Modified Bristow-Latarjet procedure for treatment of recurrent traumatic anterior glenohumeral dislocation

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Modiﬁed

Bristow-Latarjet

procedure

for

treatment

of

recurrent

traumatic

glenohumeral

dislocation

夽

Diogo

Lino

Moura

∗

,

Augusto

Reis

e

Reis,

João

Ferreira,

Manuel

Capelão,

José

Braz

Cardoso

SetordoOmbro,DepartamentodeOrtopedia,CentroHospitalareUniversitáriodeCoimbra,Coimbra,Portugal

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received30December2016 Accepted24February2017 Availableonline23February2018

Keywords: Glenohumeraljoint Jointdislocations Shoulderdislocation Orthopedicprocedures/methods

a

b

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r

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c

t

Objective:Retrospectivecase–controlstudyofauthorsexperienceinthemodiﬁed Bristow-Latarjetprocedurefortreatmentofrecurrenttraumaticanteriorglenohumeraldislocation withglenoidboneinjury.

Methods:Samplewith102recurrentglenohumeraldislocationcasessubmittedtomodiﬁed Bristow-Latarjetprocedure.Indicationsincludedsituationsofrecurrenttraumaticanterior glenohumeralinstabilitywithmorethantwodislocationepisodesandwithglenoidbone attritionalorfragmentaryinjuries,withoutpossibilityofreconstruction.Meanfollow-up timewas5.33±2.74years(minimum1;range1–13).

Results:The mean Walch-Duplay Score at the last evaluation was 91.23±11.46 (range 15–100).Thefunctionalscoreofpatientswithglenoidbonelossgreaterthan20%didnot showasignificantdifferenceincomparisonwithpatientswithglenoidbonelosslowerthan 20%(90vs.92,respectively).Thefunctionalscorealsodidnotshowasignificantdifference betweensportspracticecategoriesandbetweenrecreationalandcompetitivepractice,being excellent(greaterthan90)ineverycategory.Therewerenodislocationrecurrencesandthe onlycomplicationswereacaseofpersistentinstabilityandascrewrevision.Mild gleno-humeralosteoarthrosisimagingsignswereidentifiedin7.84%ofthepatients;however, theirfunctionalscoreswerenotsignificantlydifferentincomparisontootherpatients.

Conclusion:ThemodiﬁedBristow-Latarjetprocedureisaveryeffectiveprocedurewithfew complicationsinthemedium-term,showingverysatisfactoryfunctionaloutcomesinthe treatmentofrecurrenttraumaticanteriorglenohumeraldislocationassociatedwithglenoid boneinjury.

夽_Study_conducted_at_Centro_Hospitalar_e_{Universitário}_de_Coimbra,_Departamento_de_Ortopedia,_Setor_do_Ombro,_Coimbra,_Portugal. ∗ _{Corresponding}_author.

E-mail:dﬂmoura@gmail.com(D.L.Moura).

https://doi.org/10.1016/j.rboe.2017.02.009

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Operac¸ão

de

Bristow-Latarjet

modiﬁcada

no

tratamento

na

luxac¸ão

glenoumeral

traumática

recidivante

Palavras-chave: Articulaçãoglenoumeral Luxaçãoarticular Luxaçãodoombro Procedimentos ortopédicos/métodos

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e

s

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Objetivo: Estudoretrospectivosobreaexperiênciadosautoresnaoperaçãode Bristow-Latarjet modificada como tratamento da luxação glenoumeral anterior traumática recidivantecomlesãoósseaglenoidea.

Métodos: Amostra com102 casos de luxações glenoumeraissubmetidos à cirurgia de Bristow-Latarjetmodificada.Asindicaçõesforamsituaçõesdeinstabilidadeglenoumeral anteriortraumáticarecidivantecomnúmero deepisódiosdeluxaçõessuperioradoise comlesãoósseadaglenoideerosivaoufragmentária,sempossibilidadedereconstrução.O tempodeseguimentomédiofoide5,33±2,74anos(mínimo1;intervalo1-13).

