- Email: [email protected]
Anatomical Glenoid Reconstruction Using Fresh Osteochondral Distal Tibia Allograft After Failed Latarjet Procedure
Anatomical Glenoid Reconstruction Using Fresh Osteochondral Distal Tibia Allograft After Failed Latarjet Procedure Anthony Sanchez, B.S., Marcio B. Ferrari, M.D., Ramesses A. Akamefula, Rachel M. Frank, M.D., George Sanchez, B.S., and Matthew T. Provencher, M.D.
Abstract: In the treatment of recurrent anterior glenohumeral instability, the Latarjet procedure has been shown to fail. This results in a need for viable revisional procedures for patients who present with this challenging pathology. We report our preferred technique for anatomical glenoid reconstruction using a fresh osteochondral distal tibia allograft after a failed Latarjet procedure. This bony augmentation technique employs a readily available dense, weight-bearing osseous tissue source that has excellent conformity, as well as the added benefit of a cartilaginous surface to correct chondral deficiencies. Given its effectiveness in the Latarjet revision setting and low complication rate, the distal tibia allograft is a reasonable treatment option.
S
houlder instability currently affects 2% of the population, with dislocations representing 11% of all shoulder traumas and/or complications.1 Glenohumeral instability mainly affects young athletes with high functional demands, such as football and rugby players. However, a shoulder dislocation can be caused by both traumatic and nontraumatic events and can occur in the anterior, posterior, and inferior directions with the possibility of multidirectional instability not excluded.2,3 Amongst all shoulder dislocations, 95% of these cases illustrate the humeral head displacing anteriorly in respect to the glenoid.4 Bony defects many times occur as a result of anterior dislocation either in the form of a bony Bankart lesion and/or a Hill-Sachs lesion.4 Even after soft tissue stabilization,
From the Department of Quality and Patient Safety, Jackson Memorial Hospital (A.S.), Miami, Florida; Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center (R.M.F.), Chicago, Illinois; Steadman Philippon Research Institute (M.B.F., R.A.A., G.S., M.T.P.), Vail, Colorado; and The Steadman Clinic (M.T.P.), Vail, Colorado, U.S.A. The authors report the following potential conflicts of interest or sources of funding: M.T.P. receives support from Arthrex, JRF Ortho, and SLACK; and has patent numbers (issued): 9226743, 20150164498, 20150150594, and 20110040339. Received October 18, 2016; accepted November 15, 2016. Address correspondence to Matthew T. Provencher, M.D., Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/161012/$36.00 http://dx.doi.org/10.1016/j.eats.2016.11.003
recurrent instability of the shoulder still occurs 67% of the time after surgery when significant glenoid bone loss is present.5,6 In cases where there is more than 20% to 25% glenoid bone loss, reconstruction with a bony procedure is almost imminent.7 In 1954, Latarjet introduced a coracoid bone transfer procedure to treat patients with glenoid bone loss, who exhibited recurrent anterior shoulder instability. This procedure involves the transfer of the coracoid process to the anteroinferior margin of the glenoid where bone loss has occurred.5,8 Emami et al.2 illustrate different surgical procedures such as Bristow-Latarjet and bony Bankart repair as ways to treat anterior instability with glenoid bone loss. However, depending on the case, some surgical procedures for the treatment of recurrent anterior shoulder instability may pose to be more suitable than others depending on variables such as patient activity level and age as well as severity of complication. For example, it has been described by Balg et al. that many young athletes, especially those involved with high contact sports, are bad candidates for bony Bankart repair. Therefore, in this specific patient population, a Latarjet would be more suitable.9,10 However, the Latarjet procedure is subject to complications and failure of its own. Specifically, resorption of the coracoid graft, prominence or incorrect drilling of fixation screws, and malpositioning of the graft may result in need of revision surgery after the Latarjet procedure. In certain patients, the possibility of failure after a Latarjet procedure is greater than others. Gwathmey and Warner11 illustrated a few risk factors
Arthroscopy Techniques, Vol 6, No 2 (April), 2017: pp e477-e482
e477
e478
A. SANCHEZ ET AL.
Fig 1. Deltopectoral incision performed in a right shoulder with the patient positioned in the beach chair position. The approach is performed between the deltoid and pectoralis major muscle, starting at the inferior aspect of the clavicle and following the deltopectoral groove distally for approximately 7 cm. The deltoid muscle is retracted laterally and the pectoralis major medially. The deltopectoral fascia is the first structure behind the subcutaneous tissue and should be incised in accordance to the skin incision. The cephalic vein is identified using blunt dissection and carefully protected and retracted either medially or laterally. Of note, because of adhesions and scar tissue formation from previous surgery, the vein position can be altered and care must be taken to avoid damage during dissection.
for a failed shoulder instability procedure: status as a young athlete below 20 years of age, participation in a contact/collision sport at a high level of competition, and/or the presence of a Hill-Sachs lesion. One potential graft option for glenoid reconstruction after a failed Latarjet procedure is a osteochondral distal tibia allograft (DTA) because of its similar radius of curvature compared with that of the glenoid as well as dense bony quality and robust articular chondral surface.7 The objective of this Technical Note is to describe the application of a DTA for the treatment of severe anterior glenoid bone loss in the setting of a failed Latarjet procedure.
