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Evaluation of Complications of Shoulder Arthroscopy in the Treatment of Sub acromial Pathologies

Acta of Shoulder and Elbow Surgery | Volume 3 | Issue 1 | Jan- June 2019 | Page 7-12 | Alexandre de Almeida, Nayvaldo Couto de Almeida, Rafael Filipini Carraro, Samuel Pante, Ana Paula Agostini, Daniel C Agostini


Authors: Alexandre de Almeida [1], Nayvaldo Couto de Almeida [1], Rafael Filipini Carraro [2], Samuel Pante [1], Ana Paula Agostini [3], Daniel C Agostini [4].

[1] Department of Orthopaedic, Pompeia Hospital, Caxias do Sul, RS, Brazil
[2] Second Year Fellowship Resident at Pompeia Hospital, Caxias do Sul, RS, Brazil
[3] Department of Pediatrics, Caxias do Sul University, Caxias do Sul, RS, Brazil
[4] Department of Radiology, General Hospital, Caxias do Sul, RS, Brazil

Address of Correspondence
Dr. Alexandre de Almeida,
Rua Vitório Buzelatto, 222/601. Caxias do Sul, RS, Brazil.
Zip: 95020290.
E-mail: alealmeida19613@gmail.com


Abstract

Objectives: to analyze the prevalence of complications of arthroscopic shoulder surgery for the treatment of sub acromial pathologies and verify if it is affected by sex, age, obesity, smoking habit or by the surgeon’s learning curve.
Methods: from Aug 2001 to Oct 2017, 1322 shoulders were treated for sub acromial pathologies by arthroscopic technique. One surgeon operated all the cases of subacromial pathologies. Exclusion criteria were revision surgeries and insufficient medical records, resulting in a total of 1246 patients.
Results: The analysis of the sample showed a significant predominance (p<0.0001) of the female patients (60.5%). The group of female patients had the highest age (p<0.001). There were complications in 197 patients. The prevalence of complications was 15.8%. Analyzing the female patients separately, a prevalence of complications of 16.5% was verified, while the male patients had 14.8% (p=0.432). Statistical analysis showed a higher prevalence of complications in younger patients (p=0.036). Obese patients (25.8% of the sample) had 13.4% of complications, while non-obese patients had 16.7% (p=0.161). The analysis of complications according to smoking habits did not show a higher prevalence of complications when comparing smokers and nonsmokers (p=0.492). The most frequent complication found in the study was stiffness, with 63 cases (32.5% of the complications). We found 36 cases of stiffness (6.3%) in the immobilized group with a common sling, while the immobilized group with a neutral rotation cushion of the MS presented 27 cases of stiffness (4%). The reduction of 2.3% with the use of sling in neutral rotation was not considered significant (p = 0.066). We analyzed the first 400 arthroscopic cases with the last 400 cases operated. 20.8% of complications were found in the first 400 cases operated and 10.5% in the last 400 cases (p<0.001).
Conclusion: The prevalence of complications of arthroscopic shoulder surgery for the treatment of sub acromial disorders was 15.8%. It was not possible to demonstrate sex, obesity and smoking as risk factors for shoulder arthroscopy complications. It was possible to demonstrate that the age under 65 years and the surgeon’s learning curve significantly affect the prevalence of complications after shoulder arthroscopy.
Keywords: shoulder, arthroscopy, complications.


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How to Cite this article: Almeida A, Almeida N, Carraro R F, Pante S, Agostini A P, Agostini D C. Evaluation of Complications of Shoulder Arthroscopy in the Treatment of Sub acromial Pathologies. Acta of Shoulder and Elbow Surgery Jan- June 2019;3(1):7-12.


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The Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder: A Review Article

Acta of Shoulder and Elbow Surgery | Volume 2| Issue 1 | Jan-Jun 2017 | Page 15-21| Bijayendra Singh, N Bakti


Authors: Bijayendra Singh [1], N Bakti [1]

[1]Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University.

Address of Correspondence
Prof. Bijayendra Singh,
Consultant Orthopaedic Surgeon,
Medway NHS Foundation Trust, Visiting Professor Canterbury Christchurch University, Medway, KENT
Emial:- bijayendrasingh@gmail.com


Abstract

The labrum helps deepen the glenoid and serves as an attachment of the long head of biceps. Superior Labrum antero posterior (SLAP) tears are common in the overhead throwing athlete and is a common cause of shoulder pain in the younger population. Often its due to repetitive throwing action or may present after a single acute injury. The diagnosis can be challenging and hence a careful history and examination followed by investigation is key to clinch the diagnosis. The normal variants of the capsulo – labral complex can make the diagnosis difficult. A thorough understanding of the condition is hence essential. This article reviews the relevant anatomy, clinical diagnosis, investigations and management of the condition.
Keywords: Superior Labrum Antero Posterior, SLAP, Arthroscopy, Stabilization, Tenodesis.


Introduction

Andrews et al first described superior labral anterior-posterior lesions (SLAP) of the shoulder in 1985 amongst overhead-throwing athletes [1]. Recent published studies have reported an incidence between 6% and 20% and are not exclusive to these athletes [2]. Pathogenesis can be related to trauma or part of a degenerative process. For the treating Orthopaedic surgeon, SLAP pathologies can be a challenging problem to manage due to ambiguity in clinical diagnosis, variation in normal labral anatomy and controversies in treatment.

Role and function
The labrum helps deepen the anatomically shallow glenoid, which in turn helps confer additional passive stability to the glenohumeral joint [3]. The superior aspect of the labrum also serves as points of attachment of the tendon for the long head of biceps, the superior and middle glenohumeral ligament (MGHL) and the posterior-superior aspect of the capsule, they have an important role in stabilizing the shoulder especially in the first half of shoulder elevation [4, 5].

