Arthroscopic Bristow-Latarjet combined with bankart repair restores shoulder stability in patients with glenoid bone loss

Abstract

Background: Arthroscopic Bankart repair alone cannot restore shoulder stability in patients with glenoid bone loss involving more than 20% of the glenoid surface. Coracoid transposition to prevent recurrent shoulder dislocation according to Bristow-Latarjet is an efficient but controversial procedure.

Questions/purposes: We determined whether an arthroscopic Bristow-Latarjet procedure with concomitant Bankart repair (1) restored shoulder stability in this selected subgroup of patients, (2) without decreasing mobility, and (3) allowed patients to return to sports at preinjury level. We also evaluated (4) bone block positioning, healing, and arthritis and (5) risk factors for nonunion and coracoid screw pullout.

Methods: Between July 2007 and August 2010, 79 patients with recurrent anterior instability and bone loss of more than 20% of the glenoid underwent arthroscopic Bristow-Latarjet-Bankart repair; nine patients (11%) were either lost before 2-year followup or had incomplete data, leaving 70 patients available at a mean of 35 months. Postoperative radiographs and CT scans were evaluated for bone block positioning, healing, and arthritis. Any postoperative dislocation or any subjective complaint of occasional to frequent subluxation was considered a failure. Physical examination included ROM in both shoulders to enable comparison and instability signs (apprehension and relocation tests). Rowe and Walch-Duplay scores were obtained at each review. Patients were asked whether they were able to return to sports at the same level and practice forced overhead sports. Potential risk factors for nonhealing were assessed.

Results: At latest followup, 69 of 70 (98%) patients had a stable shoulder, external rotation with arm at the side was 9° less than the nonoperated side, and 58 (83%) returned to sports at preinjury level. On latest radiographs, 64 (91%) had no osteoarthritis, and bone block positioning was accurate, with 63 (90%) being below the equator and 65 (93%) flush to the glenoid surface. The coracoid graft healed in 51 (73%), it failed to unite in 14 (20%), and graft osteolysis was seen in five (7%). Bone block nonunion/migration did not compromise shoulder stability but was associated with persistent apprehension and less return to sports. Use of screws that were too short or overangulated, smoking, and age higher than 35 years were risk factors for nonunion.

Conclusions: The arthroscopic Bristow-Latarjet procedure combined with Bankart repair for anterior instability with severe glenoid bone loss restored shoulder stability, maintained ROM, allowed return to sports at preinjury level, and had a low likelihood of arthritis. Adequate healing of the transferred coracoid process to the glenoid neck is an important factor for avoiding persistent anterior apprehension.

Level of evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1A–B

The benefits of the Bristow-Latarjet-Bankart procedure are illustrated. (A) In the throwing (abduction external rotation) position, the subscapularis slides over the equator, leaving only the weak detached anteroinferior labrum and stretched capsule to stabilize the humeral head. The 5 o’clock point is truly the vulnerable point of the glenoid rim. (B) By performing two procedures (Bankart + Bristow-Latarjet), a triple blocking of the shoulder is obtained (2B3 procedure): (1) bumper (or Bankart) effect, (2) bony (or bone block) effect, and (3) belt (or biceps) effect.

Fig. 2A–C

The surgical principles of the Bristow-Latarjet procedure are illustrated. (A) The osteotomized tip of the coracoid process is passed through the subscapularis split, turned 90° laterally, and fixed on the glenoid neck with a screw; the conjoined tendon provides both a belt (or sling) effect and dynamic tensioning of the lower part of subscapularis when the arm is abducted, whereas the bone graft restores (B) the width and (C) the concavity of the glenoid surface.

Fig. 3

Patient and portal positioning for the Bristow-Latarjet-Bankart procedure is shown.

Fig. 4A–C

Arthroscopic views of the Bristow-Latarjet-Bankart procedure are shown. (A) An intraarticular view shows the coracoid graft positioned standing, fixed with a screw below the equator and flush to the glenoid surface (bony effect). (B) Associated capsulolobral repair (using two to three suture anchors) places the bone block in an extraarticular position and improves the concavity of the glenoid surface (bumper effect). (C) An extraarticular view shows the transferred conjoint tendon passing through the subscapularis muscle to reinforce the weak and stretched anteroinferior capsule (belt or sling effect).

Fig. 5A–B

An example of coracoid graft optimal position and healing is shown. Postoperative (A) AP and (B) lateral radiographs demonstrate optimal positioning of the coracoid bone graft: below the equator and flush to the glenoid surface, restoring the concavity of the glenoid with perfect bone healing.

Fig. 6A–D

Postoperative (A) vertical and (B) axial CT scans and (C, D) three-dimensional CT reconstructions of the transferred coracoid bone graft demonstrate coracoid graft optimal positioning and healing.

Fig. 7A–E

An example of coracoid graft nonunion is shown. Early postoperative (A) AP and (B) lateral radiographs demonstrate good positioning of the bone block but eccentric positioning of the screw in the bone block. (C) AP, (D) lateral, and (E) axillary radiographs at 3 years’ followup demonstrate loss of fixation and nonunion of the graft with screw pullout and a chamber of osteolysis. This patient was a 40-year-old woman and a heavy smoker.

Fig. 8A–B

Photographs demonstrate restoration of shoulder mobility: (A) active elevation and (B) external rotation.