glenoid to retract the deltoid laterally. Attention is then turned to the subscapularis (SSc). Typically, an SSc split is performed sharply in line with its fibers, at the junction of the superior and middle thirds. In the revision setting, pending the quality of the SSc tissue and underlying capsule tissue, this may not be possible, and an SSc takedown can instead be performed (Fig 2). The SSc is then tagged with a No. 2 Fiberwire suture (Arthrex, Naples, FL) for easier identification and repair later on in the technique. Next, the underlying capsule is freed bluntly from the posterior aspect of the SSc and a medial-based T capsulotomy is performed. The remaining capsule is then gently elevated off of the glenoid neck medially in a subperiosteal fashion using a No. 15 scalpel. Next, the anterior glenoid rim is evaluated and prepared. At this time, one should also evaluate the humeral head for the presence of an engaging Hill-Sachs lesion (also can be identified on the preceding diagnostic arthroscopy). If not previously removed (as in this case), hardware from the prior Latarjet procedure must be removed at this point. The combination of an osteotome and rongeur can be used to debride the scar tissue and prior implants, and a high-speed burr and/or rasp is used to establish a bleeding bony surface along the anterior glenoid rim. The size of the anterior glenoid bone defect is evaluated and documented to aid in preparation of the allograft (30% in this case). Allograft Preparation On the back table, the anterior glenoid bone graft is harvested from the lateral one-third of the fresh
Surgical Technique After the induction of regional general anesthesia, the patient is placed into the beach chair position with a bump placed behind the medial border of the scapula. After an initial diagnostic arthroscopy, attention is turned to the open approach. The surgical incision is performed with a No. 10 scalpel from the tip of the coracoid process extending inferiorly along the axillary fold for approximately 7 cm (Fig 1). The deltopectoral interval is then identified and dissected, taking care to identify and preserve the cephalic vein. Gelpi or Weitlaner retractors are placed to expose the fascia overlying the conjoined tendon, which is incised, and then the lateral aspect of the conjoined tendon is retracted medially. A Fukuda retractor is then placed behind the
Fig 2. Deltopectoral approach performed in a right shoulder. After superficial dissection, deep structures are identified. A tenotomy of the subscapular tendon is performed near the tendon insertion site at the lesser tuberosity of the humeral head. The subscapular tendon is then tagged with a No. 2 high-strength suture and retracted medially. A medial-based T capsulotomy is performed to access the joint. Glenoid bone loss, humeral head bony defects, and chondral lesions are evaluated at this point.
ANATOMICAL GLENOID RECONSTRUCTION USING DTA
e479
Fig 3. A custom distal tibia allograft cutting device (Arthrex, Naples, FL) is used to perform necessary cuts of the distal tibia allograft to arrive at the desired graft for bony augmentation (A, B). The graft is placed with the distal cartilage surface facing up and firmly secured in the device. The cuts are performed at the lateral aspect of the bone, which provides a better congruency with the humeral head. Of note, care must be taken to maintain constant saline irrigation to keep the graft cool while the cuts are performed.
osteochondral DTA (JRF Ortho, Centennial, CO). In this case, the graft was sized to be 10 15 25 mm in dimension, and 12 mm in depth (Fig 3). Constant saline irrigation is used to cool the graft while it is being cut. Next, two 4.0-mm drill holes are drilled in the graft, using the graft holder as a guide. Pulsatile lavage is applied to the graft to remove all marrow elements before graft placement for approximately 5 minutes (Fig 4A). After the pulse lavage, the allograft is soaked in a combination of autologous-conditioned plasma and platelet-rich plasma for application through use of a double syringe system (Greyledge Technologies, Vail, CO). Before this, 60 cm3 of peripheral blood is collected from the patient and submitted to centrifugation for approximately 10 minutes to heterogeneously divide the blood (Fig 4B). Graft Placement The graft is then brought to the surgical field and provisionally fixed to the anterior glenoid rim with 2 K-wires placed in a bicortical fashion to the posterior
aspect of the glenoid; a third K-wire can be used to aid in fixation to the native glenoid. The K-wires are then measured to aid in screw selection (typically 32 to 36 mm in length), and then a cannulated drill is used over the K-wires, through the previously drilled 4.0mm holes, into the near cortex of the native glenoid, which will allow for lag screw compression of the graft to the glenoid. The K-wires are then removed and two 3.75-mm noncannulated fully threaded screws with suture washers are inserted (Arthrex). Fixation of the allograft onto the native glenoid is finalized (Fig 5). The fit of the graft on the glenoid is assessed, as is the congruency of the humeral head on the glenoid. The cartilage of the graft should be flush with the cartilage of the glenoid. The anterior-inferior capsule is then repaired using the sutures from the suture washers. Afterward, the SSc is identified based on the No. 2 Fiberwire suture (Arthrex) previously placed as a tag, and then the tendon is repaired with multiple suture anchors through a double-row technique. Finally, the subcutaneous and skin are closed in layers through the
Fig 4. After preparation of the distal tibia allograft, the graft is submitted to pulsed lavage (A) for approximately 5 minutes to assure removal of all marrow elements and bone debris that may be left from previous osteotomies. After the pulsed lavage, the graft is soaked with platelet-rich plasma (B) before graft placement to improve the potential for bony union with the native glenoid.
e480
A. SANCHEZ ET AL.
performed. After week 12 until week 16, the goal is to restore strength. External and internal rotation at 90 with cable, push-up, and plyometric exercises are incentivized. When the goals of all previous phases are achieved, the last phase begins (normally >16 weeks). The patient may start swimming, military-press, and lat pulldown exercises. Throwing is progressed from short to long distances. The return to full previously activities is individualized to each patient.