Resultados: OescoredeWalch-Duplaymédionaúltimaavaliaçãofoide91,23±11,46 (inter-valo15-100).Oescorefuncionaldospacientescomlesãoósseadaglenoidesuperiora20% nãodemonstroudiferençasignificativaemcomparaçãocomaquelescomlesãoósseada glenoideinferiora20%(90vs.92,respetivamente).Oescorefuncionaltambémnão demon-stroudiferençasignificativaentre ascategoriasde prática desportivaeentre a prática recreativaoudecompetição,foiexcelente(superiora90)emtodasascategorias.Nãose verificouqualquerrecidivadasluxaçõeseasúnicascomplicaçõesobservadasforamum casodeinstabilidadepersistenteeumarevisãodeumparafuso.Foramidentificadossinais imagiológicosdeosteoartroseglenoumeralligeiraem7,84%dospacientes;noentanto,o escorefuncionaldessespacientesnãodemonstroudiferençasignificativaemcomparação comodosdemais.

Conclusão: AcirurgiadeBristow-Latarjetmodificadadescritaéumaintervençãomuito efi-cazecomreduzidascomplicaçõesemmédioprazo,apresentaresultadosfuncionaismuito satisfatóriosnotratamentodainstabilidadeglenoumeralanteriorrecidivanteassociadaa lesõesósseasdaglenoide.

Introduction

Theglenohumeraljointisthemainjointcomplexofthe shoul-der;it isthejoint withthe highestmobilityinthe human body,andthereforehasahighsusceptibilityofdislocationand instability.Glenohumeraldislocationsareclassiﬁedaccording tothepositionofthehumeralheadinrelationtotheglenoid cavity;the anteroinferiordirectionaccountsfor 95%ofthe dislocations.1,2

Recurrentglenohumeraldislocationsoccurwhenoneor moreoftheactiveorpassivestabilizersoftheglenohumeral jointareaffected,eitherbychangesincoordinationand mus-cle power of the rotator cuff or deltoid; by lesions of the labrum,ligaments,orjointcapsule;orbysingleorrepeated trauma,involvingdirectorindirectforces.3_Recurrent

gleno-humeralinstabilityoftencausestraumaticbonedefectsofthe glenoidandhumeralhead,andareresponsibleforincreasing theriskoffurtherdislocations.Inaseriesof100 recurrent anterior glenohumeral dislocations, Sugaya et al.4

demon-stratedthatBankartcapsulolabrallesionswerepresentin97% ofcasesandglenoidbonelesionswerepresentin90%ofcases, dividedintofragmentarylesionsorbonyBankart(50%)and erosionofthe glenoid edge(40%).In other seriesof recur-rentanteriorglenohumeraldislocations,glenoidbonelesions wereobservedin80–90%ofthepatients.5–8_The_treatment_of

recurrentglenohumeraldislocationissurgical;thetypeof pro-ceduredependsonthecharacteristicsoftheinstability,type ofunderlyinglesion,numberofdislocationsuntilsurgery,age, and levelofphysicalactivitypracticed andexpected.3,6,7 _In

ordertorespondtothebroadspectrumofpathological alter-ationsthataffecttheunstableglenohumeraljoint,fourgroups of procedures have emerged: osteotomies,capsulorrhaphy, labrumrepairs,andbonetransfers.Withinthelattergroup, the transferofthecoracoidapophysis tothe glenoidisthe best-knowntechnique,appliedworldwide.9

Inthisarticle,theauthorspresenttheirexperiencewith a modiﬁed Bristow-Latarjetprocedure for the treatmentof recurrentanteriorglenohumeralinstabilitiesandtheirresults.

