- Email: [email protected]
Failed Latarjet procedure treated with a revision bone block stabilization using a suture-button fixation
ARTICLE IN PRESS J Shoulder Elbow Surg (2017) ■■, ■■–■■
www.elsevier.com/locate/ymse
CASE REPORTS
Failed Latarjet procedure treated with a revision bone block stabilization using a suture-button fixation Graham M. Tytherleigh-Strong, FRCS(Orth)*, David I. Morrissey, FRCS(Orth) Division of Orthopaedics, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Cambridge, UK Keywords: Instability; Failed Latarjet; bone loss; auto-graft; suture-button fixation; revision Eden-Hybinette
Failure, in the form of recurrent instability after a Latarjet procedure, is rare.18 However, when it does occur, it presents as a challenging problem. One particular issue can be with glenoid bone stock. A Latarjet procedure may often have been undertaken after a failed soft-tissue stabilization where suture anchors have been used. As a result, there are often a number of pre-existing anchor defects and voids within the glenoid, potentially compromising further boney fixation with screws at the time of revision surgery. We describe the case of a patient with a failed Latarjet procedure that had originally been undertaken for a failed softtissue Bankart repair. As well as having 5 boney voids in the glenoid, from previous bioabsorbable anchors, the screw shafts from the Latarjet had also broken off, further compromising available bone stock.
Case report A 17-year-old right-handed rugby player presented to our department with recurrent instability of his left shoulder. At the age of 14, he sustained a traumatic anterior shoulder dislocation with a second dislocation, and magnetic resonance Informed consent was obtained from the patient in this case report *Reprint requests: Graham M. Tytherleigh-Strong, Division of Orthopaedics, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Hills Rd, Cambridge CB2 2QQ, UK. E-mail address: [email protected] (G.M. Tytherleigh-Strong). 1058-2746/$ - see front matter Crown Copyright © 2017 All rights reserved. http://dx.doi.org/10.1016/j.jse.2017.01.004
imaging demonstrated a soft-tissue Bankart tear. The patient underwent treatment by an arthroscopic soft-tissue stabilization using 3 biocomposite suture anchors. After surgery, he rehabilitated his shoulder and returned to full contact play at the beginning of the next rugby season, 9 months later. Unfortunately, he suffered a further traumatic anterior dislocation and continued to suffer symptoms of instability. An MRI scan showed a further Bankart tear, but with some anterior glenoid bone loss. A coracoid transfer was subsequently undertaken in the form of an open Latarjet procedure in which 2 cannulated, partially threaded lag-screws were used to hold the bone block. The capsule was reattached using 2 biocomposite suture anchors. He rehabilitated his shoulder and returned to contact training, but began to develop a feeling of instability and sustained a further anterior dislocation while playing rugby 8 months after the revision surgery. At the time of his presentation to our institution, his shoulder had dislocated on 2 further occasions, and he was experiencing symptoms of instability. On examination he had a Beighton Score of 1 and was extremely apprehensive as soon as he brought his arm up into abduction and external rotation.3 He had lost the last 15° of external rotation, compared with the right side, but had otherwise maintained a full range of motion. His rotator cuff appeared intact, but he had a positive apprehension and relocation test. Plain radiographs showed that the coracoid bone graft had failed to unite and had pulled off anteriorly. The lag screws had partly pulled out of the glenoid and were broken at the
ARTICLE IN PRESS 2
G.M. Tytherleigh-Strong, D.I. Morrissey
Figure 1 (A and B) Preoperative anteroposterior and axillary view x-rays demonstrate nonunion and pulling off of the coracoid bone graft, with the broken shafts of the screws left in the glenoid. (C and D) Preoperative coronal and axial computed tomography images of the anterior edge of the glenoid demonstrate the ends of the broken screws and multiple bone voids from previous suture anchors.
anterior edge of the glenoid at the junction between the shaft and the threaded portion. A computed tomography (CT) scan of the shoulder confirmed these findings with bone loss of the anterior inferior glenoid. Coronal cuts at the anterior edge of the glenoid demonstrated the ends of the 2 broken screws with multiple bone voids that were presumed to be from the previous biocomposite anchors (Fig. 1). The senior author (G.M.T.-S.) had previously used an open modified Eden-Hybinette procedure, as described by Lunn et al,17 to treat patients with a failed Latarjet procedure with good success. In this case, the presence of broken screws and multiple bone voids would impair our ability to successfully use this technique in a standard fashion. Our concerns were that attempting to remove the broken screws would be likely to result in even further bone loss and that fixing the bone block around the broken screws would compromise the position of the bone block and further decrease the glenoid bone stock available for healing. In light of the above, we decided to undertake the EdenHybinette procedure using a suture-button technique rather than with screw fixation. This is a commercially produced system (Smith & Nephew, Andover, MA, USA) that has recently been described and used by Boileau et al5 to secure the coracoid bone block during an arthroscopic Latarjet procedure. The fixation device consists of 2 purposedesigned titanium cortical buttons used with a No. 3-4
ultrahigh-molecular-weight polyethylene suture sling running through them.