Discussion Fig 5. The distal tibia allograft must be correctly positioned and fixed at the glenoid bone of the affected right shoulder. The graft is provisionally fixed to the anterior glenoid rim with 2 K-wires placed in a bicortical fashion to the posterior aspect of the glenoid. The K-wires are then measured to aid in screw selection. After this, a cannulated drill is used over the K-wires, through the previously drilled 4.0-mm holes, into the near cortex of the native glenoid, which will allow for lag screw compression of the graft to the glenoid. The K-wires are then removed and two 3.75-mm noncannulated fully threaded screws with suture washers are inserted.
standard fashion. The advantages and disadvantages as well as the pearls and pitfalls associated with this technique in the setting of a failed Latarjet procedure (Video 1) are listed in Tables 1 and 2, respectively. Postoperative Rehabilitation After the procedure, the patient should use an ultrasling at all times for 4 to 6 weeks. The rehabilitation is divided into 6 phases. The first phase consists in the first 2 weeks. No biceps activation should be performed. Aerobic exercises, stationary bike, and walking on the level surface are performed for 30 minutes. Passive range of motion should be performed 4 times a week and should reach the limits as follows: 120 of forward flexion (FF), 120 of motion in scapular plane (SC), 30 of external rotation (ER) at side, and abduction (AB) to 90 . Active wrist and elbow range of motion is incentivized in this week. Once the goals of the first phase are reached, the second phase starts (week 2-4). The aerobic exercises are progressed to 45 to 60 minutes. The limits in passive range of motion must improve to 150 of FF, 150 of motion in SC, 45 of ER at side, and AB to 90 . Isometric exercises for extension, ER, internal rotation and AB are recommended. After the goals are achieved, the use of the ultrasling is discontinued. The third phase (week 6-12) consists in progression of passive range of motion to 160 of FF, 160 of motion in SC, 45 of ER at side, and AB to 140 . Deltoid isometric exercises start at 4 weeks. For the fourth phase, inclined treadmill, active-assisted range of motion is progressed to active range of motion and more internal and external rotation exercises are
The DTA has been used successfully in early efforts to treat anterior glenoid bone loss and instability,12 even in high-risk populations.13 Provencher et al.,12 in the Technical Note that first described the procedure, reported computed tomography-confirmed successful osseous incorporation and remodeling of tibial allografts without resorption in all 3 cases performed at that point. Subsequently, as part of a larger short-term outcome (2 years’ follow-up) report on various bone block procedures in a high-risk military population, 3 successful tibial allografts were reported.13 The patient population that stands to most benefit from advancements of DTA is patients with recurrent anterior instability after a failed Latarjet procedure. Reports in the literature of recurrence after Latarjet stabilization are heterogeneous in patient groups, follow-up time, techniques used, and postoperative evaluation of instability, varying greatly in reported rates. At the systematic review level, the overall rate of recurrence has been reported as 11.6%14 and 7.5%,15 and specifically the revision surgery rate after failed Latarjet has been reported as 3.4%.14 Thus, a substantial patient population may turn to DTA as a reasonable treatment option. However, certain points should be made in the revision setting of a Latarjet procedure including why a revision may be necessary. In the experience of the senior author (MTP), the coracoid bone block used in the Latarjet procedure does undergo resorption, which warrants an additional revision procedure for bony augmentation in severe cases of resorption. The Table 1. Advantages vs Disadvantages Advantages
Disadvantages
Addresses large defects of the glenoid while restoring anatomy and biomechanics Good articular congruency with the humeral head
High cost and may be difficult to acquire or unavailable in certain regions Bone consolidation can be delayed compared with autografts
No morbidity at the donor site Distal tibia allograft can be used to treat either anterior or posterior defects of the glenoid
ANATOMICAL GLENOID RECONSTRUCTION USING DTA Table 2. Pearls vs Pitfalls Pearls
Pitfalls
Graft should be prepared after intraoperative measurement of the defect to ensure optimal sizing of the graft. The use of the custom distal tibia allograft cutting device will ease graft preparation.
Damaging of the graft as well as inappropriate graft sizing may be seen if graft preparation is mishandled. Inappropriate fixation of the graft will not restore shoulder anatomy and biomechanics.
