge. The long-term outcome of single-stage RSA with glenoid bone grafting is unknown. This study assesses the indications, technique, and outcome of RSA with glenoid bone grafting. MATERIALS AND METHODS: Between 2001 and 2010, there were 1074 RSAs performed at our institution; 94 patients had significant glenoid bone loss. Each glenoid defect was subclassified as centric or eccentric and graded 1-4. The patients underwent a single-stage or 2-stage RSA with glenoid bone grafting. A retrospective analysis of the preoperative and postoperative clinical and radiologic outcome was carried out. The mean follow-up was 2.4 years (0.52-10.7 years). RESULTS: Of these patients, 17% had a centric defect and 83% had an eccentric glenoid defect. Composite glenoid grafts were required in 12 patients, 9 of whom required a glenoid baseplate with a long central peg; 92.5% (87/94) of the patients could be managed with a single-stage procedure. Improvement in the Constant score of 61 points (17.9 to 78.9; P < .01) and the mean Simple Shoulder Test score of 5.8 points (1.6 to 7.5; P < .001) was noted. No correlation was found between the clinical outcome and indication for surgery, age, location of defect, and size of defect. CONCLUSION: Severe glenoid bone loss can usually be managed by a single-stage bone graft and RSA. A 2-stage procedure is recommended when primary baseplate stability is not attainable.

Reverse total shoulder arthroplasty with structural bone grafting of large glenoid defects.

BACKGROUND: Large glenoid defects pose difficulties in shoulder arthroplasty. Structural grafts consisting of a humeral head autograft, iliac crest, and allograft have been described. Few series describe grafts used with reverse total shoulder arthroplasty (RTSA). METHODS: We retrospectively reviewed patients who had undergone primary or revision RTSA. We identified 44 patients (20 men and 24 women; mean age, 69 years) as having a bulk structural graft to the glenoid behind the baseplate. The grafts consisted of a humeral head autograft in 29, iliac crest autograft in 1, or femoral head allograft in 14. Range of motion data, American Shoulder and Elbow Surgeons score, simple shoulder test, shoulder pain and disability index, and Constant scores were obtained from preoperative and the latest follow-up visits. Radiographs were reviewed from the initial postoperative visit and the latest follow-up. The grafting cohort was compared with an age- and sex-matched cohort of RTSA patients without glenoid grafting. RESULTS: Improvements were seen in the functional outcome scores at the latest follow-up. No significant differences were found in the preoperative or postoperative data between allografts and autografts. Postoperative scores for the bone graft cohort were significantly lower than those in the cohort without grafting. Complete or partial incorporation was shown radiographically in 81% of grafts. Six baseplates were considered loose. Complications included 2 infections, 1 dislocation, 1 humeral loosening, and 2 instances of clinical aseptic baseplate loosening. Six patients showed mild scapular notching. CONCLUSIONS: The use of bulk structural grafts is a promising treatment option. Allografts may yield equally acceptable results compared with autografts.

A patient-specific guide for optimizing custom-made glenoid implantation in cases of severe glenoid defects: an in vitro study.

BACKGROUND: Glenoid component and screw malpositioning in cases of severe glenoid defects might result in complications. We examined the efficacy of a surgical method to treat severe glenoid defects, including a custom-made glenoid component and accurate screw positioning, using a patient-specific positioning guide. METHODS: Glenoid defects were created in 10 cadaveric shoulders. Computed tomography images were used to plan reversed shoulder arthroplasty and design patient-specific glenoid components. A patient-specific positioning guide was designed for 5 specimens. The remaining 5 specimens were implanted without the guide. Computed tomography images were used to determine the postoperative glenoid component and screw positions. Differences from the preoperatively planned implant and screw positions were calculated. RESULTS: The patient-specific positioning guide significantly reduced the angular deviations from the planned glenoid implant positioning (P < .05) and also significantly improved the positioning of the screws (P < .001). In the group without the guide, the average total intraosseous screw length was 52% of the ideal preoperatively planned length compared with 89% for the group with the guide. A strong correlation (r = -0.85) was found between the orientation of the implant and the postoperative total intraosseous screw length. CONCLUSIONS: A patient-specific positioning guide significantly improves the position and fixation of a custom-made glenoid component in cases of severe glenoid defects.

Bony defects in chronic anterior posttraumatic dislocation of the shoulder: Is there a correlation between humeral and glenoidal lesions?