Material

and

methods

This is a retrospective series of 102 cases of recurrent glenohumeral dislocations in 102 patients who underwent the modiﬁed Bristow-Latarjet surgery performed by the same orthopedic team using the same surgical technique. Indications for this procedure are cases of recurrent trau-maticanteriorglenohumeralinstabilitywithmorethantwo episodesofglenohumeraldislocationandpresenceofglenoid erosive or fragmentary bone injury, without possibility of reconstruction due to high comminution, reduced size, or

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resorptionofthebonefragment.Allpatientspreviously under-went conservative treatment with immobilizationfollowed byrehabilitation,whichwasunsuccessful,andthe instabil-ity persisted. Patients with glenohumeralinstabilities with engagingHill-Sachslesions,ligamenthyperlaxity,instabilities indirectionsotherthantheanterior,otherpathologies,or pre-vious surgeriesofthe shoulderinquestion were excluded. Themean follow-up time was5.33±2.74 years(minimum: 1;range: 1–13years).Patientswereretrospectivelyclinically andradiologicallyevaluatedattheﬁnalfollow-up consulta-tion, and the following information was collected:gender; causeofandageattheﬁrstglenohumeraldislocation; activ-ity level and type of sport practiced; dominance and side ofthe affected shoulder;number ofrecurrentdislocations; typeofdislocation;presenceofglenoidorhumeralheadbone injury(evaluatedthroughsimpleradiographyon anteropos-terior,axillary, and scapular Yviews,as well ascomputed tomography and magnetic resonance imaging done in the preoperativeperiod; the percentageof glenoid bonedefect wasevaluatedusingthecirclemethod4_);_and_the_presence_or

absenceofligamenthyperlaxity.TheWalch-Duplayfunctional scorewasused;ithasbeenvalidatedfortheevaluationof situ-ationsofglenohumeralinstability.10,11_The_sport_practiced_was

classifiedintofivecategories accordingtotheriskof gleno-humeraldislocation:non-practitioner,withoutrisk(trackand field, swimming – breaststroke, diving, leisure gymnastics, rowing,sailing, and shooting), contactsports (judo,karate, cycling,motorcycling,soccer,skiing,waterskiing,paragliding, equestrian sports, and surfing), arm-locking sports (swim-ming – butterfly or freestyle strokes, hockey, golf, tennis, andmountaineering),andhigh-risksports(basketball, hand-ball,volleyball,canoeing,andwindsurfing).Patientswerealso evaluatedforperioperativecomplicationsandlevelof satis-faction(range:0–5).Inthelastfollow-upconsultation,simple radiographyandcomputedtomographywere usedtocheck thepresenceofnon-consolidationsigns (persistenceofthe radiolucentlinebetweenthegraft andthe glenoid), osteol-ysisor bone block migration, screw loosening failure, and signsofglenohumeral arthrosis(glenohumeralarthropathy classifiedusingtheSamilsonandPrietocriteria).12_The

vari-ableswerestatisticallyanalyzedusingSPSS,version23.The Mann–Whitneytestwasusedtocomparequantitative vari-ablesintwogroups;inseveralgroups,theKruskal–Wallistest wasused,asthenormalityofthesamplewasnotconﬁrmedin theKolmogorov–Smirnovtest.Thesigniﬁcancelevelwasset at0.05.AllpatientssignedtheInformedConsentFormand thepresentstudywasapprovedbythisinstitution.

DescriptionofthemodiﬁedBristow-Latarjetsurgery

Theosteotomyofthecoracoidapophysisanditstransferalong withtheinsertionoftheconjointtendontotheglenoidneck wasﬁrstdescribedbyLatarjet13_and_later_by_Helfet.14_The

sur-gical techniqueused inthis study is amodiﬁcation ofthe originaltechniquesandhasbeenusedbytheShoulder Depart-mentoftheUniversityofCoimbraHospitalfor20years(Fig.1). Themainmodiﬁcationsintroducedintheoriginaltechniques aredescribedbelow.

