Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts. A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded. 177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.). The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates. Level II.

Purpose: The approach to resect subscapular and subrhomboid tumors needs elevation of the scapula. This is usually performed by detaching the muscles from the margo medialis of the scapula. We wish to communicate our technique of a longitudinal osteotomy of the margo medialis for improved refixation of the muscles. Patients and Methods: 5 patients with subscapular and one patient with a subrhomboid benign tumor were operated on using this technique. Results: All patients achieved stable healing and full functional recovery; only in one patient there was slightly reduced elevation of the arm. Conclusion: Elevation of the muscles inserting into the medial scapular margo with a small rim of bone facilitates refixation and allows for excellent restitution of function.

Chronische Massenrupturen bei jüngeren und aktiven Patienten können eine Herausforderung für den behandelnden Chirurgen darstellen. Das oberste Ziel bleibt die Wiederherstellung der Integrität der Rotatorenmanschette. Arthroskopische Débridements können kurzfristig v. a. bei älteren Patienten mit kleinem funktionellem Anspruch Nutzen erbringen, haben sich jedoch bei aktiven Patienten nicht bewährt. Extraanatomische Eingriffe wie Muskeltransfers können eine Alternative darstellen, sind jedoch mit höheren Komplikationsraten verbunden und biomechanisch hinsichtlich der Zugrichtung nicht optimal. Mit der Möglichkeit der Patch-Augmentation oder Interposition können früher als irreparabel bezeichnete Rupturen intraoperativ rekonstruiert und ausgedünnte Sehnen mit schlechter Qualität verstärkt werden. Zur Verfügung stehen Xenografts, Allografts und synthetische Patches. Der erste Xenograft wurde aus porciner intestinaler Submukosa hergestellt, sein Gebrauch wurde aufgrund schlechter Ergebnissen jedoch eingestellt. Die neue Generation der porcinen Xenografts besteht meist aus Dermis und ist bedeutend dicker als die früheren Versionen. Die meisten heute erhältlichen Allografts bestehen aus azellulärer humaner Dermis und werden sowohl zur Interposition wie auch zur Augmentation verwendet. Zunehmend werden synthetische Patches verwendet, von denen ebenfalls eine ganze Reihe seitens der Industrie zur Verfügung steht. Die meisten davon werden aus Polyethylenterephthalat hergestellt und dienen hauptsächlich der Verstärkung der Sehne. Leider ist die Datenlage zum Gebrauch der Patches noch immer sehr dünn, klare Leitlinien zur Anwendung fehlen. Aufgrund der aktuell erhältlichen Daten zeigt sich jedoch, dass die synthetischen Patches den Xenografts und den Allografts wahrscheinlich überlegen sind. Zudem konnte in einem eigenen Kollektiv eine kleinere Reruptur- oder Nichteinheilungsrate nach Rekonstruktion von massiven Rotatorenmanschettendefekten nachgewiesen werden als in der aktuellen Literatur beschrieben. Groß angelegte randomisiert-kontrollierte Studien fehlen jedoch.

Chronic large tears in younger and active patients can still represent a certain challenge for the treating surgeon. The ultimate objective is the restoration of the integrity of the rotator cuff. Arthroscopic debridement can be beneficial in the short-term, especially in older patients with low functional requirements; however, this is not the case with active patients. Extra-anatomical interventions, such as muscle transfer, can be an alternative but are associated with higher complication rates and with respect to the biomechanics are not optimal for the direction of movement. With the possibility of patch augmentation or interposition, tears that were previously considered to be irreparable can be intraoperatively reconstructed and thin tendons with poor quality can be strengthened. Currently available are xenografts, autografts and synthetic patches. The first xenografts were made from porcine intestinal submucosa but with poor results, which is why the use was discontinued. The new generation of porcine xenografts is mostly made of dermis and is substantially thicker than the earlier versions. Most currently available allografts consist of acellular human dermis and are used for interposition and augmentation. Synthetic patches are available as commercial products and increasingly being used. Most are made from polyethylene terephthalate and are mainly used for strengthening tendons. Unfortunately, the data situation on the use of patches is very thin and clear guidelines on the applications are lacking; however, based on the currently available data it has been shown that synthetic patches are probably superior to xenografts and allografts. In addition, in an in-house collective a lower retearing rate and/or a lower nonhealing rate after reconstruction of massive rotator cuff defects compared to those described in the current literature could be detected; however, large randomized controlled studies are lacking.

