J Shoulder Elbow Surg (2014) -, 1-8
www.elsevier.com/locate/ymse
Graft osteolysis and recurrent instability after the Latarjet procedure performed with bioabsorbable screw fixation Jean-Christian Balestro, MDa,*, Allan Young, FRACS, PHDa, Cristobal Maccioni, MDa, Gilles Walch, MDb a b
Sydney Shoulder Research Institute, Sydney, NSW, Australia Centre Orthopedique Santy, H^ opital Prive Jean Mermoz, Lyon, France Hypothesis and Background: The Latarjet procedure is a reliable treatment of recurrent anterior shoulder instability. The coracoid process is usually fixed with metallic screws; however, these can lead to irritation and the necessity for hardware removal and also can produce artifacts on imaging studies. The use of resorbable screws could avoid these complications. The purpose of this study was to assess the clinical results of the Latarjet procedure performed with bioabsorbable screws in addition to healing of the graft and resorption of the screws. Methods: In 2009, we performed a prospective study (case series, Level of evidence: IV) of 11 patients (12 shoulders) who underwent a Latarjet procedure fixed with resorbable screws. Each patient was observed clinically and had a computed tomography scan at 3 months and 2 years of follow-up. Results: Every graft healed at 3-month follow-up. At 2-year follow-up, 4 patients had at least one instability episode, and one underwent a revision surgery. Three of these 4 patients were unhappy or disappointed. The Walch-Duplay score was excellent or good for 7 shoulders and medium or poor for 5. Screw resorption appeared complete in every case. No drill hole enlargement was observed. Every drill hole was partially filled with bone. Of 12 shoulders, 8 (66.67%) were associated with a severe osteolysis and an almost complete disappearance of the graft. Conclusion: Coracoid graft osteolysis, previously reported after the Latarjet procedure, appears to be exacerbated with a risk of complete disappearance of the graft when the procedure is performed with the bioabsorbable screws used in this study. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Shoulder instability; Latarjet procedure; coracoid graft; resorbable screws; osteolysis
Ethical committee and Institutional Review Board: Centre Orthopedique Santy, H^ opital Prive Jean Mermoz: Number 2014-02. *Reprint requests: Jean-Christian Balestro, MD, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia. E-mail address: [email protected] (J.-C. Balestro).
The Latarjet-Bristow procedure is a reliable and safe procedure for management of recurrent anterior instability, particularly in cases with significant bone loss.12,34,46,48 Traditionally, the coracoid graft has been fixed to the glenoid with metallic screws. One of the reported reasons for
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.07.014
2 revision surgery relates to screw removal5,13,35 because of pain related to irritation from the head of the screw. This occurred in a small but appreciable incidence of 2% to 3% in our experience of more than 2000 cases. Other concerns with metallic screws are interference artifacts with followup imaging studies and the risk of chondral damage to the humeral head if an extensive graft osteolysis appears. To avoid these potential problems, we proposed use of bioabsorbable screws for fixation of the coracoid graft. Our primary concern was the ability of the graft to heal satisfactorily with the use of bioabsorbable screws. The screws must provide sufficient compression to encourage bone union and need to maintain their strength until the graft has healed sufficiently, typically at 3 months postoperatively. Finally, osteolysis or drill hole enlargement, which has been reported with the use of bioabsorbable implants for other applications,2,3,23,38,42,44 could increase the risk of secondary fractures and recurrent shoulder instability.
Materials and methods The open Latarjet procedure is the senior author’s primary procedure for recurrent anterior instability. In 2009, we conducted a prospective study (case series without comparison group, Level IV) of 12 open Latarjet-Bristow procedures performed with bioabsorbable screws in 11 patients with recurrent anterior instability. Seven of the patients were male and 4 female. Ten of the 11 patients were right-hand dominant, and 6 of the procedures were performed on the dominant shoulder. The mean age at the time of surgery was 28.6 years (16.6-43.3 years). All patients had a preoperative positive apprehension test result and positive relocation test result.30,47 One patient for whom both shoulders were operated on was noted to have congenital hyperlaxity in addition to traumatic instability (preoperative imaging demonstrating both Bankart and Hill-Sachs lesions bilaterally). Preoperatively, 2 patients presented with a bony Bankart lesion and 3 with a bone loss of the anteroinferior glenoid rim.