Irrigation should be used while performing all graft cuts to minimize potential damage. Pulsatile lavage on the graft should be performed to remove all marrow elements before graft fixation. Platelet-rich plasma can also be used before fixation of the graft to maximize potential for bony union with the native glenoid.
osteolysis experienced by the bone block ultimately compromises the bony foundation necessary for appropriate glenohumeral stability; therefore, complete removal of the bone block is needed followed by placement of the allograft (i.e., DTA). Moreover, as a result of the previous Latarjet procedure, risk of possible nerve damage in the revision setting heightens as experienced by the senior author. In particular, during exposure, caution is necessary to avoid damage to nearby nerves, especially the musculocutaneous nerve. DTA has also been successfully applied in a posterior glenoid deficiency reconstruction by Millett et al.16 in 2 cases with a follow-up of 2 years. Yet another potential use for this versatile procedure, first described in a case report by Provencher et al.,17 may be in the treatment of postsurgical glenohumeral anchor arthropathy. DTA was used successfully in combination with a fresh humeral allograft to focal sites of humeral head damage. Additional evidence to be weighed when considering failed Latarjet revision with an osteochondral DTA has been reported in the form of multiple biomechanical studies comparing the properties of coracoid grafts with DTA. Using the Mose circles of a standard goniometer, one group found that both inferior coracoid autograft and osteochondral allograft of the lateral distal tibia provided the best match to re-establish the native radius of curvature of the glenoid at a 94% rate match within 5 mm of the glenoid anterior to posterior radius of curvature.18 Another group reported this same similarity in radius of curvature between the 2 grafts using statistical analysis of 3D computed tomography images.19 In a contact pressure comparison study, Bhatia et al.20 found that DTA may allow for improved joint congruity and lower peak forces than coracoid at 60 of AB and the abduction and external rotation (ABER)
e481
position, giving insight into what this similarity in radius of curvature may translate into in terms of biomechanics. We have presented our preferred technique for the DTA procedure after failed Latarjet. To further advance this technique, randomized controlled clinical trials are needed. With sufficient long-term follow-up of large patient cohorts, the usefulness of DTA will be evident. Ultimately, the DTA may develop into a viable primary treatment option for recurrent anterior glenohumeral instability with confirmation of positive, long-term treatment outcomes.
References 1. Ciais G, Klouche S, Fournier A, Rousseau B, Bauer T, Hardy P. Bony defects in chronic anterior posttraumatic dislocation of the shoulder: Is there a correlation between humeral and glenoidal lesions? Eur J Orthop Surg Traumatol 2016;26:581-586. 2. Emami MJ, Solooki S, Meshksari Z, Vosoughi AR. The effect of open Bristow-Latarjet procedure for anterior shoulder instability: A 10-year study. Musculoskelet Surg 2011;95:231-235. 3. Dauzère F, Faraud A, Lebon J, Faruch M, Mansat P, Bonnevialle N. Is the Latarjet procedure risky? Analysis of complications and learning curve. Knee Surg Sports Traumatol Arthrosc 2016;24:557-563. 4. Mazzocca AD, Cote MP, Solovyova O, Rizvi SH, Mostofi A, Arciero RA. Traumatic shoulder instability involving anterior, inferior, and posterior labral injury: A prospective clinical evaluation of arthroscopic repair of 270 labral tears. Am J Sports Med 2011;39:1687-1696. 5. Alvi HM, Monroe EJ, Muriuki M, Verma RN, Marra G, Saltzman MD. Latarjet fixation: A cadaveric biomechanical study evaluating cortical and cannulated screw fixation. Orthop J Sports Med 2016;4:2325967116643533. 6. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am 2003;85:878-884. 7. Decker MM, Strohmeyer GC, Wood JP, et al. Distal tibia allograft for glenohumeral instability: Does radius of curvature match? J Shoulder Elbow Surg 2016;25:15421548. 8. Young DC, Rockwood CA. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am 1991;73:969-981. 9. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477. 10. da Silva LA, da Costa Lima ÁG, Kautsky RM, Santos PD, do Val Sella G, Checchia SL. Evaluation of the results and complications of the Latarjet procedure for recurrent anterior dislocation of the shoulder. Rev Bras Ortop Engl Ed 2015;50:652-659. 11. Gwathmey FW, Warner JJP. Management of the athlete with a failed shoulder instability procedure. Clin Sports Med 2013;32:833-886. 12. Provencher MT, Ghodadra N, LeClere L, Solomon DJ, Romeo AA. Anatomic osteochondral glenoid
e482
13.
14.
15.
16.
A. SANCHEZ ET AL.
reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy 2009;25:446-452. Waterman BR, Chandler PJ, Teague E, Provencher MT, Tokish JM, Pallis MP. Short-term outcomes of glenoid bone block augmentation for complex anterior shoulder instability in a high-risk population. Arthroscopy 2016;32:1784-1790. An VVG, Sivakumar BS, Phan K, Trantalis J. A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair. J Shoulder Elbow Surg 2016;25: 853-863. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:1184-1211. Millett PJ, Schoenahl JY, Register B, Gaskill TR, van Deurzen DF, Martetschläger F. Reconstruction of posterior glenoid deficiency using distal tibial osteoarticular
17.
18.
19.
20.
allograft. Knee Surg Sports Traumatol Arthrosc 2013;21: 445-449. Provencher MT, LeClere LE, Ghodadra N, Solomon DJ. Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head. J Shoulder Elbow Surg 2010;19:e6-e11. Dehaan A, Munch J, Durkan M, Yoo J, Crawford D. Reconstruction of a bony Bankart lesion: Best fit based on radius of curvature. Am J Sports Med 2013;41:1140-1145. Rios D, Jansson KS, Martetschläger F, Boykin RE, Millett PJ, Wijdicks CA. Normal curvature of glenoid surface can be restored when performing an inlay osteochondral allograft: An anatomic computed tomographic comparison. Knee Surg Sports Traumatol Arthrosc 2014;22: 442-447. Bhatia S, Van Thiel GS, Gupta D, et al. Comparison of glenohumeral contact pressures and contact areas after glenoid reconstruction with Latarjet or distal tibial osteochondral allografts. Am J Sports Med 2013;41:19001908.