Anatomy
Histologically, the superior labrum is a triangular structure and is composed of fibrous and fibrocartilaginous tissue [3, 6]. Vascular supply to this region of the labrum is from joint capsule via the branches of the suprascapular artery, the circumflex scapular branch of the subscapular artery and the posterior humeral circumflex artery [6].
Literature describes significant variability in the anatomy of the superior aspect of the glenoid labrum and the attachment of the long head of biceps, which can cloud the management of a SLAP pathology [3]. Williams et al retrospectively reviewed 200 consecutive shoulder arthroscopies to find a 12% incidence of a sublabral foramen [7]. When this variation was present, 75% of the patients had a ‘cord-like’ appearance of the MGHL that attaches directly to the labrum. The group also noted a rare variation, known as the Buford complex, which occurred in 1.5% of the arthroscopies they reviewed. This is described as a cord like MGHL with an anterior superior glenoid that is devoid of a labrum. Subsequent published studies have further confirmed the incidence rates of these normal anatomical variations [ 8, 9].
In addition, the labrum can appear meniscoid as it drapes over the superior glenoid articular cartilage, which may give an appearance of labral detachment [10]. The surgeon must be aware of these, as reattachment or repair of these normal variations can lead to a significant loss of range of motion of the shoulder [11].

Pathogenesis
SLAP lesions were first noted as a repetitive injury in overhead-throwing athletes [1]. Increased external rotation of the shoulder at the cocking phase of a throw displaces the labrum and biceps tendon medially and is thought to increase torsional force at the biceps anchor. This results in a phenomenon known as ‘peel-back’ injury to the labrum [12]. These athletes also increase the forces at the superior labrum by adopting a reduced internal rotation motion while in the abducted position of a throw [12, 13]
SLAP tears can also occur due to forceful traction to the shoulder, direct compression injuries or fall on an abducted and externally rotated arm. The position of the shoulder at the point of impact loading is thought to be key and studies have shown SLAP tears are more likely to occur when the shoulder is forward flexed rather than extended [14]

Classification
In 1990, Snyder et al described four types of SLAP lesions based retrospective review of 700 shoulder arthroscopies [15]. Over the last 30 years, this classification has been expanded to include six more types but Synder’s original classification is still the most recognized and widely used.
In Snyder’s paper, he described Type I SLAP lesions as a superior labral fraying with localized degeneration. The superior labrum and the biceps anchor remain intact and patients are commonly middle-aged and clinically asymptomatic.
Type II lesions occur when there is detachment of the labrum and the biceps anchor from its attachment to the glenoid. This type of SLAP pathology is the most clinically significant variant.
Type III lesion is a bucket handle tear superior labrum with the biceps anchor still intact. This phenomenon is very similar to a bucket handle injury of the meniscus in the knee joint and if significantly unstable, it can displace into the glenohumeral joint to cause mechanical symptoms.
Type IV lesions differ form Type III lesions by having split in the biceps tendon itself and this split is included in the bucket handle component of the SLAP tear.

Clinical diagnosis
Making a clinical diagnosis of a SLAP lesion can be challenging for a myriad of reasons. Patients’ history of preceding events can be variable and examination is often ambiguous and frequently reveals a variety of other co-existing pathologies.

History
Depending of the specific pathogenesis of the SLAP tear, symptoms can arise insidiously or acutely. Overhead throwing athletes are more likely to present with an insidious history due to the progressive nature of the tear and may complain of reduced throwing velocity and overhead movement. Acute trauma causing a SLAP lesion can be due to a traction injury can be due to unexpected weight shift of a heavy object or a compression injury from a fall on an outstretched limb.
The most common presenting complain in patients with a SLAP pathology is pain [16]. The location of pain can either be felt deep in the shoulder joint or a discomfort radiating to the anterior aspect of the shoulder. The nature of the pain can either be sharp or a dull ache that is often exacerbated by activities of pushing, heavy lifting or overhead actions. For patients with a Type III or IV SLAP pathology, they may complain of mechanical symptoms including sensation of giving way especially when performing overhead activities.
Patient may also complain of weakness to the affected limb. Ganglion cyst formation secondary to a chronic SLAP lesion can cause compression of the suprascapular nerve to result in this symptom.

Examination
Clinical examination of patients with suspected SLAP pathology can be unequivocal and confusing as the numerous provocative tests to elicit SLAP lesions lack sensitivity or specificity. Patients also often present with co-existing shoulder pathology to further cloud the clinical picture. One study found 88% of patients with SLAP lesions found at arthroscopy had co-existing shoulder pathology ranging from subacromial impingement, rotator cuff pathology acromioclavicular joint arthritis [8].

When examining a patient with a possible SLAP lesion, pay particular attention to the symmetry of muscle around the shoulder girdle. Wasting of the supraspinatus and infraspinatus muscle may indicate the presence of a glenoid cyst impinging on the suprascapular nerve. In these patients, the active range of motions of the glenohumeral joints often remains normal but pain may be elicited in the position of internal impingement (external rotation of the abducted and externally rotated shoulder) [11]. Stability and apprehension tests of the joint should be tested but significant instability of the joint is rare in SLAP pathologies [16].
Table 1 shows the various tests used to clinically elicit a SLAP lesion. Of these, the O’Brien test is probably the most commonly utilized [17]. To perform this test, the shoulder is position at 90° of flexion, 15° of adduction, full internal rotation and pronation of the forearm. At this point, the patient is asked to flex against resistance. A positive test is declared if patient experiences a deep or anterior shoulder pain. Symptoms should not be reproduced with the shoulder in similar position but in external rotation. Due to the poor reproducibility, sensitivity and specificity the various special tests available, Arnander & Tennant suggested the combination of Kim’s biceps load test II and the O’Brien’s test gave the best likelihood of a positive result in identifying an isolated SLAP lesion [18].