Surgical procedure Having discussed the surgical options with the patient and his parents, and having obtained consent, we undertook an open Eden-Hybinette procedure using a double suturebutton fixation. The patient was anesthetized with a general anesthetic and an interscalene nerve block. Prophylactic antibiotics were given. He was positioned in the beach chair with the posterior section of the bed removed to allow access to the posterior shoulder. The shoulder and the ipsilateral iliac crest were prepared and draped in the standard fashion. Dissection began through the previous anterior incision and was taken down through the deltopectoral groove. The coracoid tip, with the broken screws, and the conjoined tendon were identified within the previous subscapularis split. The broken screw ends were removed, the remnant of coracoid bone was resected, and the tagged conjoined tendon was mobilized. The subscapularis split was then opened, and the anterior glenoid and front of the joint was exposed. The anterior glenoid was lightly decorticated down to bleeding bone, revealing the ends of the broken screws and the partly resorbed bodies of the previous anchors. The residual
ARTICLE IN PRESS Failed Latarjet treated with bone block anchor material was removed, and the remaining defects curetted. The iliac bone graft was then taken using a standard technique. A tricortical bone graft measuring 20 mm long and 10 mm deep was harvested using osteotomes. The graft was positioned in a specifically designed clamp, and two 2-mm holes were drilled through the graft, 12 mm apart. A spinal needle was inserted posteriorly into the glenohumeral joint and passed anteriorly, parallel to the glenoid articular surface. Through a 1-cm incision, in line with the needle, the drill guide was inserted through the joint, and the hooked tip of the guide, which is 5 mm long, was positioned on the anterior edge of the glenoid to initially drill the inferior hole. A slightly longer second posterior incision was made 2 cm medial to the stab incision. Two transverse splits were made in the infraspinatus, in line with the fibers, and dissection was taken down to the back of the glenoid to allow the 2 drill guides for the jig to be inserted down on to the bone. The whole assembly was then ratcheted down (Fig. 2). A specially designed 2.5-mm drill bit with an outer sleeve was drilled through the glenoid to emerge at the tip of the jig. The drill was removed and the sleeve left in situ. When it came to drilling the superior hole, the end of the inferior cannulated broken screw was exactly 12 mm above the inferior drill hole. It was possible to pass the unsleeved drill bit through the lumen of the broken screw and then to drill through the glenoid behind it, with the drill exiting through the medial posterior incision. The suture tail ends of 2 suture-button implants were passed through the prepared drill holes in the iliac bone graft. A
3 suture-grasping device passed from the back and through the drill holes in the glenoid was used to grasp the suture tails, which were pulled through. The suture tails were pulled from the back, and the bone graft was docked onto the front of the glenoid. A metal suture button was then threaded over the suture tails and passed down onto the posterior glenoid. After a sliding knot was passed, a tensioning device was used to tighten the suture-button devices to 100 N. Locking knots were tied to secure the implants. At the end of the procedure, the bone graft was securely positioned on the anterior glenoid, flush to the articular cartilage. Because of concerns about the lack of glenoid bone stock, no attempt was made to repair the remnants of the anterior capsule, negating the use of anchors. The subscapularis split was closed with interrupted sutures. The stump of the conjoined tendon was sutured onto the front of the repaired subscapularis. The fat layer and skin were closed in layers.
Postoperative outcome Postoperatively, the patient’s shoulder was immobilized in a sling for 3 weeks. He then underwent a standard stabilization rehabilitation program. Postoperative check x-rays showed the bone block was in a satisfactory position, with the suture buttons positioned anteriorly and posteriorly. A CT scan at 6 months demonstrated that the bone graft had united satisfactorily (Fig. 3). At the patient’s most recent follow-up, 18 months after the operation, his shoulder appeared stable. He had lost the last 5° of external rotation, compared with the right side, but
Figure 2 (A and B) Inferior axial and sagittal view of the jig in position with the drill guides inserted (Smith & Nephew, Andover, MA, USA). (C and D) Diagram of the bone block in position with knots being tied over the posterior buttons (Smith & Nephew).
ARTICLE IN PRESS 4
G.M. Tytherleigh-Strong, D.I. Morrissey
Figure 3 (A and B) Postoperative anteroposterior and axillary x-rays at 6 months demonstrate the iliac crest bone graft held in position by the 2 suture-button devices. The broken screw shafts are still present. (C and D) Axillary view computed tomography scans demonstrate union of the bone block at the level of the inferior button and the tract through which the superior suture-button device passed through the center of the broken screw shaft.
otherwise had regained all other movements. He had no weakness on testing his rotator cuff strength and had no evidence of instability on the apprehension or relocation tests. He considered his shoulder was now stable, and he had been able to return to all sporting activities. However, he had decided to give up playing rugby.