Bioabsorbable screws The screws used in this study were 4.5-mm bioabsorbable compression screws (RFS [Resorbable Fixation System]; Tornier, TX, USA) composed of L-lactic/co-glycolic acid copolymer (PLGA 85L/15G) (Fig. 1). The screws were inserted according to the manufacturer’s instructions. These screws are reported to maintain their original strength for the initial 8 weeks, with complete absorption taking place within 2 years. These polymers degrade in vivo by hydrolysis into a-hydroxy acids that are metabolized by the body. The screws are designed to be compatible with AO instrumentation and include a disposable metallic insertion adapter.
Surgical technique The procedure was performed as previously described,48 derived from the Latarjet technique34 and modified by Patte.40 Under general anesthesia and interscalene block, the patient was placed in the beach chair position. A vertical skin incision was made from
J.-C. Balestro et al.
Figure 1 RFS (Resorbable Fixation System; Tornier, TX, USA) screw made of L-lactic/co-glycolic acid copolymer PLGA 85L/ 15G, with adapter allowing AO instrumentation compatibility. the tip of the coracoid process extending 5 cm toward the axillary fold. A limited deltopectoral approach was used. The coracoacromial ligament was divided 1 cm from its insertion on the coracoid process, and the pectoralis minor was released from the coracoid process. The coracoid process was then osteotomized between its horizontal and vertical parts. The cortex of the inferior aspect was removed to create a flat cancellous bone surface. Two holes were drilled with a 3.2-mm drill bit approximately 1 cm apart (one superior, one inferior) and then prepared with a 4.5-mm tap and a countersink. The subscapularis muscle was divided in line with its fibers at the junction of the superior two thirds and inferior third to expose the anterior capsule. A vertical arthrotomy was performed and an intra-articular retractor placed. The Bankart lesion with any anterior periosteal sleeve was excised. The anterior cortex of the glenoid was removed to provide a flat cancellous bed. The inferior hole was drilled into the glenoid and tapped with a 4.5-mm tap. The coracoid graft was then fixed with the first screw to lie flush with the glenoid articular surface. A 4.5-mm bioabsorbable screw (RFS screw), typically 35 mm in length, was inserted by a 2-finger technique to avoid overtightening. Definitive fixation was achieved by drilling the superior hole through the coracoid and the glenoid, tapping, determining screw length, and inserting a second 4.5-mm bioabsorbable screw. The initial screw was further tightened to ensure adequate compression of the graft. The position of the graft was checked to ensure that it was lying flush with the glenoid articular surface and, importantly, that there was no lateral overhang. Last, the coracoacromial ligament stump was sutured to the anterior capsule with the arm positioned in maximal external rotation.
Postoperative rehabilitation The patients wore a simple sling for 15 days. Rehabilitation with self-mobilization exercises in elevation and external rotation was commenced at day 1 after surgery. Usual activities of daily living were allowed at day 15, and at 1 month, patients could progressively resume athletic conditioning (e.g., jogging, cycling, swimming) without any strengthening exercises for the upper limbs. Progressive return to sporting activities, including contact sports, was allowed at 3 months after clinical and radiographic
Latarjet procedure fixed with resorbable screws
3
Figure 2 Complete healing demonstrated on CT scan with the graft lying flush with the glenoid (A) and with the screws still visible at 3 months (B). evaluation demonstrating satisfactory healing of the coracoid graft.