Abstract: In the treatment of recurrent anterior glenohumeral instability, the Latarjet procedure has been shown to fail. This results in a need for viable revisional procedures for patients who present with this challenging pathology. We report our preferred technique for anatomical glenoid reconstruction using a fresh osteochondral distal tibia allograft after a failed Latarjet procedure. This bony augmentation technique employs a readily available dense, weight-bearing osseous tissue source that has excellent conformity, as well as the added benefit of a cartilaginous surface to correct chondral deficiencies. Given its effectiveness in the Latarjet revision setting and low complication rate, the distal tibia allograft is a reasonable treatment option.
S
houlder instability currently affects 2% of the population, with dislocations representing 11% of all shoulder traumas and/or complications.1 Glenohumeral instability mainly affects young athletes with high functional demands, such as football and rugby players. However, a shoulder dislocation can be caused by both traumatic and nontraumatic events and can occur in the anterior, posterior, and inferior directions with the possibility of multidirectional instability not excluded.2,3 Amongst all shoulder dislocations, 95% of these cases illustrate the humeral head displacing anteriorly in respect to the glenoid.4 Bony defects many times occur as a result of anterior dislocation either in the form of a bony Bankart lesion and/or a Hill-Sachs lesion.4 Even after soft tissue stabilization,
From the Department of Quality and Patient Safety, Jackson Memorial Hospital (A.S.), Miami, Florida; Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center (R.M.F.), Chicago, Illinois; Steadman Philippon Research Institute (M.B.F., R.A.A., G.S., M.T.P.), Vail, Colorado; and The Steadman Clinic (M.T.P.), Vail, Colorado, U.S.A. The authors report the following potential conflicts of interest or sources of funding: M.T.P. receives support from Arthrex, JRF Ortho, and SLACK; and has patent numbers (issued): 9226743, 20150164498, 20150150594, and 20110040339. Received October 18, 2016; accepted November 15, 2016. Address correspondence to Matthew T. Provencher, M.D., Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/161012/$36.00 http://dx.doi.org/10.1016/j.eats.2016.11.003
recurrent instability of the shoulder still occurs 67% of the time after surgery when significant glenoid bone loss is present.5,6 In cases where there is more than 20% to 25% glenoid bone loss, reconstruction with a bony procedure is almost imminent.7 In 1954, Latarjet introduced a coracoid bone transfer procedure to treat patients with glenoid bone loss, who exhibited recurrent anterior shoulder instability. This procedure involves the transfer of the coracoid process to the anteroinferior margin of the glenoid where bone loss has occurred.5,8 Emami et al.2 illustrate different surgical procedures such as Bristow-Latarjet and bony Bankart repair as ways to treat anterior instability with glenoid bone loss. However, depending on the case, some surgical procedures for the treatment of recurrent anterior shoulder instability may pose to be more suitable than others depending on variables such as patient activity level and age as well as severity of complication. For example, it has been described by Balg et al. that many young athletes, especially those involved with high contact sports, are bad candidates for bony Bankart repair. Therefore, in this specific patient population, a Latarjet would be more suitable.9,10 However, the Latarjet procedure is subject to complications and failure of its own. Specifically, resorption of the coracoid graft, prominence or incorrect drilling of fixation screws, and malpositioning of the graft may result in need of revision surgery after the Latarjet procedure. In certain patients, the possibility of failure after a Latarjet procedure is greater than others. Gwathmey and Warner11 illustrated a few risk factors
Arthroscopy Techniques, Vol 6, No 2 (April), 2017: pp e477-e482
e477
e478
A. SANCHEZ ET AL.
Fig 1. Deltopectoral incision performed in a right shoulder with the patient positioned in the beach chair position. The approach is performed between the deltoid and pectoralis major muscle, starting at the inferior aspect of the clavicle and following the deltopectoral groove distally for approximately 7 cm. The deltoid muscle is retracted laterally and the pectoralis major medially. The deltopectoral fascia is the first structure behind the subcutaneous tissue and should be incised in accordance to the skin incision. The cephalic vein is identified using blunt dissection and carefully protected and retracted either medially or laterally. Of note, because of adhesions and scar tissue formation from previous surgery, the vein position can be altered and care must be taken to avoid damage during dissection.
for a failed shoulder instability procedure: status as a young athlete below 20 years of age, participation in a contact/collision sport at a high level of competition, and/or the presence of a Hill-Sachs lesion. One potential graft option for glenoid reconstruction after a failed Latarjet procedure is a osteochondral distal tibia allograft (DTA) because of its similar radius of curvature compared with that of the glenoid as well as dense bony quality and robust articular chondral surface.7 The objective of this Technical Note is to describe the application of a DTA for the treatment of severe anterior glenoid bone loss in the setting of a failed Latarjet procedure.