Discussion The Latarjet procedure was initially described in 1954, and multiple modifications have since been described.15 It has become increasingly popular for the treatment of more complex shoulder instability. Its mechanism of action is thought to be 3-fold. It increases the arc of bony glenoid congruence, reconstitutes the anterior capsule, and as a result of the repositioning of the conjoined tendon, provides a dynamic sling effect. It has a favorably low rate of recurrence compared with anatomic soft-tissue procedures. This is tempered, however, by a relatively high complication rate. In the case described here, the initial management of the patient was an arthroscopic Bankart repair using suture anchors. He had become a recurrent dislocator after an initial traumatic anterior dislocation with an MRI-proven soft-tissue
Bankart tear and minimal bone loss. Several studies have shown that the recurrence rate after a soft-tissue Bankart repair is higher in patients who return to contact sports. A recent systematic review by Leroux et al16 found that the pooled failure rate for contact or collision athletes was 17.8%. Despite this, undertaking a soft-tissue stabilization for this patient would have been considered entirely reasonable, particularly considering his age (17 years). The management of a patient with a failed soft-tissue Bankart repair can be challenging. More recently there has been a general move toward an anatomic reconstruction of the anterior glenoid surface using a bone-block technique rather than a revision soft-tissue repair.20 The most popular are variations of the open Latarjet procedure,11,12 Eden-Hybinette procedure7,23 or a J-Graft procedure.2 Arthroscopic boneblock procedures have also been described for the Latarjet4,14 and the Eden-Hybinette22 procedures. The perceived advantage of a Latarjet procedure over the others is the “dynamicsling” effect of the conjoint tendon and that the coracoid tip is also a local, autologous transfer, thus avoiding potential donor site morbidity. However, the Latarjet procedure is more technically demanding, has an increased risk of neurovascular complications, and leaves the coracoid tip and conjoined tendon in a nonanatomic position.1,10,12
ARTICLE IN PRESS Failed Latarjet treated with bone block Failure of a bone-block procedure, in the form of recurrent instability, presents an even more challenging problem. If a revision procedure is to be undertaken, consideration of pre-existing anchors, metalwork, glenoid bone loss, and scar formation, particularly around neurovascular structures, must be considered.9 As well as this, loss or incompetence of the remaining capsule and whether a coracoid transfer has previously been undertaken need to be taken into account. In a multicenter study of 76 patients who underwent revision surgery for recurrent instability, 17 patients were treated with a modified Eden-Hybinette procedure for a failed Latarjet. None of the patients were reported as having a subsequent recurrence.21 The series reported by Lunn et al17 describes the results of 34 patients who underwent a modified EdenHybinette procedure as a salvage for a failed Latarjet procedure. At an average follow-up of 6.8 years, a recurrent dislocation had occurred in 4 patients, with 90% of the patients rating their shoulder as excellent or good.17 Problems with metalwork and screws after a coracoid transfer and bone-block procedures are relatively frequent and are recognized as the main source of intraoperative and postoperative complications during these procedures.6,13 Removal of metalwork is the most common reason for a further operative procedure after a Latarjet stabilization.10 Recently, in response to this, an interest has been taken in using a suturebutton device to secure the bone graft instead of screws. This has the advantage of requiring smaller drill holes to pass the sutures through the glenoid, preserving glenoid bone stock, not compromising the glenoid articular surface, and avoiding most of the complications caused by screws. Gendre et al8 recently published a series of 70 patients, half having undergone a Latarjet procedure and half having undergone a Bristow procedure, in which the coracoid bone block was fixed using a suture-button device. At 6 months, bone union was confirmed by CT scan in 91% of the Latarjet procedures and in 74% of the Bristow procedures. No neurologic or hardware complications that would classically be associated with screw fixation were encountered. A series of 76 patients who underwent an arthroscopic Latarjet procedure using a commercially available guided surgical approach and suture-button fixation system has been reported by Boileau et al.5 At a mean of 14 months postoperatively, 75 of the 76 patients had a stable shoulder, 91% of the coracoid grafts had healed on CT imaging, and none of the neurologic or hardware complications associated with screw fixation had occurred. A biomechanical evaluation of the median ultimate load to failure of 2 bicortical malleolar screws used to fix the coracoid bone graft in a Latarjet procedure was 202 N (range, 95300 N).24 In comparison, the load to failure using a cortical button fixation device for anterior cruciate ligament reconstruction was up to 800 N.19 A similar ultimate load to failure for the suture-button fixation device used in the reported case has been claimed (unpublished data from Smith & Nephew). In the patient reported here, our major concern was with the broken screw shafts in the glenoid. Problems with pulled
5 out and bent screws after a failed bone-block procedure are not uncommon but are relatively easy to address. We felt an attempt to extract the broken screws might result in significant glenoid bone loss and trying to insert new screws around the broken shafts would compromise the position of our bone block. Because of these concerns, we chose to undertake a revision Eden-Hybinette procedure using a guided suturebutton fixation system. We can find no reported case of a revision procedure where both of the screw shafts have broken in the glenoid. At the time of the procedure, we were impressed with how well the drill guide and suture-button system worked. We were able to very accurately position the inferior drill hole, avoiding the broken screw shaft, and to then precisely pass the guidewire and suture through the broken cannulated screw superiorly. Postoperatively, CT at 6 months showed the bone graft had united, and there had been no specific complications at the 18-month follow-up. It may be worth considering the use of this technique for primary repairs; certainly, this would have averted the complication that we encountered.
