Alberto Costantini

Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients

BACKGROUND The Latarjet procedure has been advocated as an option for the treatment of anteroinferior shoulder instability in certain patients. However, progression of the transferred coracoid bone graft to osteolysis has been reported in the literature. We propose that the coracoid bone graft osteolysis could be one of the causes of failure of the Latarjet procedure. MATERIALS AND METHODS A computed tomography scan analysis was done of 26 patients prospectively followed-up after the Latarjet procedure to determine the location and the amount of the coracoid graft osteolysis. RESULTS The most relevant osteolysis was represented by the superficial part of the proximal coracoid, whereas the distal region of the coracoid bone graft, especially in the deep portion, was the least involved in osteolysis and had the best bone healing. DISCUSSION To our knowledge, this is the first study to quantify and localize coracoid osteolysis after Latarjet procedure for anteroinferior shoulder instability using CT scan analysis. CONCLUSION Our study suggests that the bone-block effect from the Latarjet procedure may not be the principal effect in its treatment of anteroinferior shoulder instability in patients without significant bony defects.

Postoperative analgesia for arthroscopic shoulder surgery: a prospective randomized controlled study of intraarticular, subacromial injection, interscalenic brachial plexus block and intraarticular plus subacromial injection efficacy.

Background and objectives The aim of the present study was to compare the new combination of intraarticular + subacromial injection, with intraarticular, subacromial injection and interscalenic brachial plexus block as postoperative analgesia in shoulder arthroscopy. Methods One hundred and twenty patients scheduled for shoulder arthroscopy were enrolled and randomly assigned to one of five groups: intraarticular, subacromial, interscalenic brachial plexus block (IBPB), intraarticular + subacromial (intraarticular + subacromial) injection or a control group. All patients received standardized general anaesthesia and all the injections were given with the same dose and volume of local anaesthetic. The number of boluses (fentanyl 1 μg kg−1) delivered by a patient-controlled analgesia pump applied at the end of the surgery and the visual analogue pain score (VAPS) at 0, 2, 4, 6, 12, 18 and 24 h after the intervention were recorded. A patient satisfaction score was also assessed at 24 h. Results Mean bolus consumption, compared with control group, was significantly less in all groups (P < 0.01). Intraarticular + subacromial group utilized fewer boluses compared with subacromial group and significantly lower boluses than intraarticular group (P < 0.01), but IBPB group utilized significantly fewer boluses than intraarticular + subacromial group. Patients in IBPB, intraarticular + subacromial and subacromial groups showed VAPSs that were significantly better than that of the control group at all time points (P < 0.01). The VAPS in intraarticular + subacromial group was statistically comparable with those in IBPB and subacromial groups at each time interval. IBPB and intraarticular + subacromial groups showed comparable patient satisfaction scores. Conclusion These results confirm the analgesic efficacy of IBPB for shoulder surgery. Nonetheless, the combination of intraarticular and subacromial infiltration, studied for the first time, appears to be a clinically valid alternative with no clinical meaningful adverse effects.

Atlas of functional shoulder anatomy

Scapulothoracic Joint.- Acromioclavicular Joint and Scapular Ligaments.- Glenohumeral Joint (Muscle-Tendon).- Glenohumeral Capsule.- Neuromuscular Control and Proprioception of the Shoulder.

Coracoid bone graft osteolysis after Latarjet procedure: A comparison study between two screws standard technique vs mini-plate fixation

Aims: One of the reason for Latarjet procedure failure may be coracoid graft osteolysis. In this study, we aimed to understand if a better compression between the coracoid process and the glenoid, using a mini-plate fixation during the Latarjet procedure, could reduce the amount of coracoid graft osteolysis. Materials and Methods: A computed tomography scan analysis of 26 prospectively followed-up patients was conducted after modified Latarjet procedure using mini-plate fixation technique to determine both the location and the amount of coracoid graft osteolysis in them. We then compared our current results with results from that of our previous study without using mini-plate fixation to determine if there is any statistical significant difference in terms of corcacoid bone graft osteolysis between the two surgical techniques. Results: The most relevant osteolysis was represented by the superficial part of the proximal coracoid, whereas the deep part of the proximal coracoid graft is least involved in osteolysis and has best bone healing. The current study showed a significant difference only for the deep part of the distal coracoid with our previous study (P < 0.01). Discussion: To our knowledge, there are no studies in literature that show the causes of coracoid bone graft osteolysis after Latarjet procedure. Conclusion: Our study suggests that there is a significant difference only for the deep part of the distal coracoid in terms of osteolysis. At clinical examination, this difference did not correspond with any clinical findings. Level of Evidence: Level 4. Clinical Relevance: Prospective case series, Treatment study.