Investigations
As a baseline, standard plain radiographs (anteroposterior view of shoulder, axillary and scapular ‘Y’ view) of the affected shoulder should be attained. Although this will not help with the diagnosis of SLAP pathology, this practice might highlight any co-existing pathology that will help in formulating a surgical management plan.
Magnetic resonance imaging (MRI) is the gold standard for imaging labral pathologies. When compared to arthroscopy, MRI is thought to have a sensitivity of 90%, specificity of 89.5% and accuracy of 98% [25]. Although there have been debates in the past, several studies have shown that introducing intra-articular contrast into the shoulder can help increase diagnostic sensitivity [26-28]. Despite this, and taking into consideration anatomical variations, interpretation of the MRI images can remain difficult. Identifying SLAP lesions on MRI scan is best done from the coronal oblique sequences and positioning the shoulder in abduction and external rotation is thought to further help with diagnosis.11 Applying axial traction to the arm has also been suggested as a possible technique to increase contrast dissipation into the intra-articular space and hence improve sensitivity [29].

Arthroscopy
Arthroscopy remains the gold standard in diagnosing SLAP lesions [26, 28, 30]. Direct visualization and gentle probing of the labral-biceps complex often helps identify the lesion. Despite this, arthroscopic findings can be difficult to interpret and knowledge of patients’ presenting history, examination findings, imaging results can help the clinician determine if the visualized labrum represents a pathological process. Awareness of the possible anatomical variations to the superior labrum will also prevent inadvertent repair of an otherwise normal biceps-labral complex.
Several authors have suggested dynamic testing the biceps attachment to the labrum can assist diagnosis by making subtle pathologies more obvious. This is achieved by placing the arm in abduction and external rotation which applies tension to the biceps and can cause the labrum to “peel-away” from the glenoid [12, 31]. Other signs of a pathological labrum-biceps complex include signs of reactive synovitis under the labrum, excessive sublabral recess beyond the edge of the glenoid cartilage and hypermobility of more than 5mm on biceps manipulation [32].

Treatment options
Non operative
Conservative treatment of SLAP pathology revolves mainly around physiotherapy, non-steroidal medications and steroid injections into the shoulder. Although there are no published studies on conservative management of SLAP lesions, authors have experienced poor long-term outcomes following conservative management. Patients are rarely satisfied with their function and ends up requiring surgical intervention an average of one or two years following initial presentation [33].

Surgical Treatment
Controversies
The role of surgical treatment of SLAP tears is shrouded in controversy. The lack of clear guidelines and randomized control studies further compounds this issue. It is critical to note that not all SLAP lesions identified intra-operatively require repair. Meticulous patient selection taking into consideration patient age, levels of activity and co-existing shoulder pathology should guide the treating surgeon which is the best way to surgically treat a SLAP lesion.

Isolated SLAP Lesions
Type I
This subtype of SLAP lesions is often an incidental finding at arthroscopy as it is usually subclinical in terms of its symptoms. Thought to be secondary to degeneration, it is not usually picked up during MRI imaging and when encountered intraoperatively, it can be left alone. If significantly frayed, it is recommended that the lesion is debrided back to healthy labral tissue [30, 34-36]. Care should be taken to find other co-existing pathology such as subacromial impingement or rotator cuff pathology as a cause of symptoms.

Type II
This is the most common and clinically important subtype of SLAP lesions. It should be treated if patients’ symptoms, clinical examination is suggestive of SLAP pathology and arthroscopic examination of the rest of the shoulder does not reveal any other co-existing shoulder pathology. Managing these isolated lesions can be achieved via various techniques and is again a source of much controversy.
Suture anchors are the most common method of repairing SLAP lesions with more predictable and favorable outcomes when compared to biodegradable tacks [31, 35, 36]. Patients from this treatment group report at least 94% good to excellent results post-operatively and about 74% of patients returned to their pre-injury sporting activities [8, 37] The ideal configuration in terms of the number of anchors and suturing technique; simple, dual simple or horizontal mattress, is again a subject of heated debate. Various studies have been published to support the use of each argument with good outcomes [35, 36, 38]. A prospective study by Bedi et al found similar clinical outcomes in patients independent of the number of suture anchors used for repairing of the SLAP lesion [39].
Despite several of these studies showing good outcomes with primary repair, Denard, in his study, noticed a trend of poor outcomes with increasing age [40]. Provencher et al carried out a large prospective study and agreed with Denard’s findings and highlighted an increased rate of failure of SLAP repairs in patients above the age of 36 [41]. Boileau and his team were first to study the differences in outcome between primary repairs versus biceps tenodesis for SLAP injuries. His team found that 60% of patients who had a repair were dissatisfied or disappointed with their outcomes while 87% of patients in the tenodesis group were satisfied with their outcome with higher rates of return to sports [42]. He also went on to report 40% of patients from the repair cohort required revision surgery due to persistent pain and inability to participate in sports.
Findings of this study were replicated in several other studies and based on these recent evidence, a significant shift has taken place in the management of this subtype of SLAP lesions [10, 43]. It is now recommended that in patients with a isolated type II SLAP lesion, aged above 36 years old, low sporting demand and poor tissue repair quality, a biceps tenodesis is a viable surgical option. This can be performed either arthroscopically or via a mini-open technique. The biceps tendon tenotomised, doubled on a suture and pulled into a humeral socket drilled at the proximal aspect of the bicipital groove. It is fixed in placed using a biodegradable interference screw. These patients had functional outcomes comparable to younger patients with primary repair of their lesions [10].
However, if the patient is under 36 years-old, active athlete with good tissue quality, the recommendation is to still perform a repair of the lesion using suture anchors [42, 44]. This option aims to restore normal anatomy and is most likely influenced by several studies suggesting a key role of the labral-biceps complex in maintaining glenohumeral stabilization [45, 46]. In the event of non-resolution of symptoms or poor overhead performance, biceps tenodesis can still be performed as a salvage procedure with good and predictable outcomes.