Conclusion Management of a failed Latarjet procedure presents a challenging problem. In the patient reported here, the presence of broken screws within the glenoid added to this. The option of using a suture-button fixation system to fix the bone block during the revision Eden-Hybinette procedure enabled us to achieve a successful result without further compromising the glenoid bone stock.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-52. 2. Auffarth A, Schauer J, Matis N, Kofler B, Hitzl W, Reach H. The J-bone graft for anatomical glenoid reconstruction for recurrent posttraumatic anterior shoulder dislocation. Am J Sports Med 2008;36:638-47. http://dx.doi.org/10.1177/0363546507309672 3. Beighton PH, Solomon L, Sosklone CL. Articular mobility in an African population. Ann Rheum Dis 1973;32:413-7. 4. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: the “belt-and-suspenders” operative technique and
ARTICLE IN PRESS 6
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
G.M. Tytherleigh-Strong, D.I. Morrissey preliminary results. Arthroscopy 2007;23:593-601. http://dx.doi.org/ 10.1016/j.arthro.2007.03.096 Boileau P, Gendre P, Baba M, Thelu CE, Baring T, Gonzalez JF, et al. A guided surgical approach and novel fixation method for arthroscopic Latarjet. J Shoulder Elbow Surg 2016;25:78-89. http://dx.doi.org/ 10.1016/j.jse.2015.06.001 Butt U, Charalambous CP. Complications associated with open coracoid transfer procedures for shoulder instability: A Systematic Review of Early Results. J Shoulder Elbow Surg 2012;21:1110-9. http://dx.doi.org/ 10.1016/j.arthro.2012.11.022 Gebhard F, Draeger M, Steinmann R, Hoellen I, Hartel W. Functional outcome of Eden-Hybinette-Lange operation in post-traumatic recurrent shoulder dislocation. Unfallchirurg 1997;100:770-5. Gendre P, Thélu CE, d’Ollone T, Trojani C, Gonzalez JF, Boileau P. Coracoid bone block fixation with cortical buttons: an alternative to screw fixation? Orthop Traumatol Surg Res 2016;102:983-7. http://dx.doi.org/ 10.1016/j.otsr.2016.06.016 Giannakos A, Vezeridis PS, Schwartz DG, Jany R, Lafosse L. Allarthroscopic revision Eden-Hybinette procedure for failed instability surgery: technique and preliminary results. Arthroscopy 2016;16:30255-9. http://dx.doi.org/10.1016/j.arthro.2016.05.021 Griesser MJ, Harris JD, McCoy BW, Hussain WM, Jones MH, Bishop JY, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg 2013;22:28692. http://dx.doi.org/10.1016/j.jse.2012.09.009 Hovelius L, Sandström B, Olfsson A, Svensson O, Rahme H. The effect of capsular repair, bone block healing and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders. J Shoulder Elbow Surg 2012;21:647-60. http://dx.doi.org/ 10.1016/j.jse.2011.03.020 Hovelius L, Sandström B, Saebö M. One hundred eighteen BristowLatarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg 2006;15:279-89. http://dx.doi.org/10.1016/j.jse.2005.09.014 Hovelius L, Vikerfors O, Olfsson A, Svensson O, Rahme H. Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up. J Shoulder Elbow Surg 2011;20:1095-101. http://dx.doi.org/10.1016/ j.jse.2011.02.005 Lafosse L, Boyle S. Arthroscopic Latarjet procedure. J Shoulder Elbow Surg 2010;19:2-12. http://dx.doi.org/10.1016/j.ocl.2010.02.004
15. Latarjet M. Treatment of recurrent dislocation of the shoulder. Lyon Chir 1954;49:994-7. 16. Leroux TS, Saltzman BM, Meyer M, Frank RM, Bach BR Jr, Cole BJ, et al. The influence of evidence based surgical indications and techniques on failure rates after arthroscopic shoulder stabilization in contact or collision athletes with anterior shoulder instability [e-pub ahead of print]. Am J Sports Med 2016 [Epub ahead of print] http://dx.doi.org/10.1177/ 0363546516663716 17. Lunn JV, Castellano-Rosa J, Walch G. Recurrent anterior dislocation after the Latarjet procedure: outcome after revision using a modified Eden-Hybinette operation. J Shoulder Elbow Surg 2008;17:744-50. http://dx.doi.org/10.1016/j.jse.2008.03.002 18. Mizuno N, Denard PJ, Raiss P, Melis B, Walch G. Long-term results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg 2014;23:1691-9. http://dx.doi.org/10.1016/ j.jse.2014.02.015 19. Petre BM, Smith SD, Jansson KS, de Meijier PP, Hacket TR, LePrade RF, et al. Femoral cortical suspension devices for soft-tissue anterior cruciate ligament reconstruction: a comparative biomechanical study. Am J Sports Med 2013;41:416-22. http://dx.doi.org/10.1177/ 0363546512469875 20. Provencher MT, Bhatia S, Ghodadra NS, Grumet RC, Bach BR, Dewing CB, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am 2010;92:133-51. http://dx.doi.org/10.2106/JBJS.J.00906 21. Rouxel Y, Rolland E, Saillant G. Postoperative recurrence: results of surgical revisions. Rev Chir Orthop Reparatrice Appar Mot 2000; 86(Suppl 1):137-47. 22. Taverna E, Golano P, Pascale V, Battistella F. An arthroscopic bone graft procedure for treating anterior-inferior glenohumeral instability. Knee Surg Sports Traumatol Arthrosc 2008;16:872-5. http://dx.doi.org/ 10.1007/s00167-008-0541-y 23. Warner JP, Gill TJ, O’Hollerhan JD, Pathare N, Millett PJ. Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med 2006;34:205-12. http://dx.doi.org/10.1177/ 0363546505281798 24. Weppe F, Magnussen RA, Lustig S, Demey G, Neyret P, Servien E. A biomechanical evaluation of bicortical metal screw fixation versus absorbable interference screw fixation after coracoid transfer for anterior shoulder instability. Arthroscopy 2011;27:1358-63. http://dx.doi.org/ 10.1016/j.arthro.2011.03.074
www.elsevier.com/locate/ymse
CASE REPORTS
Failed Latarjet procedure treated with a revision bone block stabilization using a suture-button fixation Graham M. Tytherleigh-Strong, FRCS(Orth)*, David I. Morrissey, FRCS(Orth) Division of Orthopaedics, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Cambridge, UK Keywords: Instability; Failed Latarjet; bone loss; auto-graft; suture-button fixation; revision Eden-Hybinette
Failure, in the form of recurrent instability after a Latarjet procedure, is rare.18 However, when it does occur, it presents as a challenging problem. One particular issue can be with glenoid bone stock. A Latarjet procedure may often have been undertaken after a failed soft-tissue stabilization where suture anchors have been used. As a result, there are often a number of pre-existing anchor defects and voids within the glenoid, potentially compromising further boney fixation with screws at the time of revision surgery. We describe the case of a patient with a failed Latarjet procedure that had originally been undertaken for a failed softtissue Bankart repair. As well as having 5 boney voids in the glenoid, from previous bioabsorbable anchors, the screw shafts from the Latarjet had also broken off, further compromising available bone stock.