Acromioclavicular Joint and Scapular Ligaments

The acromioclavicular (AC) joint is a diarthrodial joint ostensibly connecting the acromion and the distal clavicle, but in reality suspending the entire arm, via the clavicle and sternoclavicular joint, from the axial skeleton. Using the AC joint as a pivot point, the scapula (acromion) can protract and retract. The AC joint, which is approximately 9 mm by 19 mm, is formed by the distal clavicle and the acromion process of the scapula (Fig. 2.1). The articular surface of the acromion is concave (relative to the subacromial space) and has an anterior and medial orientation toward the convex, distal, end of the clavicle. The joint allows gliding, shearing and rotational motion. The articular surface of the acromial end of the clavicle is hyaline cartilage until 17 years of age, at which time it acquires the structure of fibrocartilage. Similarly, the articular surface of the clavicular side of the acromion becomes fibrocartilage at approximately 23 years of age [1]. The angle of the AC joint on AP view is variable. Urist found it was inclined from superolateral to inferomedial in 49% of cases, vertically oriented in 27%, incongruous in 21% and laterally oriented in 3% [2]. The joint is also inclined a few degrees from anterolateral to posterior medial on the axillary view. Viewed anteriorly, the inclination of the joint may be almost vertical or downward medially, the clavicle overriding the acromion by an angle of as much as 50°.

Tennis: Epidemiology and Injury Mechanism

Tennis injuries have been reported throughout all regions of the body with more common areas being the spine, the ankle and the shoulder. Tennis injuries can occur as a consequence of a trauma (acute injuries, more common in the lower extremity), but most of the injuries in tennis can be defined as overuse injuries (chronic injuries, more common in the upper extremity and trunk) coming from the repetitive microtrauma inherent in the sport. Upper extremity injuries were most frequently located in the elbow and the shoulder regions, with tendon injuries of the shoulder and tennis elbow (humeral epicondylitis) as most frequent injuries. Lower extremity injuries were most frequently located in the ankle and the knee regions, with ankle sprain and patellar tendinosis as most frequent injuries. Usually upper extremity injuries are associated with kinetic chain dysfunction, scapular dyskinesis and GIRD. The repetitive stressors and loading sequences in tennis create muscular imbalances specific to the sport that requires preventative interventions believed to lower injury risk. This chapter will show an overview of the epidemiology and the mechanism of the most common injuries in tennis players.

Posterior Surgical Approaches to the Shoulder

The posterior approach to the shoulder is an uncommon surgical procedure, as it is reserved only for posterior shoulder instability or posterior fractures of the scapula; conditions representing a very low percentage incidence among shoulder injuries – arthroscopy is most often used for posterior shoulder instability. However, the knowledge of the anatomical structures of said posterior region can allow access without risking damage to the posterior anatomic structures of the scapular region or to the glenohumeral joint.

Latarjet Procedure: The Miniplate Surgical Technique

The Latarjet procedure [1], first described in 1958 and used to address anteroinferior shoulder instability, involves using coracoid transfer to stabilize the shoulder by the static action of the transferred bone block and by the dynamic action of the attached conjoined tendon sling (short head of biceps and coracobrachialis).

Glenohumeral Joint (Muscle-Tendon)

The deltoid is the largest and perhaps most important muscle in the shoulder girdle (Fig. 3.1a). It is made up of three major parts: the anterior deltoid taking its origin from the anterior and superior surfaces of the outer third of the clavicle and anterior acromion; the middle deltoid, originating from the lateral margin of the acromion; and the posterior deltoid, originating from almost the entire scapular spine. The deltoid covers the proximal portion of the humerus and converges into a thick tendinous insertion at the lateral surface of the humeral shaft [1, 2]. The most important function of the deltoid is forward elevation on the scapular plane. However, differences in activity of the three portions of the deltoid related to arm position have been observed by electromyographic analysis [3]. The function of the deltoid is highly differentiated and is not restricted to only abducting moment of the arm. Although its integrity is critical to shoulder function, it has not been extensively studied with reference to its stabilising function [4]. The axillary nerve and posterior humeral circumflex artery are the only nerve and the major blood supply of this muscle [2] (Fig. 3.1b).

Neuromuscular Control and Proprioception of the Shoulder

Stability of the shoulder joint emanates from numerous mechanisms including articular geometry, static restraints (capsuloligamentous tissue), dynamic (muscular) stabilizers, and intra-articular forces. Capsuloligamentous structures not only provide mechanical restraint to joint subluxation, but also provide vital sensory feedback information that regulates involuntary muscular activation for joint stability (neuromuscular control).