glenoid to retract the deltoid laterally. Attention is then turned to the subscapularis (SSc). Typically, an SSc split is performed sharply in line with its fibers, at the junction of the superior and middle thirds. In the revision setting, pending the quality of the SSc tissue and underlying capsule tissue, this may not be possible, and an SSc takedown can instead be performed (Fig 2). The SSc is then tagged with a No. 2 Fiberwire suture (Arthrex, Naples, FL) for easier identification and repair later on in the technique. Next, the underlying capsule is freed bluntly from the posterior aspect of the SSc and a medial-based T capsulotomy is performed. The remaining capsule is then gently elevated off of the glenoid neck medially in a subperiosteal fashion using a No. 15 scalpel. Next, the anterior glenoid rim is evaluated and prepared. At this time, one should also evaluate the humeral head for the presence of an engaging Hill-Sachs lesion (also can be identified on the preceding diagnostic arthroscopy). If not previously removed (as in this case), hardware from the prior Latarjet procedure must be removed at this point. The combination of an osteotome and rongeur can be used to debride the scar tissue and prior implants, and a high-speed burr and/or rasp is used to establish a bleeding bony surface along the anterior glenoid rim. The size of the anterior glenoid bone defect is evaluated and documented to aid in preparation of the allograft (30% in this case). Allograft Preparation On the back table, the anterior glenoid bone graft is harvested from the lateral one-third of the fresh
Surgical Technique After the induction of regional general anesthesia, the patient is placed into the beach chair position with a bump placed behind the medial border of the scapula. After an initial diagnostic arthroscopy, attention is turned to the open approach. The surgical incision is performed with a No. 10 scalpel from the tip of the coracoid process extending inferiorly along the axillary fold for approximately 7 cm (Fig 1). The deltopectoral interval is then identified and dissected, taking care to identify and preserve the cephalic vein. Gelpi or Weitlaner retractors are placed to expose the fascia overlying the conjoined tendon, which is incised, and then the lateral aspect of the conjoined tendon is retracted medially. A Fukuda retractor is then placed behind the
Fig 2. Deltopectoral approach performed in a right shoulder. After superficial dissection, deep structures are identified. A tenotomy of the subscapular tendon is performed near the tendon insertion site at the lesser tuberosity of the humeral head. The subscapular tendon is then tagged with a No. 2 high-strength suture and retracted medially. A medial-based T capsulotomy is performed to access the joint. Glenoid bone loss, humeral head bony defects, and chondral lesions are evaluated at this point.
ANATOMICAL GLENOID RECONSTRUCTION USING DTA
e479
Fig 3. A custom distal tibia allograft cutting device (Arthrex, Naples, FL) is used to perform necessary cuts of the distal tibia allograft to arrive at the desired graft for bony augmentation (A, B). The graft is placed with the distal cartilage surface facing up and firmly secured in the device. The cuts are performed at the lateral aspect of the bone, which provides a better congruency with the humeral head. Of note, care must be taken to maintain constant saline irrigation to keep the graft cool while the cuts are performed.
osteochondral DTA (JRF Ortho, Centennial, CO). In this case, the graft was sized to be 10 15 25 mm in dimension, and 12 mm in depth (Fig 3). Constant saline irrigation is used to cool the graft while it is being cut. Next, two 4.0-mm drill holes are drilled in the graft, using the graft holder as a guide. Pulsatile lavage is applied to the graft to remove all marrow elements before graft placement for approximately 5 minutes (Fig 4A). After the pulse lavage, the allograft is soaked in a combination of autologous-conditioned plasma and platelet-rich plasma for application through use of a double syringe system (Greyledge Technologies, Vail, CO). Before this, 60 cm3 of peripheral blood is collected from the patient and submitted to centrifugation for approximately 10 minutes to heterogeneously divide the blood (Fig 4B). Graft Placement The graft is then brought to the surgical field and provisionally fixed to the anterior glenoid rim with 2 K-wires placed in a bicortical fashion to the posterior
aspect of the glenoid; a third K-wire can be used to aid in fixation to the native glenoid. The K-wires are then measured to aid in screw selection (typically 32 to 36 mm in length), and then a cannulated drill is used over the K-wires, through the previously drilled 4.0mm holes, into the near cortex of the native glenoid, which will allow for lag screw compression of the graft to the glenoid. The K-wires are then removed and two 3.75-mm noncannulated fully threaded screws with suture washers are inserted (Arthrex). Fixation of the allograft onto the native glenoid is finalized (Fig 5). The fit of the graft on the glenoid is assessed, as is the congruency of the humeral head on the glenoid. The cartilage of the graft should be flush with the cartilage of the glenoid. The anterior-inferior capsule is then repaired using the sutures from the suture washers. Afterward, the SSc is identified based on the No. 2 Fiberwire suture (Arthrex) previously placed as a tag, and then the tendon is repaired with multiple suture anchors through a double-row technique. Finally, the subcutaneous and skin are closed in layers through the
Fig 4. After preparation of the distal tibia allograft, the graft is submitted to pulsed lavage (A) for approximately 5 minutes to assure removal of all marrow elements and bone debris that may be left from previous osteotomies. After the pulsed lavage, the graft is soaked with platelet-rich plasma (B) before graft placement to improve the potential for bony union with the native glenoid.
e480
A. SANCHEZ ET AL.
performed. After week 12 until week 16, the goal is to restore strength. External and internal rotation at 90 with cable, push-up, and plyometric exercises are incentivized. When the goals of all previous phases are achieved, the last phase begins (normally >16 weeks). The patient may start swimming, military-press, and lat pulldown exercises. Throwing is progressed from short to long distances. The return to full previously activities is individualized to each patient.