Case report A 17-year-old right-handed rugby player presented to our department with recurrent instability of his left shoulder. At the age of 14, he sustained a traumatic anterior shoulder dislocation with a second dislocation, and magnetic resonance Informed consent was obtained from the patient in this case report *Reprint requests: Graham M. Tytherleigh-Strong, Division of Orthopaedics, Addenbrooke’s Hospital, Cambridge University Hospitals Trust, Hills Rd, Cambridge CB2 2QQ, UK. E-mail address: [email protected] (G.M. Tytherleigh-Strong). 1058-2746/$ - see front matter Crown Copyright © 2017 All rights reserved. http://dx.doi.org/10.1016/j.jse.2017.01.004
imaging demonstrated a soft-tissue Bankart tear. The patient underwent treatment by an arthroscopic soft-tissue stabilization using 3 biocomposite suture anchors. After surgery, he rehabilitated his shoulder and returned to full contact play at the beginning of the next rugby season, 9 months later. Unfortunately, he suffered a further traumatic anterior dislocation and continued to suffer symptoms of instability. An MRI scan showed a further Bankart tear, but with some anterior glenoid bone loss. A coracoid transfer was subsequently undertaken in the form of an open Latarjet procedure in which 2 cannulated, partially threaded lag-screws were used to hold the bone block. The capsule was reattached using 2 biocomposite suture anchors. He rehabilitated his shoulder and returned to contact training, but began to develop a feeling of instability and sustained a further anterior dislocation while playing rugby 8 months after the revision surgery. At the time of his presentation to our institution, his shoulder had dislocated on 2 further occasions, and he was experiencing symptoms of instability. On examination he had a Beighton Score of 1 and was extremely apprehensive as soon as he brought his arm up into abduction and external rotation.3 He had lost the last 15° of external rotation, compared with the right side, but had otherwise maintained a full range of motion. His rotator cuff appeared intact, but he had a positive apprehension and relocation test. Plain radiographs showed that the coracoid bone graft had failed to unite and had pulled off anteriorly. The lag screws had partly pulled out of the glenoid and were broken at the
ARTICLE IN PRESS 2
G.M. Tytherleigh-Strong, D.I. Morrissey
Figure 1 (A and B) Preoperative anteroposterior and axillary view x-rays demonstrate nonunion and pulling off of the coracoid bone graft, with the broken shafts of the screws left in the glenoid. (C and D) Preoperative coronal and axial computed tomography images of the anterior edge of the glenoid demonstrate the ends of the broken screws and multiple bone voids from previous suture anchors.
anterior edge of the glenoid at the junction between the shaft and the threaded portion. A computed tomography (CT) scan of the shoulder confirmed these findings with bone loss of the anterior inferior glenoid. Coronal cuts at the anterior edge of the glenoid demonstrated the ends of the 2 broken screws with multiple bone voids that were presumed to be from the previous biocomposite anchors (Fig. 1). The senior author (G.M.T.-S.) had previously used an open modified Eden-Hybinette procedure, as described by Lunn et al,17 to treat patients with a failed Latarjet procedure with good success. In this case, the presence of broken screws and multiple bone voids would impair our ability to successfully use this technique in a standard fashion. Our concerns were that attempting to remove the broken screws would be likely to result in even further bone loss and that fixing the bone block around the broken screws would compromise the position of the bone block and further decrease the glenoid bone stock available for healing. In light of the above, we decided to undertake the EdenHybinette procedure using a suture-button technique rather than with screw fixation. This is a commercially produced system (Smith & Nephew, Andover, MA, USA) that has recently been described and used by Boileau et al5 to secure the coracoid bone block during an arthroscopic Latarjet procedure. The fixation device consists of 2 purposedesigned titanium cortical buttons used with a No. 3-4
ultrahigh-molecular-weight polyethylene suture sling running through them.