Clinical assessment Patients were clinically reviewed with a minimum of 2 years of follow-up or assessed by telephone when they were not available for a clinical examination. Any episode of dislocation or subluxation was recorded. The subjective shoulder value as well as the patient’s satisfaction was noted. The Walch-Duplay score for instability was also calculated and categorized as excellent (91100 points), good (76-90 points), medium (51-75 points), or poor (
www.elsevier.com/locate/ymse
Graft osteolysis and recurrent instability after the Latarjet procedure performed with bioabsorbable screw fixation Jean-Christian Balestro, MDa,*, Allan Young, FRACS, PHDa, Cristobal Maccioni, MDa, Gilles Walch, MDb a b
Sydney Shoulder Research Institute, Sydney, NSW, Australia Centre Orthopedique Santy, H^ opital Prive Jean Mermoz, Lyon, France Hypothesis and Background: The Latarjet procedure is a reliable treatment of recurrent anterior shoulder instability. The coracoid process is usually fixed with metallic screws; however, these can lead to irritation and the necessity for hardware removal and also can produce artifacts on imaging studies. The use of resorbable screws could avoid these complications. The purpose of this study was to assess the clinical results of the Latarjet procedure performed with bioabsorbable screws in addition to healing of the graft and resorption of the screws. Methods: In 2009, we performed a prospective study (case series, Level of evidence: IV) of 11 patients (12 shoulders) who underwent a Latarjet procedure fixed with resorbable screws. Each patient was observed clinically and had a computed tomography scan at 3 months and 2 years of follow-up. Results: Every graft healed at 3-month follow-up. At 2-year follow-up, 4 patients had at least one instability episode, and one underwent a revision surgery. Three of these 4 patients were unhappy or disappointed. The Walch-Duplay score was excellent or good for 7 shoulders and medium or poor for 5. Screw resorption appeared complete in every case. No drill hole enlargement was observed. Every drill hole was partially filled with bone. Of 12 shoulders, 8 (66.67%) were associated with a severe osteolysis and an almost complete disappearance of the graft. Conclusion: Coracoid graft osteolysis, previously reported after the Latarjet procedure, appears to be exacerbated with a risk of complete disappearance of the graft when the procedure is performed with the bioabsorbable screws used in this study. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Shoulder instability; Latarjet procedure; coracoid graft; resorbable screws; osteolysis
Ethical committee and Institutional Review Board: Centre Orthopedique Santy, H^ opital Prive Jean Mermoz: Number 2014-02. *Reprint requests: Jean-Christian Balestro, MD, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia. E-mail address: [email protected] (J.-C. Balestro).
The Latarjet-Bristow procedure is a reliable and safe procedure for management of recurrent anterior instability, particularly in cases with significant bone loss.12,34,46,48 Traditionally, the coracoid graft has been fixed to the glenoid with metallic screws. One of the reported reasons for
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.07.014
2 revision surgery relates to screw removal5,13,35 because of pain related to irritation from the head of the screw. This occurred in a small but appreciable incidence of 2% to 3% in our experience of more than 2000 cases. Other concerns with metallic screws are interference artifacts with followup imaging studies and the risk of chondral damage to the humeral head if an extensive graft osteolysis appears. To avoid these potential problems, we proposed use of bioabsorbable screws for fixation of the coracoid graft. Our primary concern was the ability of the graft to heal satisfactorily with the use of bioabsorbable screws. The screws must provide sufficient compression to encourage bone union and need to maintain their strength until the graft has healed sufficiently, typically at 3 months postoperatively. Finally, osteolysis or drill hole enlargement, which has been reported with the use of bioabsorbable implants for other applications,2,3,23,38,42,44 could increase the risk of secondary fractures and recurrent shoulder instability.
Materials and methods The open Latarjet procedure is the senior author’s primary procedure for recurrent anterior instability. In 2009, we conducted a prospective study (case series without comparison group, Level IV) of 12 open Latarjet-Bristow procedures performed with bioabsorbable screws in 11 patients with recurrent anterior instability. Seven of the patients were male and 4 female. Ten of the 11 patients were right-hand dominant, and 6 of the procedures were performed on the dominant shoulder. The mean age at the time of surgery was 28.6 years (16.6-43.3 years). All patients had a preoperative positive apprehension test result and positive relocation test result.30,47 One patient for whom both shoulders were operated on was noted to have congenital hyperlaxity in addition to traumatic instability (preoperative imaging demonstrating both Bankart and Hill-Sachs lesions bilaterally). Preoperatively, 2 patients presented with a bony Bankart lesion and 3 with a bone loss of the anteroinferior glenoid rim.