The ideal treatment strategy for traumatic anterior shoulder instability with glenoid bone loss in young, physically active patients is still controversial. This study examines sporting activity, the ability to practice sports and the ability to return to sports after the arthroscopic Latarjet procedure. A total of 47 physically active patients with an average age of 24.5 ± 5.9 years were included in the study and evaluated at a minimum of two years after surgical treatment using shoulder and sport-specific scores. The shoulder sport activity score, Brophy marx activity score, Athletic shoulder outcome scoring system and the SPORTS score were used to assess the ability to practice sports, the sporting activity and the ability to return to sports. To assess functional outcome and shoulder stability, the evaluation was conducted using the Western Ontario shoulder instability index, the Constant score, the American shoulder and elbow surgeon score, and the Subjective shoulder value. 89.4% of the patients examined were able to perform the sport they had previously practiced after an average of 4.6 ± 2.0 months. Overhead athletes and martial arts athletes demonstrated a significantly lower return to sports rate than non-collision/non-overhead athletes (p = 0.01). With regard to sport-, instability-, or function-specific scores, no significant difference was found between patients after primary Latarjet procedure and patients after Latarjet procedure following a failed open or arthroscopic Bankart repair. All scores showed good to very good functional results on average. Two patients suffered a traumatic recurrent instability (4.1%) during the follow-up period and were therefore excluded from this study. Arthroscopic Latarjet procedure presents a good surgical option, especially for young, physically active patients; it has very good clinical outcome, a high return to sports rate and a low probability of recurrent dislocation.

BACKGROUND:The optimal technique for arthroscopic rotator cuff repair is still controversial. Large tears with a high grade of retraction have an especially high risk of retearing. This study reports the clinical and radiologic results of a triple-row modified suture bridge technique for the treatment of full-thickness rotator cuff tears with medium and high grades of retraction. METHODS:A total of 101 shoulders in 100 patients underwent a triple-row modified suture bridge reconstruction for full-thickness rotator cuff tears with retraction grade II and grade III according to Patte; 81 patients were reached for follow-up 36.2 months after surgery. At follow-up, clinical outcome was assessed by the American Shoulder and Elbow Surgeons score, subjective shoulder value, visual analog scale score, University of California-Los Angeles shoulder score, and Constant score (CS). At follow-up, an ultrasound examination was performed to determine tendon integrity or retears in all patients. RESULTS:The overall retear rate was 4.9% (4/81). The clinical outcome was good to excellent (American Shoulder and Elbow Surgeons score, 94 ± 11; subjective shoulder value, 92 ± 12; University of California-Los Angeles shoulder score, 33 ± 5; Constant score, 90 ± 9). In the radiologic follow-up, no retear was found in any of the follow-up patients after an average of 36.2 months. There was no significant difference in clinical outcome parameters between rotator cuff tears Patte II and Patte III (P > .05). CONCLUSION:For tears with a high grade of retraction, surgical treatment using a triple-row modified suture bridge technique represents a good treatment option with a low rate of retearing and good to excellent clinical results.

Background: Massive rotator cuff (RC) tears still present a clinically challenging problem, with reported rerupture rates in up to 94%. The study objective was to determine the impact of synthetic patch augmentation for massive RC tears. Methods: Between June 2012 and 2014, we performed 50 arthroscopic RC reconstructions augmented with a synthetic polyester patch. Pre- and postoperative imaging methods included arthrographic magnetic resonance imaging, arthrographic computed tomography, and ultrasound examination to determine tendon integrity or rerupture. Clinical outcome was evaluated using the Constant-Murley score and the subjective shoulder value. Mean clinical midterm and final follow-up was 22 months (9-35 months) and 52 months (25-74 months), respectively. Results: The mean Constant-Murley score increased significantly from 36.5 (+/- 16.4 standard deviation [SD]) preoperatively to a midterm value of 81.2 (+/- 9.6 SD; P < .0001) and further improved to a mean of 83.4 (+/- 10.8 SD) at final follow-up. The mean subjective shoulder value increased from 40.3 (+/- 24.3 SD) to 89.2 (+/- 12.9 SD; P < .0001) at midterm and to 89.6 (+/- 15.2 SD) at final follow-up. We observed 7 complete reruptures (14%). However, reruptures did not correlate with revision surgery, which was performed in 8 patients. The main reason for revision was frozen shoulder or arthrofibrosis with an intact reconstruction and patch, which was performed in 6 cases. Conclusions: The retear rate of 14% compared favorably with nonaugmented RC repairs in the literature. Therefore, we conclude that patch augmentation in massive RC tears is feasible to reduce retears and to improve clinical outcome. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Purpose: To analyze the learning curves of 5 experienced, fellowship-trained shoulder surgeons and their respective 25 first arthroscopic Latarjet cases in regard to surgical time, graft placement, complication rates, and recurrent instability. Methods: The first 25 arthroscopic Latarjet procedures of 5 surgeons were retrospectively analyzed in an international multicenter setting, and thus 125 patients were included in this study. The surgical time, intraoperative and postoperative events out of the ordinary, and graft positioning were examined. Results: The 125 patients consisted of 16 women (12.8%) and 109 men (87.2%). In 81.6% (n = 102), surgery was undertaken as a first-line procedure, whereas 18.4% (n = 23) were revisions. Surgical time decreased significantly from an average of 123.8 minutes (range 70 to 210) to 92.6 minutes (range 50 to 160) from the first 5 cases to the last 5 cases of each surgeon within a period of < 2 years. Overall, 22 events in 21 patients requiring additional treatment were reported (17.6%). Five (4%) were unlikely to affect final outcome and did not require revision surgery. Twelve (9.6%) required revision surgery that was not trauma related yet was prone to affect outcomes. Five events were trauma-related (4%), 4 requiring revision surgery and 1 treated conservatively. Overall, 6 patients (4.8%) had recurrent shoulder instability, 3 as a result of a traumatic event. Conventional radiology showed the bone-block in ideal positioning in 93 cases (74.4%), flush with the glenoid in a true anteroposterior view. In 3 cases (2.4%), it was considered too high, 15 too low (12%), 5 too lateral (4%), and 15 too medial (12%). Some patients had combinations of the above. Conclusion: This analysis shows that surgical time in arthroscopic Latarjet can be significantly reduced after only 20 cases. However, complication rates did not decrease over this time. The authors believe that the arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting.