Surgical procedure Having discussed the surgical options with the patient and his parents, and having obtained consent, we undertook an open Eden-Hybinette procedure using a double suturebutton fixation. The patient was anesthetized with a general anesthetic and an interscalene nerve block. Prophylactic antibiotics were given. He was positioned in the beach chair with the posterior section of the bed removed to allow access to the posterior shoulder. The shoulder and the ipsilateral iliac crest were prepared and draped in the standard fashion. Dissection began through the previous anterior incision and was taken down through the deltopectoral groove. The coracoid tip, with the broken screws, and the conjoined tendon were identified within the previous subscapularis split. The broken screw ends were removed, the remnant of coracoid bone was resected, and the tagged conjoined tendon was mobilized. The subscapularis split was then opened, and the anterior glenoid and front of the joint was exposed. The anterior glenoid was lightly decorticated down to bleeding bone, revealing the ends of the broken screws and the partly resorbed bodies of the previous anchors. The residual
ARTICLE IN PRESS Failed Latarjet treated with bone block anchor material was removed, and the remaining defects curetted. The iliac bone graft was then taken using a standard technique. A tricortical bone graft measuring 20 mm long and 10 mm deep was harvested using osteotomes. The graft was positioned in a specifically designed clamp, and two 2-mm holes were drilled through the graft, 12 mm apart. A spinal needle was inserted posteriorly into the glenohumeral joint and passed anteriorly, parallel to the glenoid articular surface. Through a 1-cm incision, in line with the needle, the drill guide was inserted through the joint, and the hooked tip of the guide, which is 5 mm long, was positioned on the anterior edge of the glenoid to initially drill the inferior hole. A slightly longer second posterior incision was made 2 cm medial to the stab incision. Two transverse splits were made in the infraspinatus, in line with the fibers, and dissection was taken down to the back of the glenoid to allow the 2 drill guides for the jig to be inserted down on to the bone. The whole assembly was then ratcheted down (Fig. 2). A specially designed 2.5-mm drill bit with an outer sleeve was drilled through the glenoid to emerge at the tip of the jig. The drill was removed and the sleeve left in situ. When it came to drilling the superior hole, the end of the inferior cannulated broken screw was exactly 12 mm above the inferior drill hole. It was possible to pass the unsleeved drill bit through the lumen of the broken screw and then to drill through the glenoid behind it, with the drill exiting through the medial posterior incision. The suture tail ends of 2 suture-button implants were passed through the prepared drill holes in the iliac bone graft. A
3 suture-grasping device passed from the back and through the drill holes in the glenoid was used to grasp the suture tails, which were pulled through. The suture tails were pulled from the back, and the bone graft was docked onto the front of the glenoid. A metal suture button was then threaded over the suture tails and passed down onto the posterior glenoid. After a sliding knot was passed, a tensioning device was used to tighten the suture-button devices to 100 N. Locking knots were tied to secure the implants. At the end of the procedure, the bone graft was securely positioned on the anterior glenoid, flush to the articular cartilage. Because of concerns about the lack of glenoid bone stock, no attempt was made to repair the remnants of the anterior capsule, negating the use of anchors. The subscapularis split was closed with interrupted sutures. The stump of the conjoined tendon was sutured onto the front of the repaired subscapularis. The fat layer and skin were closed in layers.
Postoperative outcome Postoperatively, the patient’s shoulder was immobilized in a sling for 3 weeks. He then underwent a standard stabilization rehabilitation program. Postoperative check x-rays showed the bone block was in a satisfactory position, with the suture buttons positioned anteriorly and posteriorly. A CT scan at 6 months demonstrated that the bone graft had united satisfactorily (Fig. 3). At the patient’s most recent follow-up, 18 months after the operation, his shoulder appeared stable. He had lost the last 5° of external rotation, compared with the right side, but
Figure 2 (A and B) Inferior axial and sagittal view of the jig in position with the drill guides inserted (Smith & Nephew, Andover, MA, USA). (C and D) Diagram of the bone block in position with knots being tied over the posterior buttons (Smith & Nephew).
ARTICLE IN PRESS 4
G.M. Tytherleigh-Strong, D.I. Morrissey
Figure 3 (A and B) Postoperative anteroposterior and axillary x-rays at 6 months demonstrate the iliac crest bone graft held in position by the 2 suture-button devices. The broken screw shafts are still present. (C and D) Axillary view computed tomography scans demonstrate union of the bone block at the level of the inferior button and the tract through which the superior suture-button device passed through the center of the broken screw shaft.
otherwise had regained all other movements. He had no weakness on testing his rotator cuff strength and had no evidence of instability on the apprehension or relocation tests. He considered his shoulder was now stable, and he had been able to return to all sporting activities. However, he had decided to give up playing rugby.