Thepatientispositionedinabeachchairposition.Through adeltopectoralapproach(Fig.1A),thecoracoidapophysisand

the conjointtendon inserted init are identified. The cora-coacromialligamentissectionedatapproximately5mmfrom itsinsertioninthecoracoidapophysis;thepectoralisminor isidentified,referenced,andsectioned.Afteradequate expo-sure ofthecoracoidapophysis,anosteotomyisperformed atits baseusing asaw,in apositionimmediately anterior to theinsertion ofthe coracoclavicularligaments and ina medialto lateral direction(Fig. 1B).Subsequently,the con-jointtendonisisolatedandthecoracoidapophysisiscentrally drilledwitha3.2mmdiameterdrill(Fig.1C).Afterthelong portionofthebrachialbicepsisidentified,aU-shaped inci-sionismadeinthesubscapularisandthejointcapsule(with amedialopening),withtheshoulderinlateralrotation.This incision beginsattherotatorinterval andsparesthe lower thirdofthesubscapularis,soastoavoidtheaxillarynerve (Fig.1D).Atthistime,theglenohumeraljointisexplored; cap-sulolabralrepairsofany lesionsidentified atthislevel can beperformed.Subsequently,theanteriorfaceoftheglenoid neckisexposedandopened,withthecreationofmicro-holes usingadrill.Thecoracoidapophysisisalsoopenedonits con-cavefacewiththeuseofadrillorsaw.Theconcavesurface ofthecoracoidboneblock(concavesurfacecorrespondingto theinferiororposterioraspectofthecoracoidapophysisat itsanatomicalsite)isthenadaptedtotheconvexsurfaceof theanterioraspectoftheglenoidneckintheinferiorthirdof thelatterandintheextensionofits articularface(without passingit laterally).Theadaptationofthecoracoid-glenoid blockshouldbeascongruentaspossible;itsstabilityshould alwaysbetestedintraoperativelyafterfixation.Forfixation, aself-tappingmalleolarscrew(cancellousbonescrew, usu-ally35-mmlong)isused;itisplacedinthepre-drilledholein thecenterofthecoracoidboneblockandmanuallyscrewed, perpendiculartotheglenoidneckandparalleltotheglenoid articularsurface(Figs.1EandF).Thearticularcapsuleisthen closed,reinforcedwithsuturetothecoracoacromialligament, whichwaspreviouslydividedandinsertedintothecoracoid boneblock.Therotatorintervalisclosedandthe subscapu-laris issuturedinneutralrotation, witheventualretention (tensioning)ofthatmuscleifnecessary(Fig.1G).Thepectoralis minor is reinserted into the excision zone ofthe coracoid apophysis,and the deltoidisrepaired withseparatesingle suturesafteravacuumdrainisplaced.Afterthesurgical pro-cedure,theshoulderisimmobilizedwithbrachialsuspension and thoracicbandforthreeweeks,inordertoavoidlateral rotation and allowadequate subscapularis healing. Subse-quently,pendularmovementsofthelimbareinitiated,andthe rehabilitationprotocolprogressesafterradiographiccontrol.

Results

The sampleconsistedof102 patients, witha mean ageof 26±6.9years(range16–47)atthetimeofthemodiﬁed Bristow-Latarjet surgery. Most patients (87.3%; n=89) were males and the dominant shoulder was affected in 68.6% (n=70) of the cases. Themean age ofthe ﬁrst traumatic anterior glenohumeraldislocationwas24±5.4years;in46.08%ofthe sample,thetraumaoccurredinasportingcontext,andthe remainder was divided between car accidentsand injuries inactivitiesofdailyliving.Themeannumberofepisodesof

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A

D

E

F

G

B

C

Fig.1–Surgicaltechnique.(A)Skinreferencemarkingsforthedeltopectoralapproach;(B)Osteotomyofthecoracoid apophysisandisolationoftheconjointtendon;(C)Centraldrillingofthecoracoidapophysiswitha3.2mmdrillbitforthe passageofthemalleolarscrewforﬁxationtotheglenoid;(D)SubscapularisandthejointcapsuleU-incision;(E)Application oftheself-tappingmalleolarscrewinitiallyatthesiteofthepreviousdrilling,inthecenterofthecoracoidboneblock;(F) Applicationofthecoracoidboneblockinthelowerthirdoftheglenoidneck,intheextensionofitsarticularface,and ﬁxationwithamalleolarscrew(arrow);(G)Repairofthesubscapularisandofthecapsule’spreviousU-incision.

glenohumeraldislocationsuntilthemodiﬁedBristow-Latarjet surgicalprocedurewas6.07±2.16.