Background The treatment of anterior glenohumeral instability with a Bankart repair combined with a capsular plication is a frequently used arthroscopic technique. Latarjet created an open bone block procedure in 1954 for the treatment of anteroinferior glenohumeral instability. This procedure has been further developed by Lafosse in 2003 for arthroscopic surgery. The aim of this study is to evaluate the clinical outcome and complications of the latter procedure, most notably infection rate and nerve damage. Materials and Methods 132 shoulders (106 males/19 females, 68 right/64 left) were included in this retrospective study. Patients were included if treatment was performed for anterior instability and if the patient’s instability severity index score was at least 4, or if a revision procedure was performed after a prior unsuccessful arthroscopic or open capsule and labral repair. Treatment included the arthroscopic transfer of the coracoid process for the anterior stabilization of the shoulder joint. The disabilities of the arm, shoulder, and hand score were evaluated postoperatively in 76 patients and compared with the results found in the literature. Mean followup was 20.1 [±14.09] months. Results The rate of recurrent glenohumeral instability which needed revision surgery after the arthroscopic Latarjet procedure was 6.1% ( n = 8). There were no severe neurovascular complications seen in our cohort. In 32 cases, re-operation was performed due to subjective discomfort because of screw impingement or postoperative shoulder stiffness. Conclusion The all-arthroscopic Latarjet procedure developed by Lafosse is a valid and reliable method for the treatment of shoulder instability. Our favorable results indicating that this procedure can prevent chronic shoulder luxation are repeatable, and the rate of postoperative recurrence is low.

Introduction: The open Latarjet procedure has a proven record of success in the treatment of shoulder instability. With the recent development of arthroscopic Latatjet techniques, it is important to evaluate complication rates from six arthroscopic Latarjet specialist surgeons. Material and Methods: This study is a multicenter retrospective review of complications of 1555 arthroscopic Latarjet procedures for the treatment of chronic shoulder instability. Each of the six centers included all patients undergoing arthroscopic Latarjet since the beginning of each surgeon's arthroscopic Latarjet experience. The same fixation technique with two screws was used. The study reports on 1 to 10 years of experience. Results: Of the 1555 cases reviewed, there were 4 (0.2%) severe neurological complications, 10 (0.6%) infections, 7 (0.4%) hematomas, 14 (1%) fractures of the graft, and 30 (2%) cases of recurrent instability. 58 (3.7%) patients required an additional surgery due to these complications. Hardware removal was not included in these complications. Conclusion: This multicenter analysis of 6 arthroscopic Latarjet specialists shows a lower complication rate than previously reported in the literature. This retrospective analysis demonstrates that the arthroscopic Latarjet technique was reproducible among the six surgeons. While we report a low complication rate in this series of expert surgeons, the difficulty of this procedure should not be underestimated. The complications when they happen can be serious and difficult to manage.