Discussion The Latarjet procedure was initially described in 1954, and multiple modifications have since been described.15 It has become increasingly popular for the treatment of more complex shoulder instability. Its mechanism of action is thought to be 3-fold. It increases the arc of bony glenoid congruence, reconstitutes the anterior capsule, and as a result of the repositioning of the conjoined tendon, provides a dynamic sling effect. It has a favorably low rate of recurrence compared with anatomic soft-tissue procedures. This is tempered, however, by a relatively high complication rate. In the case described here, the initial management of the patient was an arthroscopic Bankart repair using suture anchors. He had become a recurrent dislocator after an initial traumatic anterior dislocation with an MRI-proven soft-tissue
Bankart tear and minimal bone loss. Several studies have shown that the recurrence rate after a soft-tissue Bankart repair is higher in patients who return to contact sports. A recent systematic review by Leroux et al16 found that the pooled failure rate for contact or collision athletes was 17.8%. Despite this, undertaking a soft-tissue stabilization for this patient would have been considered entirely reasonable, particularly considering his age (17 years). The management of a patient with a failed soft-tissue Bankart repair can be challenging. More recently there has been a general move toward an anatomic reconstruction of the anterior glenoid surface using a bone-block technique rather than a revision soft-tissue repair.20 The most popular are variations of the open Latarjet procedure,11,12 Eden-Hybinette procedure7,23 or a J-Graft procedure.2 Arthroscopic boneblock procedures have also been described for the Latarjet4,14 and the Eden-Hybinette22 procedures. The perceived advantage of a Latarjet procedure over the others is the “dynamicsling” effect of the conjoint tendon and that the coracoid tip is also a local, autologous transfer, thus avoiding potential donor site morbidity. However, the Latarjet procedure is more technically demanding, has an increased risk of neurovascular complications, and leaves the coracoid tip and conjoined tendon in a nonanatomic position.1,10,12
ARTICLE IN PRESS Failed Latarjet treated with bone block Failure of a bone-block procedure, in the form of recurrent instability, presents an even more challenging problem. If a revision procedure is to be undertaken, consideration of pre-existing anchors, metalwork, glenoid bone loss, and scar formation, particularly around neurovascular structures, must be considered.9 As well as this, loss or incompetence of the remaining capsule and whether a coracoid transfer has previously been undertaken need to be taken into account. In a multicenter study of 76 patients who underwent revision surgery for recurrent instability, 17 patients were treated with a modified Eden-Hybinette procedure for a failed Latarjet. None of the patients were reported as having a subsequent recurrence.21 The series reported by Lunn et al17 describes the results of 34 patients who underwent a modified EdenHybinette procedure as a salvage for a failed Latarjet procedure. At an average follow-up of 6.8 years, a recurrent dislocation had occurred in 4 patients, with 90% of the patients rating their shoulder as excellent or good.17 Problems with metalwork and screws after a coracoid transfer and bone-block procedures are relatively frequent and are recognized as the main source of intraoperative and postoperative complications during these procedures.6,13 Removal of metalwork is the most common reason for a further operative procedure after a Latarjet stabilization.10 Recently, in response to this, an interest has been taken in using a suturebutton device to secure the bone graft instead of screws. This has the advantage of requiring smaller drill holes to pass the sutures through the glenoid, preserving glenoid bone stock, not compromising the glenoid articular surface, and avoiding most of the complications caused by screws. Gendre et al8 recently published a series of 70 patients, half having undergone a Latarjet procedure and half having undergone a Bristow procedure, in which the coracoid bone block was fixed using a suture-button device. At 6 months, bone union was confirmed by CT scan in 91% of the Latarjet procedures and in 74% of the Bristow procedures. No neurologic or hardware complications that would classically be associated with screw fixation were encountered. A series of 76 patients who underwent an arthroscopic Latarjet procedure using a commercially available guided surgical approach and suture-button fixation system has been reported by Boileau et al.5 At a mean of 14 months postoperatively, 75 of the 76 patients had a stable shoulder, 91% of the coracoid grafts had healed on CT imaging, and none of the neurologic or hardware complications associated with screw fixation had occurred. A biomechanical evaluation of the median ultimate load to failure of 2 bicortical malleolar screws used to fix the coracoid bone graft in a Latarjet procedure was 202 N (range, 95300 N).24 In comparison, the load to failure using a cortical button fixation device for anterior cruciate ligament reconstruction was up to 800 N.19 A similar ultimate load to failure for the suture-button fixation device used in the reported case has been claimed (unpublished data from Smith & Nephew). In the patient reported here, our major concern was with the broken screw shafts in the glenoid. Problems with pulled
5 out and bent screws after a failed bone-block procedure are not uncommon but are relatively easy to address. We felt an attempt to extract the broken screws might result in significant glenoid bone loss and trying to insert new screws around the broken shafts would compromise the position of our bone block. Because of these concerns, we chose to undertake a revision Eden-Hybinette procedure using a guided suturebutton fixation system. We can find no reported case of a revision procedure where both of the screw shafts have broken in the glenoid. At the time of the procedure, we were impressed with how well the drill guide and suture-button system worked. We were able to very accurately position the inferior drill hole, avoiding the broken screw shaft, and to then precisely pass the guidewire and suture through the broken cannulated screw superiorly. Postoperatively, CT at 6 months showed the bone graft had united, and there had been no specific complications at the 18-month follow-up. It may be worth considering the use of this technique for primary repairs; certainly, this would have averted the complication that we encountered.