Aftersurgery,nocasesofglenohumeraldislocation recurr-enceswere observed.Themean Walch-Duplayscoreatthe lastassessment(whichcorrespondedtothefollow-uptime) was91.23±11.46(range15–100). Thescorewas considered excellent(91–100points)in39.22%(n=40)ofthepatientsgood (76–90points)in52.94%(n=54), fair(51–75 points)in6.86% (n=7),andpoor(lessthan50points)inonlyonepatient.The

onlypatientwithapoorresult(Walch-Duplayscore=15)after the modiﬁedBristow-Latarjetsurgerypersistedwitha sen-sationofglenohumeralinstabilityandpresentedasigniﬁcant mobilitylimitation.Duetothispoorresult,thispatient under-wentadhesionrelease,aswellasretensioningandresectionof thesubscapularisandofthecapsule,withimprovedmobility andpain;nonetheless,theglenohumeralapprehension per-sisted,withoutanyepisodeofdislocationrecurrence.Inthis sample,allpatientspresentedglenoidbonelesion;however,

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90 92

Glenoid bone lesion >20% 100 95 90 85 80 75 70 65 60 55 50

Glenoid bone lesion <20%

Mean W

alch-Dupla

y

score

Fig.2–MeanWalch-Duplayscoreaccordingtodegreeof glenoidbonelesion.

Does not practice Without risk Contact With arm locking High risk

49 2

7

9

35

Fig.3–Graphicaldistributionofsportsactivitylevelofthe sample.Thenumbersrefertothefrequency;n=numberof individuals.

theglenoiddefectexceeded20%inonly38.24%ofthesample (n=39).Hill-Sachslesionsofvaryingdegreeswere observed in72.55%(n=74)ofthepatients.Thefunctionalscoreinthe groupofpatientswithglenoidbonelesionsgreaterthan20% (meanWalch-Duplayscore: 90)wasnotsignificantly differ-ent(p=0.38)thanthatofthegroupofpatientswithglenoid bone lesion smaller than 20% (mean Walch-Duplay score: 92; Fig. 2). The level of sport practiced was stratified into fivecategories,andtherespectivefrequenciesareshownin

Fig.3.Approximatelyhalfofthesample(51.96%,n=53) prac-ticedasportactivity,and37didsoatcompetitivelevels.In all theanalyzedcategories,the mean ofthe Walch-Duplay scorewasalwayshigherthan90points,whichcorresponds

98 96 94 92 90 88 86 90 91 92 97 95 Mean W alch-Dupla y score

Does not practice Without risk Contact With arm locking

High risk

Sports activity

Fig.4–MeanWalch-Duplayscoreaccordingtothesports activitycategory.

toanexcellentresult(Fig.4).Regardingthefunctionalscore, no significant differences were observedbetween the vari-ouscategoriesofsportspracticeandbetweenrecreationalor competitivepractice.Theonlycomplicationsobservedwere the previously described case of persistent instability and anothercaseinwhichthegraftfixationscrewwastoolong, andhadtobereplacedwithashorterscrew.Noother peri-operativecomplicationswere observed,including lesionsof themusculocutaneusoraxillarynerves;fixation, consolida-tion,orosteolysisfailure;ornecrosisorresorptionofthebone block.Imagingsignsofmildglenohumeralosteoarthrosis, par-ticularly small inferior glenoid osteophytes, were observed in 7.84% (n=8) of the patients. No significant differences were observedinthefunctional scorewhencomparingthe groupofpatientswithsignsofglenohumeralosteoarthrosis (mean Walch-Duplayscore: 96)withthose withoutsignsof osteoarthrosis (mean Walch-Duplay score: 91). All patients stated that they would undergo a new surgical procedure (meansatisfactionlevelof4.61±0.49witharangeof4–5on ascaleof0–5),includingthepatientwithafunctionalscore of15,especiallyduetotheabsenceofnewepisodesof gleno-humeraldislocationandthefunctionalimprovementofthe shoulder,whichallowedanimprovementinthequalityoflife.

