Arthroscopic Bristow-Latarjet Combined With Bankart Repair Restores Shoulder Stability in Patients With Glenoid Bone Loss

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Abstract

Background

Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure.

Questions/purposes

We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout.

Methods

Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed.

Results

At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion.

Conclusions

The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Related collections

Most cited references 58

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The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.

F Balg, P. Boileau (2007)

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation. We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour. These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead.

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Dislocation arthropathy of the shoulder.

R L Samilson, V Prieto (1983)

Seventy-four shoulders in seventy patients with a history of single or multiple dislocations of the shoulder demonstrated radiographic evidence of glenohumeral arthropathy. In every patient radiographs of the contralateral shoulder failed to reveal any abnormality (except, of course, in patients with bilateral dislocation). There were sixty-two anterior and eleven posterior dislocations, and one multidirectional dislocation. Shoulders with a posterior dislocation had a much higher incidence of moderate and severe arthrosis than those that had an anterior dislocation. This seemed to be related to delay in diagnosis. The number of recurrent dislocations or the presence of defects of either the glenoid rim or the humeral head, or both, was not related to the severity of the arthrosis. Operations in which internal fixation devices intruded on joint cartilage frequently resulted in moderate to severe arthrosis. Ten of the fifteen shoulders with severe arthrosis and six of the fourteen with moderate arthrosis had had no operation for the dislocation. Six of these sixteen shoulders had had a posterior dislocation for which reduction had been delayed.

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Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.

Pascal Boileau, Matias Villalba, Jean-Yves Héry … (2006)

The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability. Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers. At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03). In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization.

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All references

Author and article information

Contributors

Pascal Boileau: boileau.p@chu-nice.fr

Journal

Journal ID (nlm-ta): Clin Orthop Relat Res

Journal ID (iso-abbrev): Clin. Orthop. Relat. Res

Title: Clinical Orthopaedics and Related Research

Publisher: Springer US (Boston )

ISSN (Print): 0009-921X

ISSN (Electronic): 1528-1132

Publication date (Electronic): 19 June 2014

Publication date PMC-release: 19 June 2014

Publication date (Print): August 2014

Volume: 472

Issue: 8

Pages: 2413-2424

Affiliations

Department of Orthopaedic Surgery and Sports Traumatology, Hôpital de L’Archet 2, University of Nice Sophia-Antipolis, 151 route de St Antoine de Ginestière, 06202 Nice, France

Article

Publisher ID: 3691

DOI: 10.1007/s11999-014-3691-x

PMC ID: 4079880

PubMed ID: 24942959

SO-VID: de61edc5-2011-42f8-b222-e61b52601515

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

History

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ScienceOpen disciplines: Orthopedics

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