Conclusion Management of a failed Latarjet procedure presents a challenging problem. In the patient reported here, the presence of broken screws within the glenoid added to this. The option of using a suture-button fixation system to fix the bone block during the revision Eden-Hybinette procedure enabled us to achieve a successful result without further compromising the glenoid bone stock.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80:841-52. 2. Auffarth A, Schauer J, Matis N, Kofler B, Hitzl W, Reach H. The J-bone graft for anatomical glenoid reconstruction for recurrent posttraumatic anterior shoulder dislocation. Am J Sports Med 2008;36:638-47. http://dx.doi.org/10.1177/0363546507309672 3. Beighton PH, Solomon L, Sosklone CL. Articular mobility in an African population. Ann Rheum Dis 1973;32:413-7. 4. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: the “belt-and-suspenders” operative technique and
ARTICLE IN PRESS 6
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
G.M. Tytherleigh-Strong, D.I. Morrissey preliminary results. Arthroscopy 2007;23:593-601. http://dx.doi.org/ 10.1016/j.arthro.2007.03.096 Boileau P, Gendre P, Baba M, Thelu CE, Baring T, Gonzalez JF, et al. A guided surgical approach and novel fixation method for arthroscopic Latarjet. J Shoulder Elbow Surg 2016;25:78-89. http://dx.doi.org/ 10.1016/j.jse.2015.06.001 Butt U, Charalambous CP. Complications associated with open coracoid transfer procedures for shoulder instability: A Systematic Review of Early Results. J Shoulder Elbow Surg 2012;21:1110-9. http://dx.doi.org/ 10.1016/j.arthro.2012.11.022 Gebhard F, Draeger M, Steinmann R, Hoellen I, Hartel W. Functional outcome of Eden-Hybinette-Lange operation in post-traumatic recurrent shoulder dislocation. Unfallchirurg 1997;100:770-5. Gendre P, Thélu CE, d’Ollone T, Trojani C, Gonzalez JF, Boileau P. Coracoid bone block fixation with cortical buttons: an alternative to screw fixation? Orthop Traumatol Surg Res 2016;102:983-7. http://dx.doi.org/ 10.1016/j.otsr.2016.06.016 Giannakos A, Vezeridis PS, Schwartz DG, Jany R, Lafosse L. Allarthroscopic revision Eden-Hybinette procedure for failed instability surgery: technique and preliminary results. Arthroscopy 2016;16:30255-9. http://dx.doi.org/10.1016/j.arthro.2016.05.021 Griesser MJ, Harris JD, McCoy BW, Hussain WM, Jones MH, Bishop JY, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg 2013;22:28692. http://dx.doi.org/10.1016/j.jse.2012.09.009 Hovelius L, Sandström B, Olfsson A, Svensson O, Rahme H. The effect of capsular repair, bone block healing and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders. J Shoulder Elbow Surg 2012;21:647-60. http://dx.doi.org/ 10.1016/j.jse.2011.03.020 Hovelius L, Sandström B, Saebö M. One hundred eighteen BristowLatarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg 2006;15:279-89. http://dx.doi.org/10.1016/j.jse.2005.09.014 Hovelius L, Vikerfors O, Olfsson A, Svensson O, Rahme H. Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up. J Shoulder Elbow Surg 2011;20:1095-101. http://dx.doi.org/10.1016/ j.jse.2011.02.005 Lafosse L, Boyle S. Arthroscopic Latarjet procedure. J Shoulder Elbow Surg 2010;19:2-12. http://dx.doi.org/10.1016/j.ocl.2010.02.004
15. Latarjet M. Treatment of recurrent dislocation of the shoulder. Lyon Chir 1954;49:994-7. 16. Leroux TS, Saltzman BM, Meyer M, Frank RM, Bach BR Jr, Cole BJ, et al. The influence of evidence based surgical indications and techniques on failure rates after arthroscopic shoulder stabilization in contact or collision athletes with anterior shoulder instability [e-pub ahead of print]. Am J Sports Med 2016 [Epub ahead of print] http://dx.doi.org/10.1177/ 0363546516663716 17. Lunn JV, Castellano-Rosa J, Walch G. Recurrent anterior dislocation after the Latarjet procedure: outcome after revision using a modified Eden-Hybinette operation. J Shoulder Elbow Surg 2008;17:744-50. http://dx.doi.org/10.1016/j.jse.2008.03.002 18. Mizuno N, Denard PJ, Raiss P, Melis B, Walch G. Long-term results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg 2014;23:1691-9. http://dx.doi.org/10.1016/ j.jse.2014.02.015 19. Petre BM, Smith SD, Jansson KS, de Meijier PP, Hacket TR, LePrade RF, et al. Femoral cortical suspension devices for soft-tissue anterior cruciate ligament reconstruction: a comparative biomechanical study. Am J Sports Med 2013;41:416-22. http://dx.doi.org/10.1177/ 0363546512469875 20. Provencher MT, Bhatia S, Ghodadra NS, Grumet RC, Bach BR, Dewing CB, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am 2010;92:133-51. http://dx.doi.org/10.2106/JBJS.J.00906 21. Rouxel Y, Rolland E, Saillant G. Postoperative recurrence: results of surgical revisions. Rev Chir Orthop Reparatrice Appar Mot 2000; 86(Suppl 1):137-47. 22. Taverna E, Golano P, Pascale V, Battistella F. An arthroscopic bone graft procedure for treating anterior-inferior glenohumeral instability. Knee Surg Sports Traumatol Arthrosc 2008;16:872-5. http://dx.doi.org/ 10.1007/s00167-008-0541-y 23. Warner JP, Gill TJ, O’Hollerhan JD, Pathare N, Millett PJ. Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med 2006;34:205-12. http://dx.doi.org/10.1177/ 0363546505281798 24. Weppe F, Magnussen RA, Lustig S, Demey G, Neyret P, Servien E. A biomechanical evaluation of bicortical metal screw fixation versus absorbable interference screw fixation after coracoid transfer for anterior shoulder instability. Arthroscopy 2011;27:1358-63. http://dx.doi.org/ 10.1016/j.arthro.2011.03.074