Discussion

Proceduresforcoracoidapophysistransfer,suchasthe sur-geriesdescribedbyLatarjetandBristow,areoftenindicated incasesofrecurrentanteriorglenohumeralinstability associ-atedwithglenoidbonelesion.13,14 _In_these_procedures,_the

osteotomy and the transfer of a fragment of the coracoid apophysis areperformedtogetherwiththeinsertionofthe conjointtendonintotheanterioraspectoftheglenoidneck. This has a triple effect that makes it superior to the iso-lated transferofotherboneblocks:bonestopeffect,which increasesthediameteroftheglenoidcavity;stretchingeffect ontheconjointtendonintheinferiorportionofthe subscapu-laris; andtensioning effectofthe joint capsule,preventing excessiveanteriorhumeraltranslation.15–17_Before_a_surgical

procedure to treatglenohumeralinstability, it isimportant to identify who are the individuals with higher risk of

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instabilityandrecurrentdislocationandwhattypeofsurgery toperform,whether acapsulolabralrepairorabone trans-ferprocedure.Thethreemostimportantfactorsforselecting atreatment for glenohumeral instability are the degree of glenoid bonelesion,theexpected functionallevel, and the patient’sexpectations.6,7,18

Isolated capsulolabral repair in glenohumeral instabil-ity hasprovenresultsin caseswithminimal glenoid bone loss. However, no randomized prospective studies with a high level of evidence on this subject are available in the literature.19 _Many _authors_advocate _the _efﬁcacy _of_isolated

capsulolabralarthroscopicrepairinthetreatmentof gleno-humeralinstabilityforsituationswithglenoid bonelossof lessthan15–20%;bonetransfersurgeriesarepreferredonly incasesinwhichthe glenoidbonelossexceeds20–25%.6,7

Nonetheless,thelowerbonedefectthresholdvalueforwhich isolated capsulolabral repair is indicated remains contro-versial; it hasbeen increasingly considered that this value should not be exhaustive and universal, but rather only one of the parameters of each individual’s instability risk proﬁle.5,7,20,21

Any glenoid bone lesion is animportant risk factor for recurrenceofglenohumeraldislocations,andisolated capsu-lolabralrepairhashigherrecurrenceratesthanbonetransfer surgeriesinthesepatients;thelargertheglenoidbonedefect, thehighertherisk.5–8,19,22–29

Boileau et al.22 _demonstrated _that _a _glenoid _bone _loss

greaterthan25%predicted75%ofcasesofrecurrenceafter iso-latedarthroscopiccapsulolabralstabilization.Inturn,Bessière et al.27 _compared₉₃ _patients _who _underwent _arthroscopic

Bankart operations with 93 patients who underwent open Latarjet (the groups were comparable, except for the fact thatpatientsundergoingtheLatarjetsurgerypresentedmore glenoidbonelesionsandahighernumberofdislocationsin thepreoperativeperiod)fortreatmentofpost-traumatic ante-riorglenohumeralinstability.Thoseauthorsobservedthatthe recurrenceratewastwiceashighforBankartoperations(22%) whencomparedwiththeboneprocedure(11%).Inaddition, theyfoundthatrecurrencesinLatarjetoperationsoccurred predominantlyintheﬁrsttwopostoperativeyearsandthen decreased, being associated with technical surgical errors, whilerecurrencesinBankartrepairscontinuedtobeobserved throughoutfollow-up.