BACKGROUND: The prevalence of combined humeral and glenoid defects varies between 79 and 84 % in case of chronic posttraumatic anterior shoulder instability. The main goal of this study was to evaluate the relationship between humeral and glenoid defects based on quantitative radiological criteria. METHODS: A retrospective study was performed between 2000 and 2011 including patients who underwent primary surgical shoulder stabilization for chronic posttraumatic anterior shoulder instability, with bone defects in both the glenoid and humerus and a healthy contralateral shoulder. The following measurements were taken: D/R ratio (Hill-Sachs lesion depth/humeral head radius) on an AP X-ray in internal rotation and the D1/D2 ratio [diameter of the involved glenoid articular surfaces (D1)/the healthy one (D2)] on a comparative Bernageau glenoid profile view. Measurements were taken by two observers. Correlations were determined by the Spearman correlation coefficients (r), Bland and Altman diagrams, and intra-class correlation coefficients (ICC). A sample size calculation was done. RESULTS: Thirty patients were included, 25 men/5 women, mean age 29.8 ± 11.2 years. The mean D/R was 23 ± 12 % for observer 1 and 23 ± 10 % for observer 2. The mean D1/D2 was 95 ± 4 % for observer 1 and 94 ± 6 % for observer 2. No significant correlation was found between humeral and glenoid bone defects by observer 1 (r = 0.23, p = 0.22) or observer 2 (r = 0.05, p = 0.78). Agreement of the observers for the D/R ratio was excellent (ICC = 0.89 ± 0.04, p < 0.00001) and good for the D1/D2 ratio (ICC = 0.54 ± 0.14, p = 0.006). CONCLUSION: Humeral and glenoid bone defects were not correlated. Inter-observer reliability was excellent for the D/R ratio and good for the D1/D2 ratio. LEVEL OF EVIDENCE: Nonconsecutive Patients, Diagnostic Study, Level III.

Glenoid bone grafting in reverse shoulder arthroplasty for long-standing anterior shoulder dislocation.

BACKGROUND: Long-standing anterior glenohumeral dislocation results in both humeral and glenoid bone loss, as well as concomitant soft tissue pathologies. Reverse shoulder arthroplasty (RSA) is an established procedure to restore both stability and function in cuff-deficient shoulders. However, fixation of the glenoid component is prone to failure in cases of advanced glenoid vault destruction and requires substantial bone graft. The purpose of this study was to evaluate the outcome of glenoid bone grafting in RSA for neglected anterior dislocation with significant glenoid bone loss. MATERIALS AND METHODS: We reviewed 21 of 32 patients after 1-staged RSA and glenoid bone grafting with resected humeral head, with a mean follow-up period of 4.9 years (range, 2-10 years). The mean age at the time of surgery was 71 years (range, 50-85 years). Glenoid bone loss averaged 45% of glenoid width according to preoperative computed tomography or magnetic resonance imaging scans. A long-pegged glenoid baseplate was used in 9 patients. RESULTS: The mean Constant score improved from 5.7 points (range, 0-22 points) preoperatively to 57.2 points (range, 26-79 points) postoperatively (P < .001). Two patients required revision because of baseplate loosening: one patient underwent conversion to a hemiarthroplasty, and the other patient underwent a 2-staged reconstruction with tricortical iliac crest bone graft. CONCLUSION: RSA in neglected anterior dislocation is a successful treatment option even in the case of advanced glenoid bone loss. To maintain stable fixation of the glenoid component, comprehensive preoperative analysis of the remaining bone stock based on 3-dimensional computed tomography scans should be included, with particular attention to ensure optimal anchorage length of the baseplate's central peg in the native glenoid bone stock.

A narrative review of treatment strategies for major glenoid defects during primary reverse shoulder arthroplasty, with a focus on the use of structural bone graft.

Structural glenoid defects are common during primary reverse shoulder arthroplasty (RSA) and are often associated with poor outcomes. The lack of pre-operative imaging protocols for determining the depth and degree of glenoid wear hinders our ability to accurately plan and correct these defects. Although bone grafting has been reported to be effective in reducing glenoid wear during RSA, there is limited information on when to utilise it and how to prepare the graft. We conducted this review to assess the evidence for the management of glenoid defects, with an emphasis on bone grafts to treat structural glenoid bone loss in primary RSA patients.

Management of Glenoid Defects in Anterior Shoulder Instability: A Review of Current Concepts.

BACKGROUND: Bone defects of the glenoid are often found in patients with traumatic anterior glenohumeral instability. There is no consensus regarding which glenoid defects need to be treated surgically. The aim of this review is to describe the management of glenoid defects in anterior shoulder instability in patients with traumatic anterior glenohumeral instability. METHODS: We conducted a review of the literature through a Pubmed search. RESULTS: The management of glenoid defects in anterior shoulder instability consists of conservative or operative treatment. There is a wide variety in the treatment options. Also, the diagnostics of the presence and size of a glenoid bone defect is still debated on in literature. CONCLUSION: Based on the current available literature, we advise to begin management of traumatic anterior shoulder instability combined with glenoid defects with conservative treatment. Operative treatment can be used when the bone fragment consists of a large glenoid surface and the patient is active, or in the case of a chronic defect or recurrent instability.

Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation.

BACKGROUND: Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated. METHODS: We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder. RESULTS: Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons. CONCLUSION: We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.