Type III
Management of this subtype requires resection of the unstable bucket-handle lesion. It is of upmost importance that the MGHL is not destabilized during the resection process as damage can cause significant anterior instability of the joint [34, 38, 39, 47]

Type IV
Management of Type IV lesions is determined by the extent of biceps tendon involvement and patients’ age. When less than 30% of the biceps tendon is involved, both the labrum and the pathological biceps tendon is debrided and resected. If more than 30% of the biceps is involved, in a young patient, a biceps tenodesis and labral repair is carried out. However, in an older patient or if the labral tissue quality is poor, then a labral debridement is performed with either biceps tenotomy or tenodesis [16].

Type V to X
These subtypes of SLAP injuries often represent a more significant labral injury and are often associated with shoulder instability [11]. Treatment should not only address the labral-biceps complex but also the other parts of the labrum and the MGHL injury.
Slap with co-existing pathologies
Eighty-eight percent of patients with SLAP lesions diagnosed during arthroscopy have co-existing pathology [8]. In view of this, it is recommended to have a clear idea on how to manage these patients based on latest evidence.
SLAP tear with rotator cuff pathology
In patients with these pathologies, it is important to clinically determine which pathology is causing the clinical picture. If both structures are thought to be the generator of symptoms, surgical repair of both can be done at the same sitting with good outcomes [48, 49]. This treatment option is thought to help improve range of motion and patient satisfaction. However, another study looked at patients above the age of 50 with similar dual pathology and found that in this subgroup of patients, managing their pathology with a rotator cuff repair and a biceps tenotomy yielded a significantly better outcome compared to a SLAP and rotator cuff repair [50].

Subacromial Impingement
It is recommended that patients with symptoms of clinical signs of impingement in the shoulder have arthroscopic subacromial decompression during surgery for a SLAP repair. Coleman et al looked at this particular co-existing pathology in his study and concluded that although functional outcome measures were similar in both groups, patients who had an acromioplasty in the same sitting were more satisfied with their surgery [51].

Ganglion cysts
Ganglion cysts may develop secondary to chronic SLAP tears and if anatomically favorable, can cause suprascapular nerve palsy via impingement. Literature have described arthroscopic decompression with a probe, shaver and ever a spinal needle [52, 53]. However, if it occurs due to an isolated SLAP pathology, these cysts have been shows to resolve spontaneously following a SLAP repair. In Youm at al case series, even patients with clinical weakness due to compressive neuropathy of the suprascapular nerves have been shown to make a full recovery following SLAP repair [54].


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41. Provencher, M.T., et al., A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med, 2013. 41(4): p. 880-6.
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45. Pagnani, M.J., et al., Role of the long head of the biceps brachii in glenohumeral stability: a biomechanical study in cadavera. J Shoulder Elbow Surg, 1996. 5(4): p. 255-62.
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47. Mileski, R.A. and S.J. Snyder, Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg, 1998. 6(2): p. 121-31.
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52. Abboud, J.A., et al., Arthroscopy effectively treats ganglion cysts of the shoulder. Clin Orthop Relat Res, 2006. 444: p. 129-33.
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How to Cite this article:Singh B, Bakti N. The Diagnosis and Management of Superior Labral (SLAP) Tears of the Shoulder: A Review Article. Acta of Shoulder and Elbow Surgery Jan – June 2017;2(1):15-21.

Prof. Bijayendra Singh

(Abstract Full Text HTML) (Download PDF)


Arthroscopic Bristow – Latarjet Procedure: Results and Technique after nine-year experience.

Acta of Shoulder and Elbow Surgery | Volume 1 | Issue 1 | Oct-Dec 2016 | Page 27-34 | Jose Carlos Garcia Jr.


Authors: Jose Carlos Garcia Jr [1]

[1] NAEON-Santa Catarina Hospital.
[2] IFOR Hospital.

Address of Correspondence
Dr. Jose Carlos Garcia Jr., MD, MSc, PhD
NÆON-Hospital Santa Catarina-SP-Brazil
Email: jose.cjunior@hsl.org.br


Abstract

Introduction: The Bristow procedure is an established and effective method to treat anterior shoulder instability.
Following the current trend towards minimally invasive procedures, we performed the Bristow technique arthroscopically and assessed the results.
Materials and Methods: This study enrolled 33 patients with more than 2 years of follow-up. We assessed the UCLA score before and after surgery and completed post-surgical assessments of the Rowe score, Simple Shoulder Test (SST) score, and differences in external rotation (DER) at follow-up approximately 2 years or more post-surgery.
Results: At the 2-year follow-up, the average UCLA score increased from 25.48±0.64 (SD 3.67) pre-surgery to 33.03±0.57 (SD 3.26) (p<0.0001). In addition, the mean Rowe score was 93.33±2.00 (SD 10.93; compared with the cutoff score of 75, p<0.0001), the mean SST score was 11.20±0.28 (SD 1.52), and the mean DER was 11.50±1.65 (SD 9.02).
No recurrences of instability or musculocutaneous nerve lesions occurred in the patients.
Conclusion: Together, the UCLA score, SST score, DER, Rowe score and the recurrence rate suggest that the arthroscopic Bristow procedure was effective in treating anterior shoulder instability with short-term follow-up. However, although these results are encouraging, this procedure is not free of complications.
Additional data and prospective trials are important to better understand the possible advantages and disadvantages of this procedure.
Keywords: Latarjet, Bristow, shoulder instability, shoulder dislocation, arthroscopy, arthroscopic.