Background: Massive rotator cuff tendon tears have a poor clinical prognosis. This holds especially true in older patients and after revision surgery. In order to reduce tears and increase long term shoulder parameters, patches made of a variety of materials have been applied to reinforce sutures in current orthopaedic practice. Material and Methods: In a clinical study on rotator cuff surgery from 2005 to 2011 (date of surgical intervention), we tested the efficacy of three different commercial patches, with 89 patients (63 m/26 w) enrolled with a mean age of over 60. Graft Jacket, a regenerative stable human tissue scaffold, Artelon, a slow-resorbable polyurethane-urea patch and Restore, an orthobiological degradable graft, were arthroscopically implanted in order to augment the fragile tendon-bone interface after massive tears of 2 to 3 tendons (supraspinatus and/or infraspinatus and/or subscapularis). Results: An overall repair integrity score of 75 % was achieved in primary rotator cuff surgery and of 65 % in revision surgery with either non- or slowly resorbable patches outperforming the degradable material. This effect is more marked after primary surgery. CS values indicate overall patient recovery at 6 months of 81.43 vs. 47.29 for Graft Jacket, 81.34 vs. 46.18 for Artelon and 78.45 vs. 41.93 for Restore. Subjective shoulder value (SSV) at 3 years increased to 9.11 vs. 4.32 for Graft Jacket, 9.31 vs. 3.53 for Artelon and 9.45 vs. 2.9 for Restore. No severe adverse affects were encountered. Conclusions: Tendons with reduced mechanical characteristics can greatly profit from patch augmentation. This holds especially true for older patients and in revision surgery. The success rate of our patch studies was up to 87 % for Graft Jacket in primary rotator cuff surgery and a minimum of 58.3 % for Restore in pure revision surgery (comparable studies/metastudies on massive rotator cuff tear repair success rates range from 43 to 59 %). This paves the way for a continued search for better and more intelligent materials. Yield load, stiffness and ultimate load will probably improve further in the very near future.

Le but de ce travail est de comparer 3 techniques de butée de type Latarjet ciel ouvert avec vis (C0), arthroscopique avec vis (AV) et arthroscopique avec endobouton (AB).

PURPOSE:To macroscopically, histologically, and radiologically describe a time-dependent remodeling process of a neo-tendon or -ligament in the shoulder after the arthroscopic Latarjet procedure. METHODS:During follow-up surgery after the arthroscopic Latarjet procedure, 17 shoulders in 16 patients were evaluated for a remodeled tendon-like structure. The mean overall follow-up period was 27.4 months. The mean time between the arthroscopic Latarjet procedure and revision was 11.6 months. All shoulders were evaluated with magnetic resonance imaging, and seven histologic specimens were obtained during revision surgery. RESULTS:A distinct, oriented strand of tissue was found in 16 of 17 shoulders on revision surgery. Postoperative magnetic resonance imaging analyses showed a signal-free, longitudinal tendon-like structure originating at the tip of the acromion, traversing the space of the former subcoracoid bursa to attach in the course of the transposed conjoint tendon or the proximal short head of the biceps. Histologic analysis of seven specimens showed a characteristic timeline of remodeling. CONCLUSIONS:A tendon- or ligament-like structure is remodeled between the anterior bottom tip of the acromion and the transposed coracoid process in a time-dependent manner after the arthroscopic Latarjet procedure. LEVEL OF EVIDENCE:Level IV, therapeutic case series.

Background: The Latarjet-Patte procedure consisting in transfer and screw fixation of the coracoid process to the anterior glenoid is a treatment of reference for anterior shoulder instability. Over time, surgical innovations translated into a number of improvements and, in late 2003, an arthroscopically assisted variant of the procedure was described.Objective: To evaluate and compare clinical outcomes of the modified Latarjet-Patte procedure performed by open surgery, arthroscopy with screw fixation, or arthroscopy with endobutton fixation.Material and method: A total of 390 patients who underwent surgery to treat anterior shoulder instability between March 2013 and June 2014 were included and divided into three groups depending on whether they were managed using open surgery with screw fixation, arthroscopy with screw fixation, or arthroscopy with endobutton fixation. Clinical findings were recorded pre-operatively then 6 months post-operatively and at last follow-up (mean, 27.7 months). Range of motion and apprehension test (arm in external rotation at 0, 90, and 140 of abduction) were assessed and the Walch-Duplay and modified Rowe scores were determined.Results: Motion range restriction was minimal with all three techniques, and motion range continued to improve throughout follow-up. Apprehension in external rotation was noted at 90 of abduction in 11% of cases and at 140 of abduction in 4% of cases. The mean total Walch-Duplay score improved from 46 pre-operatively to 90.6 and the mean total modified Rowe score from 46 pre-operatively to 91.1. By statistical analysis, external rotation at 90 of abduction and internal rotation at 0 of abduction were better after open surgery, but the differences were of limited clinical significance. Recurrence was noted in 3.3% of cases, nerve injury in 0.8%, and infection in 1.5%.Conclusion: In this study, the three techniques produced similar clinical outcomes, with a stable shoulder and no joint stiffness. (C) 2016 Elsevier Masson SAS. All rights reserved.

