Anterior Capsulolabral Reconstruction with Semitendinosus Autograft after Latarjet Failure: A Case Report

Introduction: The treatment of chronic shoulder instability, associated with poor tissue quality, remains challenging in the setting of anterior capsular deficiency. There are a few viable alternatives in the end-stage shoulder instability when multiple surgical attempts to correct the pathology have failed. The purpose of the present paper is to demonstrate the efficacy of anterior capsular reconstruction with semitendinosus autograft for the management of capsulolabral deficiency without associated bone loss. Case Report: A 39-year-old female admitted in our institution with a history of recurrent atraumatic anterior dislocation of the left shoulder after three unsuccessful surgical attempts: Arthroscopic and open capsulorrhaphy and a Latarjet coracoid transfer. CT scan images showed adequate placement (flush) of the coracoid transfer without any sign of reabsorption. Reconstruction of anterior capsulolabral structure was performed using a Semitendinosus autograft. The middle and inferior glenohumeral ligaments, the more crucial ligaments for anterior-inferior shoulder stability, were effectively recreated. The patient did not suffer any recurrent dislocation or subjective symptoms of instability at the time of the final follow-up, 2 years after surgery, and the ASES score increased from 36 preoperatively to 86. Conclusion: This technique, described for the first time as a salvage procedure after Latarjet failure, could represent a safe and viable treatment option in the context of multiple ineffective surgeries. Keywords: Autograft, capsulolabral reconstruction, latarjet, recurrent shoulder instability.

Changes in Shoulder Rotator Strength After Arthroscopic Capsulolabral Reconstruction in Patients With Anterior Shoulder Instability

Background: The correlation between isokinetic internal and external rotation (IR and ER) strength and functional outcomes in patients with anterior shoulder instability treated by arthroscopic capsulolabral reconstruction (ACR) has not been studied. Purpose: To analyze isokinetic IR and ER strength and their correlation with clinical outcomes in patients with anterior shoulder instability treated by ACR. Study Design: Case series; Level of evidence, 4. Methods: Between January 2004 and June 2015, a total of 104 patients who underwent ACR for anterior shoulder instability were analyzed. The mean peak torque (PT) in IR (IRPT) and ER (ERPT), PT deficit (PTD; %) relative to the opposite healthy shoulder, and PT ratio (PTR; ERPT/IRPT) were calculated before and 1 year after surgery. Functional scores were evaluated before surgery and at every follow-up visit. Recurrence and postoperative apprehension during ER at 90° of arm abduction were evaluated at 1 year and the final follow-up (76.6 ± 64.4 months). Results: IR and ER strength were measured for 68 of 104 patients at 1 year after surgery. ERPT and IRPT were less on the involved side than on the uninvolved side before surgery (0.29 ± 0.10 vs 0.33 ± 0.10 N·m/kg, respectively, for ERPT [ P = .002]; 0.36 ± 0.14 vs 0.41 ± 0.16 N·m/kg, respectively; for IRPT [ P = .01]). At 1 year after surgery, IRPT on the involved side recovered (0.40 ± 0.20 N·m/kg), whereas ERPT remained weak (0.30 ± 0.13 N·m/kg) relative to the baseline value. PTD in IR (PTDIR) improved to 2.2% ± 24.4% ( P = .012), whereas PTD in ER (PTDER) showed no improvement (13.5% ± 13.8%; P = .569). PTR on the involved side improved from 1.07 ± 1.71 to 0.86 ± 0.23 at 1 year ( P < .001). All functional scores improved significantly at the final follow-up. At 1 year, 9 of 68 (13.2%) patients showed positive apprehension. PTDIR and PTDER on the involved side were worse in patients with positive apprehension than in those with negative apprehension ( P = .039 and .014, respectively). PTDER was worse than PTDIR in patients with positive apprehension at 1 year ( P = .022). Conclusion: For those with anterior shoulder instability, preoperative IR and ER strength of the involved shoulder were lower than those of the uninvolved shoulder. IRPT recovered, whereas ERPT remained weak after ACR. To prevent positive apprehension after surgery, IR and ER strengthening exercises are important, with more emphasis on exercises for ER.

Clinical and Radiographic Outcomes After Arthroscopic Iliac Bone Grafting for Traumatic Anterior Shoulder Instability with Significant Glenoid Bone Loss – A Minimum of Five-year Follow-up