Introduction

Anterior shoulder instability is one of the most common pathologies of the shoulder [8]. Among the many surgical techniques available to treat anterior shoulder instability, one of the most effective and well known techniques is the transfer of the coracoid and conjoined tendon to the anterior glenoid rim [2]. This procedure was suspected to be originally performed by Walter Rowley Bristow for the surgical treatment of recurrent anterior shoulder instability before 1929 [18]; however, no details on the surgical technique were reported until the Helfet report in 1958 over the technique he learnt in 1939 from Bristow [11]. In 1954, Michel Latarjet established the modern concept of this surgery using one screw to fix the coracoid and splitting the subscapularis in the horizontal direction [15]. Didier Patte et al. disseminated this technique throughout Europe in the 1980s and used two 4.5 mm screws to fix the graft [19].  This procedure involving the transfer of the coracoid and conjoined tendon to the anterior glenoid rim has been modified several times, but these modifications have always respected the principles established by Bristow and Latarjet [14]. Many of these modifications have resulted in successful results with some common complications. The most common complications include loss of external rotation, osteoarthritis, pain, Musculocutaneous nerve lesions and non-unions [10].  These complications have led many surgeons to avoid this procedure and prefer capsular plication with labral reconstruction.  Recently, minimally invasive arthroscopic techniques have been developed to perform Latarjet surgery [14 ].Through an intra-articular view, the surgeon is able to better position the graft and avoid some of the possible complications related to positioning, such as recurrence of dislocation and osteoarthritis. The intra-articular view of the insertion site also ensures the presence of bone marrow at the contact area, which allows for a more reliable osteosynthesis [1,14,17]. However, this new approach to the established procedure requires new instruments and increased surgical costs. In 2009, a surgical technique was created to allow the Bristow procedure to be performed with a minimally invasive procedure that uses regular arthroscopic devices and one screw [8]. In this study, we have modified this technique and present the results of 33 patients who underwent the arthroscopic Bristow procedure to treat anterior shoulder instability.
Hypothesis: This new modification of the arthroscopic Bristow procedure, which utilizes regular arthroscopic devices, is an effective procedure to treat patients with anterior shoulder instability.
Purpose: To assess the effectiveness and safety of the modified arthroscopic Bristow procedure.

Methods

This prospective case series study Stage 2a of the IDEAL-Collaboration. From September 2007 to September 2016, 47 patients underwent arthroscopic Bristow-Latarjet procedure. Of these 47 patients, the first three surgeries were not scored before the surgery and were therefore not allowed to take part of this trial. The records of two other patients were lost, one successfully returned to his high impact activities, and the records of the other present just the pictures of his recovered arch of motion. Nine patients present less than two years post surgery. The remaining 33 patients fulfilled the inclusion and exclusion criteria as described in Table 1.

table-1
Outcomes
The chosen outcomes included the following:
Modified UCLA score: The UCLA score was primarily created to assess shoulder arthroplasty patients. The modification of the UCLA score allows it to be used for various age groups and different conditions [22];
Simple Shoulder Test (SST);
Rowe score: The Rowe score is a post-surgical assessment that does not allow for a comparison with the condition before the surgery. In contrast, the results are compared with the cutoff point of 75. A score over 75 is considered good, whereas a score over 90 is considered excellent. An unstable shoulder will not result in a Rowe score over 50; therefore, comparing the results with a cutoff score of 75 offers a reasonable assessment of surgical success;
Loss of external rotation with the arm in adduction: The baseline measurements were used as a control and compared to the results at the 2-year post-surgical follow-up. Only differences before and after surgery were recorded. Because we used manual goniometry, external rotation was measured every 5º;
Elevation: The final range of motion was compared to the contralateral side if differences in elevation were greater than 10º; and Dislocation recurrence.
Assessments: Patients were assessed at baseline for external rotation in adduction of the affected shoulder and UCLA score.
Patients were assessed two years post-surgery for external rotation in adduction of the affected shoulder, shoulder elevation, Rowe score, SST score and UCLA score.
Post-surgical assessments also included roentgenograms at two weeks, five weeks and two years after surgery. Computed tomography (CT) scans were also performed when complications were suspected.
Statistical methods
Statistical analyses were performed using Prism6®for Mac (GraphPad Software Inc.).
All data were tested for normality using the D’Agostino and Person test, Shapiro-Wilk test and KS test. Thereafter, the data were assessed according to patient characteristics. The intention to treat (ITT) [24] principle was used whenever possible. Interim sample size was calculated to determine whether the study achieved significance and statistical power as an adaptive design. For all possible assessments, a two-tailed test of significance was used, and p<0.05 was considered statistically significant. Adverse events or complications are reported for all the 33 patients enrolled in the study. In addition, the causes for withdrawal from the study are also reported.

Surgical technique
Under general anesthesia, the patient was placed in the beach chair position with their arms free. A standard posterior portal was established, and the arthroscope was introduced. An arthroscopic pump with 40 mm Hg of pressure was used in the procedure. The patient’s blood pressure was not controlled during the procedure, except in cases of very high blood pressure that could potentially compromise the surgery. Diagnostic arthroscopy was performed, and a portal was placed under the anterior triangle, through the subscapularis. This anterior modified portal was inferior and medial to the traditional anterior portal. The location for the portal could be found using a needle, which was inserted where the surgeon planned to insert the screw. If the surgeon was troubled by the axillary nerve, nerve integrity could be confirmed through arthroscopic visualization using an arthroscope inserted into the lateral portal. The musculocutaneous nerve could also be visualized using this technique.
The arthroscope was returned to the posterior portal. After assessment of the joint and identification of the bony Perthes-Bankart lesion, the anterior glenoid rim was shaved. The rotator interval and coraco-clavicular ligaments were removed, and the lateral part of the coracoid was exposed using an electrocautery device. If necessary, a portion of the anterior capsule can be removed for better visualization. The subscapularis was opened in the same direction as its fibers with a Kelly device through the anterior modified portal. Caution should be taken when passing the device through the modified anterior portal, which is lateral to the conjoined tendon, to avoid nerve injuries. The electrocautery device can also be used at this point. The Kelly device was introduced through the anterior modified portal, and the subscapularis was opened from the bursal side to the articular side, which is similar to the open Bristow procedure. The tendon was opened wide in the middle of the tendon (Fig. 1).