Discussion Fig 5. The distal tibia allograft must be correctly positioned and fixed at the glenoid bone of the affected right shoulder. The graft is provisionally fixed to the anterior glenoid rim with 2 K-wires placed in a bicortical fashion to the posterior aspect of the glenoid. The K-wires are then measured to aid in screw selection. After this, a cannulated drill is used over the K-wires, through the previously drilled 4.0-mm holes, into the near cortex of the native glenoid, which will allow for lag screw compression of the graft to the glenoid. The K-wires are then removed and two 3.75-mm noncannulated fully threaded screws with suture washers are inserted.
standard fashion. The advantages and disadvantages as well as the pearls and pitfalls associated with this technique in the setting of a failed Latarjet procedure (Video 1) are listed in Tables 1 and 2, respectively. Postoperative Rehabilitation After the procedure, the patient should use an ultrasling at all times for 4 to 6 weeks. The rehabilitation is divided into 6 phases. The first phase consists in the first 2 weeks. No biceps activation should be performed. Aerobic exercises, stationary bike, and walking on the level surface are performed for 30 minutes. Passive range of motion should be performed 4 times a week and should reach the limits as follows: 120 of forward flexion (FF), 120 of motion in scapular plane (SC), 30 of external rotation (ER) at side, and abduction (AB) to 90 . Active wrist and elbow range of motion is incentivized in this week. Once the goals of the first phase are reached, the second phase starts (week 2-4). The aerobic exercises are progressed to 45 to 60 minutes. The limits in passive range of motion must improve to 150 of FF, 150 of motion in SC, 45 of ER at side, and AB to 90 . Isometric exercises for extension, ER, internal rotation and AB are recommended. After the goals are achieved, the use of the ultrasling is discontinued. The third phase (week 6-12) consists in progression of passive range of motion to 160 of FF, 160 of motion in SC, 45 of ER at side, and AB to 140 . Deltoid isometric exercises start at 4 weeks. For the fourth phase, inclined treadmill, active-assisted range of motion is progressed to active range of motion and more internal and external rotation exercises are
The DTA has been used successfully in early efforts to treat anterior glenoid bone loss and instability,12 even in high-risk populations.13 Provencher et al.,12 in the Technical Note that first described the procedure, reported computed tomography-confirmed successful osseous incorporation and remodeling of tibial allografts without resorption in all 3 cases performed at that point. Subsequently, as part of a larger short-term outcome (2 years’ follow-up) report on various bone block procedures in a high-risk military population, 3 successful tibial allografts were reported.13 The patient population that stands to most benefit from advancements of DTA is patients with recurrent anterior instability after a failed Latarjet procedure. Reports in the literature of recurrence after Latarjet stabilization are heterogeneous in patient groups, follow-up time, techniques used, and postoperative evaluation of instability, varying greatly in reported rates. At the systematic review level, the overall rate of recurrence has been reported as 11.6%14 and 7.5%,15 and specifically the revision surgery rate after failed Latarjet has been reported as 3.4%.14 Thus, a substantial patient population may turn to DTA as a reasonable treatment option. However, certain points should be made in the revision setting of a Latarjet procedure including why a revision may be necessary. In the experience of the senior author (MTP), the coracoid bone block used in the Latarjet procedure does undergo resorption, which warrants an additional revision procedure for bony augmentation in severe cases of resorption. The Table 1. Advantages vs Disadvantages Advantages
Disadvantages
Addresses large defects of the glenoid while restoring anatomy and biomechanics Good articular congruency with the humeral head
High cost and may be difficult to acquire or unavailable in certain regions Bone consolidation can be delayed compared with autografts
No morbidity at the donor site Distal tibia allograft can be used to treat either anterior or posterior defects of the glenoid
ANATOMICAL GLENOID RECONSTRUCTION USING DTA Table 2. Pearls vs Pitfalls Pearls
Pitfalls
Graft should be prepared after intraoperative measurement of the defect to ensure optimal sizing of the graft. The use of the custom distal tibia allograft cutting device will ease graft preparation.
Damaging of the graft as well as inappropriate graft sizing may be seen if graft preparation is mishandled. Inappropriate fixation of the graft will not restore shoulder anatomy and biomechanics.
Irrigation should be used while performing all graft cuts to minimize potential damage. Pulsatile lavage on the graft should be performed to remove all marrow elements before graft fixation. Platelet-rich plasma can also be used before fixation of the graft to maximize potential for bony union with the native glenoid.