Bioabsorbable screws The screws used in this study were 4.5-mm bioabsorbable compression screws (RFS [Resorbable Fixation System]; Tornier, TX, USA) composed of L-lactic/co-glycolic acid copolymer (PLGA 85L/15G) (Fig. 1). The screws were inserted according to the manufacturer’s instructions. These screws are reported to maintain their original strength for the initial 8 weeks, with complete absorption taking place within 2 years. These polymers degrade in vivo by hydrolysis into a-hydroxy acids that are metabolized by the body. The screws are designed to be compatible with AO instrumentation and include a disposable metallic insertion adapter.
Surgical technique The procedure was performed as previously described,48 derived from the Latarjet technique34 and modified by Patte.40 Under general anesthesia and interscalene block, the patient was placed in the beach chair position. A vertical skin incision was made from
J.-C. Balestro et al.
Figure 1 RFS (Resorbable Fixation System; Tornier, TX, USA) screw made of L-lactic/co-glycolic acid copolymer PLGA 85L/ 15G, with adapter allowing AO instrumentation compatibility. the tip of the coracoid process extending 5 cm toward the axillary fold. A limited deltopectoral approach was used. The coracoacromial ligament was divided 1 cm from its insertion on the coracoid process, and the pectoralis minor was released from the coracoid process. The coracoid process was then osteotomized between its horizontal and vertical parts. The cortex of the inferior aspect was removed to create a flat cancellous bone surface. Two holes were drilled with a 3.2-mm drill bit approximately 1 cm apart (one superior, one inferior) and then prepared with a 4.5-mm tap and a countersink. The subscapularis muscle was divided in line with its fibers at the junction of the superior two thirds and inferior third to expose the anterior capsule. A vertical arthrotomy was performed and an intra-articular retractor placed. The Bankart lesion with any anterior periosteal sleeve was excised. The anterior cortex of the glenoid was removed to provide a flat cancellous bed. The inferior hole was drilled into the glenoid and tapped with a 4.5-mm tap. The coracoid graft was then fixed with the first screw to lie flush with the glenoid articular surface. A 4.5-mm bioabsorbable screw (RFS screw), typically 35 mm in length, was inserted by a 2-finger technique to avoid overtightening. Definitive fixation was achieved by drilling the superior hole through the coracoid and the glenoid, tapping, determining screw length, and inserting a second 4.5-mm bioabsorbable screw. The initial screw was further tightened to ensure adequate compression of the graft. The position of the graft was checked to ensure that it was lying flush with the glenoid articular surface and, importantly, that there was no lateral overhang. Last, the coracoacromial ligament stump was sutured to the anterior capsule with the arm positioned in maximal external rotation.
Postoperative rehabilitation The patients wore a simple sling for 15 days. Rehabilitation with self-mobilization exercises in elevation and external rotation was commenced at day 1 after surgery. Usual activities of daily living were allowed at day 15, and at 1 month, patients could progressively resume athletic conditioning (e.g., jogging, cycling, swimming) without any strengthening exercises for the upper limbs. Progressive return to sporting activities, including contact sports, was allowed at 3 months after clinical and radiographic
Latarjet procedure fixed with resorbable screws
3
Figure 2 Complete healing demonstrated on CT scan with the graft lying flush with the glenoid (A) and with the screws still visible at 3 months (B). evaluation demonstrating satisfactory healing of the coracoid graft.
Clinical assessment Patients were clinically reviewed with a minimum of 2 years of follow-up or assessed by telephone when they were not available for a clinical examination. Any episode of dislocation or subluxation was recorded. The subjective shoulder value as well as the patient’s satisfaction was noted. The Walch-Duplay score for instability was also calculated and categorized as excellent (91100 points), good (76-90 points), medium (51-75 points), or poor (