figure-1-2-and-3

Although the axillary nerve is in close proximity, lesions to this nerve are not common, as in the open Bristow procedure [7].
The anterior modified portal was used to introduce a 2.5 to 3.5 mm drill to the anterior glenoid defect at the location where the screw will be inserted and at the same axis as the glenoid through the subscapularis split. This procedure was performed under direct view using the arthroscope in lateral portal and the drill perpendicular to the shaved anterior glenoid rim. The hole needs to be at least 5-6 mm medial to the glenoid rim and inferior the humeral head equator to avoid redislocation [29] . A guide should be used for the drill to avoid nerve injuries. The Glenoid Bone Loss Instrument Set from Arthrex® (Naples-Fl-USA) (Fig. 2) contains a guide that can be used to make this step safer.

figure-4-5-and-6

However, in the majority of the procedures performed in this study, we only protected the skin, deltoid and conjoined tendon because direct visualization showed that the drill was at a safe distance from the neurovascular structures. Sometimes the conjoined tendon can be medialized by the guide to enable an optimal position. The subscapularis is not affected during the drilling because of the saline solution used in arthroscopy. The 2.5 to 3.5 mm (depending on the coracoid diameter) drill was inserted until the posterior scapula cortical was felt. The distance from the hole to the glenoid rim was approximately 5 to 6 mm,29 which was measured using a probe and a surgical ruler. If the coracoid length is larger in the horizontal axis than the vertical axis, small corrections can be made by rotating the graft. Then, a second drill of equal size was placed beside the first one to compare and measure the difference in length between the two drills. This second drill is not inserted and no extra hole is made; the drill is only placed besides the other drill to measure the length. This measurement represents the glenoid length, and small differences in this measurement are expected.


figure-7-and-8

The arthroscope was then reinserted into the lateral portal. To find the best portal for the osteotomy, an 18-gauge needle was used, which was inserted lateral to the coracoid and located near the clavicle. Direct visualization using the arthroscope is optimal to determine the most adequate point to insert the osteotome. This portal can also be used to access the superior tip of the coracoid (superior coracoid portal-SCP). The pectoralis minor and the facia were detached through this portal using electrocautery. A small nitrogen saw was inserted through this portal, and the coracoid was carefully cut. A regular osteotome can also be used for this purpose. The direction of the osteotomy is vertical to the coracoid. The risk of breaking the bone is avoided by using a nitrogen saw. The coracoid and the conjoined tendon were pulled out of the body using a Kocher device through the anterior portal (Fig. 3). Any irregularity of the coracoid graft was flattened to improve the contact surface. A hole was made in the coracoid using a 2.5 to 3.5 mm drill in the horizontal axis. The coracoid length was then measured.
However, if the surgeon’s preference is to use the vertical coracoid axis, he/she will also have to drill the inferior part of the coracoid to optimize bone healing and create an extra portal to insert the screw. The best location for this additional portal is just above the coracoid at the location where the screw will be inserted. This location can be better defined using a needle under direct arthroscopic visualization and is located near the clavicle. The use of the vertical position for the coracoid without exteriorization is recommended in heavy and extremely strong patients, where exteriorization is very difficult. We have performed this modification of the procedure when necessary (Fig. 4). However, exteriorization of the coracoid makes the procedure faster and easier, and the length of the anterior portal is not modified. The size of the anterior portal is the same size as the diameter of the coracoid (10-14 mm), as measured intraoperatively using a surgical ruler. This procedure of measuring clearly defines the length of the glenoid and coracoid, and the sum of the two is the exact length of the malleolar screw to be used. A 3.5 to 4.5mm mm malleolar screw was then inserted in the coracoid (Fig. 5). Most commonly, a 34 to 40 mm sized screw is used. For fixation, the arthroscope was reinserted in the posterior portal, and the coracoid plus the conjoined tendon were inserted through the split subscapularis tendon. A Kocher device and a probe are used to make this procedure easier. The screw was inserted into the anterior glenoid rim, and fixation was achieved with the graft in the horizontal position. Often the hole is not easy to locate; therefore, the arthroscope needs to be inserted in the SCP and the lateral portal to improve visualization. The screwdriver can be used as a joystick by using traction of the screw against the screwdriver with a synthetic multifilament number 5 polyester wire. A Kocher device can be inserted in the SCP to avoid the rotation of the coracoid while the screw is fixed(Fig. 6). If the graft is overhanging, sometimes a small rotation of the graft can be enough to correct this problem once the coracoid is more elliptical than circumferential. However, if the graft remains impinging on the humeral head, it can also be shaped using an osseous shaver. Finally, shoulder external rotation was checked using the arthroscope in the posterior portal (Fig. 7). A radiographic exam was also performed (Fig. 8). The portals were closed using nylon 4.0 or 3.0 sutures (Fig. 9) The capsule was never repaired in this arthroscopic procedure; however, it can be performed if desired by the surgeon.

figure-9

Post-operative care
Post-operative care is similar to that with the open Bristow procedure protocol. The patient will use a shoulder immobilizer during the first five weeks. Minimal movements, such as free elbow flexion and extension and hand and wrist movements, are recommended, and the patient is instructed to avoid external rotation of the shoulder.The patient is encouraged to start pendular movements (external rotation from 0º to 10º) and assisted passive elevation (up to 60º) only after the second week following surgery.External rotation is avoided for five weeks. The progression of external rotation and elevation is in consideration of the patient’s pain level. Gain of range of motion begins only five weeks after the surgery. Aggressive gain of range of motion begins just six weeks after the surgery. Active rotator cuff exercises are also allowed five weeks post-surgery.
All sports can be performed after eight weeks; however, the patient may have poor external rotation at this time point, which may restrict the performance of some sports. Improvement in external rotation will occur approximately six months after surgery.