Objectives: The choice of surgical options for traumatic anterior shoulder instability with severe glenoid bony defect remains controversial. The purpose of this study was to evaluate the outcomes after arthroscopic (AS) iliac grafting with capsulolabral reconstruction with a minimum of five-year follow-up. Methods: Subjects consisted of 24 patients (24 shoulders), including 22 males and 2 females, who underwent AS iliac bone grafting and were followed for more than five years. Eighteen shoulders were primary surgery, and 6 were revision surgery. The mean age at surgery was 30 years (range, 18-52), and the mean follow-up was 8 years (range, 5-11). The mean glenoid bony defect measured on preoperative 3D-CT was 22% (range, 20-28). All surgeries were performed under general anesthesia. Free bone graft with approximately 2.0 cm length and 0.8 cm height was harvested from the iliac crest with the patients in the supine position, (Figure 1) and then the patient was placed in the beach chair position. The bone graft was inserted in the glenohumeral joint and arthroscopically fixed to the anterior glenoid using 2 cannulated screws followed by soft tissue Bankart repair using four anchors. (Figure 2 Gr: graft GL: glenoid) Functional outcomes including Rowe score, sports return, and ROM were evaluated. Radiographic findings including Samilson osteoarthritis (OA) grade and graft evaluation using 3D-CT at the final follow-up were also evaluated. Results: No patients experienced re-dislocation after surgery except one patient. All patients returned to their sports after surgery except for one patient who was not engaged in any sports. The mean Rowe score improved significantly from 19 (range, 5-40) to 95 (range, 70-100) (p<.0001). Postoperative forward flexion showed significant improvement: 157 (range, 110-180) to 170 (range, 150-180) degrees (p=.006), but no improvement in external rotation: 56 (range, 30- 85) to 56 (range, 30-70) degrees, and internal rotation: T8 (range, T5-L5) to T10 (range, T7-L5) level. OA change progressed in 8 shoulders (40%). 3DCT at the final follow-up demonstrated remodeling of the graft in 20 shoulders (88%) and absorption in 3 shoulders (12%).Failure case: A 23-year-old male experienced re-dislocation of the left shoulder during snowboarding five-year after the index surgery. Healed graft fracture and screw breakage were confirmed on 3DCT images (Figure 3). Conclusion: AS iliac bone grafting for traumatic anterior shoulder instability with significant glenoid bone loss yielded a satisfactory outcome with a minimum of five-year follow-up. Although this is technically demanding procedure, AS iliac bone grafting with capsulolabral reconstruction for shoulders with severe glenoid bone loss is an effective and practical procedure. [Figure: see text][Figure: see text][Figure: see text]

Outcomes of arthroscopic capsulolabral reconstruction for anterior instability with greater than 20% glenoid bone defects: are Latarjet procedures absolutely indicated for these patients?

Background: Recent studies have reported high rates of recurrence of shoulder instability in patients with glenoid bone defects greater than 20% after capsulolabral reconstruction. The purpose of the present study was to evaluate the failure rate of arthroscopic capsulolabral reconstruction for the treatment of anterior instability in the presence of glenoid bone deficits >20%. Methods: Retrospective analyses were conducted among cases with anterior shoulder instability and glenoid bone defects of >20% that were treated by arthroscopic capsulolabral reconstruction with a minimum 2-year follow-up (30 cases). We included the following variables: age, bone defect size, instability severity index score (ISIS), on-/off-track assessment, incidence recurrent instability, and return to sports. Results: The mean glenoid bone defect size was 25.8% ± 4.2% (range, 20.4%–37.2%), and 18 cases (60%) had defects of >25%. Bony Bankart lesions were identified in 11 cases (36.7%). Eleven cases (36.7%) had ISIS scores >6 points and 21 cases (70%) had off-track lesions. No cases of recurrent instability were identified over a mean follow-up of 39.9 months (range, 24–86 months), but a sense of subluxation was reported by three patients. Return to sports at the preinjury level was possible in 24 cases (80%), and the average satisfaction rating was 92%. Conclusions: Arthroscopic soft tissue reconstruction was successful for treating anterior shoulder instability among patients with glenoid bone defects >20%, even enabling return to sports. Future studies should focus on determining the range of bone defect sizes that can be successfully managed by soft tissue repair.

Does Labral Reconstruction Prevent Osteoarthritis After Posterior Shoulder Instability: A Population-Based Study

Objectives: Diagnosis of and treatment for posterior shoulder instability (PSI) has improved with advances in surgical technique and radiographic imaging. It is unknown if PSI, or surgical measures to correct PSI, affect the progression of osteoarthritis in the glenohumeral joint. The purpose of this study is to evaluate the effect of posterior capsulolabral reconstruction (PCLR) and demographic risk factors on the rate of radiographic progression of osteoarthritis in shoulders with PSI. Methods: The study population included 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with an average follow up of 12.5years (range 5-23). Medical records were reviewed to evaluate patient demographics, surgical intervention, and radiographic progression of osteoarthritis. Kaplan Meier survival was used to estimate survival and Cox models were used to examine associations with osteoarthritis progression. Results: Overall, 16/115 (14%) patients had radiographic progression of glenohumeral arthritis with 5-year survival at 88.3% (95% CI 79.7%-97.3%). Age ≥30 at the time of instability was associated with arthritis progression (p<0.05). The number of previous dislocations, sport, and gender each did not affect progression (p>0.05). PCLR with at least one anchor along the posterior glenoid rim was performed in 56/115 (48%) of patients. There was no difference in the rate of radiographic arthritic progression in those who underwent PCLR and those who did not (7/56, 13% vs 10/59, 17%, p>0.05). One male patient who underwent PCLR progressed to end-stage arthritis, necessitating a shoulder arthroplasty at age 53. Conclusion: Radiographic progression of glenohumeral arthritis occurred 14% of patients with PSI. Age ≥30 at the time of initial instability was associated with radiographic progression of glenohumeral arthritis.