osteolysis experienced by the bone block ultimately compromises the bony foundation necessary for appropriate glenohumeral stability; therefore, complete removal of the bone block is needed followed by placement of the allograft (i.e., DTA). Moreover, as a result of the previous Latarjet procedure, risk of possible nerve damage in the revision setting heightens as experienced by the senior author. In particular, during exposure, caution is necessary to avoid damage to nearby nerves, especially the musculocutaneous nerve. DTA has also been successfully applied in a posterior glenoid deficiency reconstruction by Millett et al.16 in 2 cases with a follow-up of 2 years. Yet another potential use for this versatile procedure, first described in a case report by Provencher et al.,17 may be in the treatment of postsurgical glenohumeral anchor arthropathy. DTA was used successfully in combination with a fresh humeral allograft to focal sites of humeral head damage. Additional evidence to be weighed when considering failed Latarjet revision with an osteochondral DTA has been reported in the form of multiple biomechanical studies comparing the properties of coracoid grafts with DTA. Using the Mose circles of a standard goniometer, one group found that both inferior coracoid autograft and osteochondral allograft of the lateral distal tibia provided the best match to re-establish the native radius of curvature of the glenoid at a 94% rate match within 5 mm of the glenoid anterior to posterior radius of curvature.18 Another group reported this same similarity in radius of curvature between the 2 grafts using statistical analysis of 3D computed tomography images.19 In a contact pressure comparison study, Bhatia et al.20 found that DTA may allow for improved joint congruity and lower peak forces than coracoid at 60 of AB and the abduction and external rotation (ABER)
e481
position, giving insight into what this similarity in radius of curvature may translate into in terms of biomechanics. We have presented our preferred technique for the DTA procedure after failed Latarjet. To further advance this technique, randomized controlled clinical trials are needed. With sufficient long-term follow-up of large patient cohorts, the usefulness of DTA will be evident. Ultimately, the DTA may develop into a viable primary treatment option for recurrent anterior glenohumeral instability with confirmation of positive, long-term treatment outcomes.
References 1. Ciais G, Klouche S, Fournier A, Rousseau B, Bauer T, Hardy P. Bony defects in chronic anterior posttraumatic dislocation of the shoulder: Is there a correlation between humeral and glenoidal lesions? Eur J Orthop Surg Traumatol 2016;26:581-586. 2. Emami MJ, Solooki S, Meshksari Z, Vosoughi AR. The effect of open Bristow-Latarjet procedure for anterior shoulder instability: A 10-year study. Musculoskelet Surg 2011;95:231-235. 3. Dauzère F, Faraud A, Lebon J, Faruch M, Mansat P, Bonnevialle N. Is the Latarjet procedure risky? Analysis of complications and learning curve. Knee Surg Sports Traumatol Arthrosc 2016;24:557-563. 4. Mazzocca AD, Cote MP, Solovyova O, Rizvi SH, Mostofi A, Arciero RA. Traumatic shoulder instability involving anterior, inferior, and posterior labral injury: A prospective clinical evaluation of arthroscopic repair of 270 labral tears. Am J Sports Med 2011;39:1687-1696. 5. Alvi HM, Monroe EJ, Muriuki M, Verma RN, Marra G, Saltzman MD. Latarjet fixation: A cadaveric biomechanical study evaluating cortical and cannulated screw fixation. Orthop J Sports Med 2016;4:2325967116643533. 6. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am 2003;85:878-884. 7. Decker MM, Strohmeyer GC, Wood JP, et al. Distal tibia allograft for glenohumeral instability: Does radius of curvature match? J Shoulder Elbow Surg 2016;25:15421548. 8. Young DC, Rockwood CA. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am 1991;73:969-981. 9. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89:1470-1477. 10. da Silva LA, da Costa Lima ÁG, Kautsky RM, Santos PD, do Val Sella G, Checchia SL. Evaluation of the results and complications of the Latarjet procedure for recurrent anterior dislocation of the shoulder. Rev Bras Ortop Engl Ed 2015;50:652-659. 11. Gwathmey FW, Warner JJP. Management of the athlete with a failed shoulder instability procedure. Clin Sports Med 2013;32:833-886. 12. Provencher MT, Ghodadra N, LeClere L, Solomon DJ, Romeo AA. Anatomic osteochondral glenoid
e482
13.
14.
15.
16.
A. SANCHEZ ET AL.
reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy 2009;25:446-452. Waterman BR, Chandler PJ, Teague E, Provencher MT, Tokish JM, Pallis MP. Short-term outcomes of glenoid bone block augmentation for complex anterior shoulder instability in a high-risk population. Arthroscopy 2016;32:1784-1790. An VVG, Sivakumar BS, Phan K, Trantalis J. A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair. J Shoulder Elbow Surg 2016;25: 853-863. Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature. Arthroscopy 2014;30:1184-1211. Millett PJ, Schoenahl JY, Register B, Gaskill TR, van Deurzen DF, Martetschläger F. Reconstruction of posterior glenoid deficiency using distal tibial osteoarticular
17.
18.
19.
20.
allograft. Knee Surg Sports Traumatol Arthrosc 2013;21: 445-449. Provencher MT, LeClere LE, Ghodadra N, Solomon DJ. Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head. J Shoulder Elbow Surg 2010;19:e6-e11. Dehaan A, Munch J, Durkan M, Yoo J, Crawford D. Reconstruction of a bony Bankart lesion: Best fit based on radius of curvature. Am J Sports Med 2013;41:1140-1145. Rios D, Jansson KS, Martetschläger F, Boykin RE, Millett PJ, Wijdicks CA. Normal curvature of glenoid surface can be restored when performing an inlay osteochondral allograft: An anatomic computed tomographic comparison. Knee Surg Sports Traumatol Arthrosc 2014;22: 442-447. Bhatia S, Van Thiel GS, Gupta D, et al. Comparison of glenohumeral contact pressures and contact areas after glenoid reconstruction with Latarjet or distal tibial osteochondral allografts. Am J Sports Med 2013;41:19001908.