Andrea De Vita

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.

Glenohumeral translation in ABER position during muscle activity in patients treated with Latarjet procedure: an in vivo MRI study

AbstractPurpose The Latarjet procedure is frequently performed when treating traumatic anteroinferior shoulder instability. This procedure is supposed to have a triple effect: osseous, muscular and ligamentous. The main stabilizing mechanism in cadaver studies on fresh-frozen shoulders seems to be the sling effect produced by the subscapularis and the conjoint tendon. It has been hypothesized that muscle contraction in ABER position (abduction–external rotation) is able to translate the humeral head posteriorly and superiorly due to the sling effect. The aim of this study was to analyse the humeral head translation relative to the glenoid with the arm in ABER position with and without muscle contraction. MethodsTwenty-one subjects divided into two groups (Group A: after Latarjet; Group B: healthy subjects) were examined with an open MRI system with the shoulder in abduction–external rotation (ABER) position to analyse humeral head translation during muscle activity.ResultsIn normal shoulders, there was no significant difference in anteroposterior or superoinferior translation between the rest position and the muscle-activated state. In subjects after the Latarjet procedure, the difference was significant and was also significant between both groups of subjects for posterior translation, but not for superior translation.ConclusionIn patients treated with Latarjet procedure, there are significant changes in glenohumeral translation during muscular activity when in ABER position, with the humeral head going more posteriorly, in comparison with normal shoulders. This study confirms the stabilizing sling effect of the transposed conjoint tendon in the ABER position.Level of evidenceRetrospective case–control study, Level III.

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).