Resume Introduction Le traitement de l’instabilite anterieure de l’epaule par butee coracoidienne vissee est une technique de reference, qui a beneficie des innovations chirurgicales, ce qui en a permis l’amelioration, puis l’adaptation arthroscopique des fin 2003. Objectif Cette etude evalue et compare les resultats cliniques de la butee coracoidienne vissee selon la technique de Patte modifiee, de la butee coracoidienne vissee sous arthroscopie et de la butee coracoidienne fixee par endoboutons. Materiel et methode Entre mars 2013 et juin 2014, 390 patients souffrant d’une instabilite anterieure de l’epaule ont ete operes et inclus dans 3 groupes : le groupe « Latarjet » correspondant a la butee vissee conventionnelle, le groupe « Arthro-Vis » correspondant a la butee vissee sous arthroscopie et le groupe « Arthro-boutons » pour la fixation par endoboutons. Les donnees de l’examen clinique ont ete colligees en preoperatoire, a 6 mois et au plus long recul (moyenne : 27,7 mois). Elles ont permis d’evaluer les amplitudes et l’apprehension (rotation externe et abduction a 0°, a 90° et a 140°). Les scores Walch-Duplay et Rowe modifie ont egalement ete realises. Resultats La perte d’amplitudes a ete tres faible, quelle que soit la technique avec des progres jusqu’au plus grand recul. Une apprehension en RE ABD 90° a ete retrouvee dans 11 % des cas et en RE ABD 140° dans 4 % des cas. Le score de Walch-Duplay moyen global passe de 46 en preoperatoire a 90,6 et le score de Rowe modifie moyen global passe de 46 a 91,1. Statistiquement, la technique conventionnelle a donne de meilleures amplitudes en RE2, RI1, mais cliniquement la difference est restee modeste. Nous avons retrouve 3,3 % de recidive, 0,8 % de lesion neurologique et 1,5 % d’infection. Conclusion Cette etude a mis en evidence des resultats cliniques superposables. La butee coracoidienne permet d’obtenir une epaule stable sans enraidissement articulaire, quelle que soit la technique. Niveau de preuve Etude observationnelle multicentrique non randomisee de niveau III.

INTRODUCTION:Full thickness rotator cuff tears are a common cause of shoulder pain and disability. While the role of the rotator cuff seems to be well known, the clinical significance of the biceps tendon for shoulder function has still been a subject of controversy. The aim of this study was to evaluate differences between tenodesis or tenotomy in simultaneous rotator cuff repair.METHODS:For this retrospective study 53 consecutive patients (25f/28m, Ø age 58 years) undergoing arthroscopic double row rotator cuff reconstruction and suture bridge repair were included. The LHB was treated with tenodesis (n = 24) or tenotomy (n = 29). Clinical examination was carried out for all patients after an average of 34 months (range 27–38) following arthroscopic surgery. The Constant score, level of pain, range of motion in flexion and abduction, and isometric force for the operated and healthy shoulder in flexion and abduction were recorded.RESULTS:Patients in the tenodesis and tenotomy group reached similar good result regarding the Constant score (86.6 ± 11.9 vs. 81.3 ± 12.2; P = 0.120), pain (median 0, range 0–8 vs. Median 0, range 0–10; P = 0.421), and range of motion (flexion: median 180°, range 90°–180° vs. median 180°, range 90°–180°; P = 0.833; abduction: median 180°, range 90°–180° vs. median 180°, range 120°–180°; P = 0.472). Postoperative popeye sign was found only in one patient (1.9 %). At the time of postoperative follow-up, no patient reported cramping of the biceps. Isometric forces in abduction of the tenotomy group (mean 4.7 ± 2.9 kg; maximum 5.5 ± 2.8 kg) was significant lower compared to the tenodesis group (mean 6.6 ± 3.0 kg, P = 0.019; maximum 7.7 ± 2.9 kg, P = 0.007) and compared to healthy shoulders (mean 6.1 ± 3.0 kg P = 0.004; maximum 7.4 ± 3.1 kg, P = 0.001), all other measurements were similar.CONCLUSION:According to our results arthroscopic biceps tenodesis and tenotomy are valuable procedures in simultaneous rotator cuff repair regarding function, pain, and range of motion. However, the tenotomy group showed reduced strength in abduction.LEVEL OF EVIDENCE:Level IV, retrospective case series.