Results

Overall results
Data loss: Of the 33 patients enrolled in this study, one died due to a car accident, one did not return for post-operative care, and another patient presented with a fracture to the coracoid, which required conjoined tendon tenodesis in the anterior glenoid rim. However, the data from these three patients were included in the study because UCLA baseline evaluations were obtained for these patients. Despite good results for pain, stability and function (UCLA=34), the patient who underwent the conjoined tendon tenodesis was graded postoperatively with the same baseline. Of the 33 patients included in the study, there were 32 males and 1 female with a mean age of 33.34 years (range: 18-60 years old). In total, 11 presented with anterior shoulder instability to the left side and 22 to the right side. The average follow-up time was 4.73 years (range 2-8 years).
The reasons for performing the procedure included bony Bankart lesions compromising 20% or more of the glenoid (20 patients), HAGHL lesions (1), failure of previous labrum reconstructions (7) and an instability severity index score higher than six(5).

table-2
Clinical results (effectiveness)
UCLA was assessed in ITT (33 patients), and the results are summarized in Table 2.

table-3

The Rowe score was assessed according to defined protocols (30 patients), and the results are summarized in Table 3.
Data showing p<0.0001 signaled for the trial to stop due to the effectiveness of the procedure.21
SST and DER were assessed according to defined protocols (30 patients), and the results are summarized in Table 4.
The frequencies of SST responses are summarized in Table 5.
There were no differences in elevation from the contralateral side of more than 10º, except in 2 cases. Internal rotation was not assessed; however, 9 of 30 patients presented with discomfort during this movement at the extremes of internal rotation, as assessed in question 11 of the SST.

table-4-and-5

Complications and revisions
i) Intraoperative complications in the 33 patients
a) Coracoid fractures
There were found two intraoperative coracoid fractures:
One was a complete fracture, and the surgeon successfully performed an anterior conjoined tendon tenodesis through the subscapularis split. The other fracture was a partial fracture, and the surgeon performed a coracoid cerclage and successfully completed the arthroscopic Bristow procedure.
b)Nerve lesions
No nerve lesions occurred.
c)Other complications
No other complications occurred.
ii) Post-surgical complications (30 patients): Of the 33 patients enrolled in this study, one died due to a car accident, one did not return for post-operative care, and another patient presented with a fracture to the coracoid, which required conjoined tendon tenodesis of the anterior glenoid rim.
I) Radiographic assessments
a) Coracoid fractures: One patient was found to have a partial coracoid fracture; however, the remaining part of the coracoid was sufficient to avoid redislocation.
b) Non-unions: There were no non-unions.
c) Screw torsion: There were no screw torsions.
d) Osteolysis: Osteolysis was assessed through an axillary roentgenogram and was present in three patients (10%), including two with no clinical repercussions, who refused screw removal, and one patient who underwent screw removal.
e) Osteoarthritis: Osteoarthritis was assessed using a roentgenogram and was present in 2 patients. Both patients presented with moderate arthrosis according to the Samilson & Prieto classification [23], although one patient presented with moderate osteoarthritis before the surgical procedure. Both received follow-up more than 2 years following the surgery (one at 7 years and the other at 5 years).
II) Clinical assessments
Infection: One patient contracted an infection more than 6 months post-surgery, which was the worst outcome observed.
Anterior impingement: Anterior impingement was present in two patients, including the patients with osteolysis. Both patients underwent hardware removal.
Subluxations: There were no subluxations reported.
Instability recurrences: There were no instability recurrences.
Sample size: An interim analysis13 was performed to confirm whether the sample size was suitable for analysis. We enrolled a total of 33 patients to provide data for the sample size calculation20 and determined that the number of individuals was sufficient to answer the research question with respect to an alpha and beta of <0.05.

Discussion

Coracoid transfer to the anterior glenoid rim is one of the most reliable procedures to treat anterior shoulder instability due to the triple-block system, which includes:
1-Conjoined tendon;
2-Tension of the inferior part of the subscapularis with the shoulder during abduction and external rotation; and
3-Bone block [14]
Given that the current trend is to use minimally invasive surgical procedures to reduce surgical trauma and scars, it seems logical to modify established procedures to this new approach. Recently, modifications of the Bristow and Latarjet procedure have been developed to allow the procedure to be performed arthroscopically [1,14,17]. There are several advantages to the use of an arthroscopic coracoid transfer procedure, including better visualization of the insertion area in the anterior glenoid rim, the possibility to correct the graft to avoid overhanging, testing external rotation under direct visualization, treatment of concomitant intraarticular lesions, and a reduction of scars and possibly post-operative pain. In addition, there are several disadvantages, such as higher costs, a steeper learning curve for the surgeon, and a need for specific training. However, in the author’s opinion, the above-listed advantages make arthroscopic modifications of the coracoid transfer procedure a reliable possibility for treating anterior shoulder instability. In this study, fracture of the coracoid was the main complication of this procedure (3 cases). Edwards and Walsh have stated that fracture of the coracoid can be avoided by using the 2-finger technique, which improves torque control.7 Another consideration is the size of the screw; in this procedure, a 3.5 to 4.0 mm screw is more suitable for avoiding fractures compared with a 4.5 mm screw. It is also important to mention that to externalize the coracoid, the surgeon can insert the Kocher device in the soft tissue of the conjoined tendon beside the coracoid, instead of in the graft, to avoid graft fractures. In fact, when considering these 3 points, we felt more confident with the procedure and did not observe any further breakage. Regarding the treatment of the fractures, in 1 case the fracture was not complete and was successfully treated using a synthetic multifilament number 5 polyester cerclage around the coracoid. The partial fracture occurred in the shoulder of the only female in the study and was possibly because the screw was too large (4.5 mm) for her coracoid. In the other case, the fracture was complete and occurred during the fixation step; therefore, we performed a conjoined tendon tenodesis in the anterior glenoid rim using suture anchors similar to the way the procedure was performed in the past by Bristow [11]. The third patient did not require any further procedure. Studies have found no significant differences in cadaveric models when comparing coracoid transfer with conjoined tendon tenodesis only [25,28] .In addition, studies have shown that the coracoid transfer does not need to produce a bone-block effect [6]. In fact, neither the original Bristow nor the original Latarjet procedure presented enough bone to produce a bone-block effect. In the original Bristow procedure, the tip of the coracoid is sutured to the anterior glenoid rim,11 whereas in the original Latarjet procedure, the coracoid graft size is small, which allows for the complete preservation of the pectorals minor insertion in the remaining coracoid [15]. The bone-block effect of some modern variations of the Bristow and Latarjet procedures has added more stability to the original surgical procedures; however, this consideration may only be important for patients who present with Hill-Sachs lesions higher than the glenoid track [27]. Moreover, the data remain inconsistent regarding the best screw diameter for coracoid transfers. Walsh and Boileau successfully performed the procedure using 4.5 mm malleolar screws [26]; Burkhed et al.[3] and Di Giacomo et al.[5] used 3.75 mm screws; and Lafosse et al. used 3.5 mm screws [14]. The author’s personal experience is that screw size is dependent on the patient’s characteristics. For example, a 4.5 mm screw may be used for tall males; however, the most recommended size is 3.5 to 4.0 mm. Walsh and Boileau do not recommend using washers to avoid impingement [4]. However, the use of small washers is recommended when using 3.5 to 4.0 mm screws to better distribute the pressure on the graft without adding impingement. In the arthroscopic Bristow procedure used in this study, osteolysis was found in 3 cases. In the author’s opinion, osteolysis caalso be associated with the high forces that the screw impose on the graft [4]. However, assessments were performed only using X-rays, which is not the most sensitive method. One case of osteolysis was accompanied by impingement and required removal of the screw [9]. The patient with impingement underwent surgery for hardware removal; however, 9 of 30 patients answered no to question 11 of the SST. This result indicates that these patients had difficulty washing the back of the opposite shoulder with the affected extremity. Therefore, impingement may be underestimated by patients, although the author accepts the impingement rate of 9/30 in this study, even if only reported for extreme movements. Because impingement can be linked to the angle of the screw and the graft, it is important to note that higher angles within the arthroscopic procedures should never be more than perpendicular to the glenoid’s border. This is because direct visualization allows the surgeon to have direct control over the position, which avoids overhanging but occasionally causes impingement or discomfort in extremes of internal rotation. Moreover, the author suggests that the size and the obliquity of the graft can influence anterior impingement and the effective glenoid depth [16] In this study, the reoperation rate was 6.67%, which was only for hardware removal and is similar to the 7% reported in the literature for the open Bristow procedure [10]. Osteoarthritis was present in only 2 (6.67%) of the patient’s shoulders, and one of the two patients presented with osteoarthritis before the surgical procedure. This low rate may be associated to better graft positioning and less overhanging. However, the follow-up for assessing osteoarthritis was too small to emphasize these benefits. It is important to insert the coracoid graft in a flush position to avoid both an increase in edge loading and to shift contact pressure to the posterosuperior quadrant of the glenoid [17]. To date, no post-surgical recurrences of instability have occurred; however, the follow-up time may be insufficient to make conclusions regarding this outcome. Regarding the graft position, studies have suggested that a medial deviation of the coracoid of 5 mm or more is associated with a higher failure rate [12]. Therefore, graft positioning may be one advantage of the arthroscopic procedure.In this study, no non-unions were found. This result may be due to better exposure of the marrowbone of the anterior glenoid rim, better visualization during fixation to avoid interpositions and the author’s preference for the horizontal position of the graft. This position allows the biological union of the graft’s marrowbone with the glenoid rim’s marrowbone. However, follow-up assessments were performed only using X-ray, which is not the most sensitive method to detect non-unions. The author believes that one screw is sufficient to fix the coracoid. In Hovelius’ report on the Bristow procedure, he reported 16 redislocations within a sample of 319 shoulders, which included 5% that underwent the Bristow procedure using only 1 screw. Of those patients, 13% presented with a non-union; however, the fibrous union did not affect the recurrence rate, and only 3 patients underwent revision surgery because of the remaining instability [12]. According to Hovelius, the recurrence of instability is linked to medialization of the coracoid graft [12]. Our low rate of recurrence may be due to improved visualization during insertion of the graft; however, the small sample size of our study and the short follow-up period prevent us from confirming this notion. Similar redislocation rates (4%) to those reported by Hovelius were recently reported by Burkhart et al. in 102 patients [3], and Collin et al. in 74 patients [4], and both reports used 2 screws for fixation (Latarjet). The musculocutaneous nerve was the most common nerve injury and was reported in 0.6% of all surgical procedures [10]. The author did not find any nerve dysfunction or lesions; however, similar low rates of nerve compromise have been reported in the literature, and further studies are necessary to suggest any conclusions on nerve safety. The procedure presented in this study uses regular arthroscopic devices and screws, which provides significant cost advantages.

Limitations:
This study was not blinded.
The learning curve for this procedure requires specific and extensive training.
The high rates of coracoid fractures were overestimated because not all of the procedures used the 2-finger technique and smaller screw sizes.
The study was not a comparative study; therefore, comparing other techniques to the technique described in this study was not possible.
The follow-up for osteoarthritis assessment was short. Future assessments will make these data more suitable for analysis.

Conclusion

The UCLA score, SST score, DER, Rowe score and the recurrence rate reported herein suggest that the arthroscopic Bristow procedure is effective in treating anterior shoulder instability with short-term follow-up. However, although these results are encouraging, this procedure is not free of complications. Additional data and more prospective trials are important to better understand the possible advantages and disadvantages of this procedure. In particular, multicenter studies are needed to confirm the effectiveness and safety of this procedure, and new devices are needed to improve the accuracy and ease of using this procedure to treat anterior shoulder instability.


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How to Cite this article: JC Garcia Jr. Arthroscopic Bristow – Latarjet Procedure: Results and Technique after nine-year experience. Acta of Shoulder and Elbow Surgery Oct – Dec 2016;1(1):27-34.

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