Several studies have demonstrated an unacceptable glenohumeraldislocationrecurrencerateafterarthroscopic isolatedcapsulolabralrepairasatreatmentoftraumatic ante-rior glenohumeralinstability inpatients under 20 years of age who practiced competitive or contactsports,or sports with gestures above the level ofthe head, who presented capsular hyperlaxityand marked bonyglenoid or humeral headdefects.Thoseauthorsconcludedthatisolated capsulo-labralrepairiscontraindicatedinthisgroupofat-riskpatients andrecommendthat, inthesecases,theinstabilityshould betreatedthroughabonetransferprocedure.3,6,20–22,24,27 _In

theirseriesofpatientswhounderwentarthroscopic capsulo-labralrepair,Mologneetal.29_demonstrated_that_recurrences

occurredexclusivelyinpatientswitherosiveglenoidinjury,

i.e.,inthoseinwhichitwasnotpossibletoincorporatethe bone fragment into the glenoid. That study demonstrated theimportanceofassessingthedegreeofglenoidboneloss

and whether there is a possibility of glenoid bone recon-struction.Thoseauthorsconcludedthaterosiveglenoidlosses indicate a higher risk of glenohumeral dislocation recur-rence and that these cases should be treated with bone transfer surgery, rather than simply isolated capsulolabral stabilization.

Thepresentauthorsadvocatetheprincipleofanatomical reconstruction: the orthopedist, in the presence ofa frag-mentary glenoid lesion(bony Bankart)with bonefragment thatcanbeincorporatedintothecapsulolabralrepair,should seek an anatomical arthroscopic glenoid reconstruction.6

Nonetheless,andaccordingtotheauthors’experience,most oftherecurrenttraumaticanteriorglenohumeraldislocations patientspresentinthesubacuteorchronicphase;thesecases are mostfrequently associated witherosive lesions,rarely presentingabonefragmentsuitableforglenoid reconstruc-tion.Assuch,giventheimportanceofglenoid bonelossin glenohumeralbiomechanical stabilityand theimpossibility of glenoid reconstruction in mostcases of recurrent trau-maticanteriorglenohumeralinstability,theauthorsadvocate thattheBristow-Latarjet surgeryisthemostindicated pro-cedureinmostpatientswiththis pathology,particularlyin thosewhopresentotherriskfactorsforconcomitant instabil-ity.Althoughitisanon-anatomicaltechniquewhoseprimary objective is toavoidmore episodesofglenohumeral dislo-cations,and despitethefactthat ithasbeen associatedin some studieswith the earlydevelopment ofglenohumeral osteoarthrosisand limitationsofshouldermobility,itisan effectiveandsafeprocedure,withlowratesofcomplications andrecurrencesthatoftenallowsverysatisfactoryfunctional resultsinthemediumandlongterms.Severalstudieshave shown that their functional results are superimposable to those of the anatomicaltechniques ofcapsulolabral repair and that theyare moreeffective than the latterin reduc-ing recurrences.1,3,6,7,13–16,20–28,30 _Bessière _et _al.27 _observed

significantlyhigherfunctionallevelsinpatientsundergoing Latarjet surgeries (mean Rowe score: 78) when compared with those undergoing Bankart arthroscopic repair (mean Rowescore:68;p=0.018).Theauthorsacknowledgetherole ofisolated capsulolabral repairsinthe treatmentof gleno-humeralinstability;however,theyrecommendcautioninits application and theimperative needofa detailedstudy of the patient’s risk profile before proceeding with this pro-cedure, particularly in cases of glenoid bone loss without possibility of reconstruction. Several studies have reported that the Bristow-Latarjet surgery is indicated and should be performed onlyin cases ofglenoid bonelesion greater than 20–25%; however this procedure has proven efficacy and is avalid functional option forthe surgical treatment of recurrent traumatic anterior glenohumeral dislocation withvaryingdegreesofglenoidbonedefect.1,6,7,13,14,16,20,28,30

The present study confirmed this last statement, insofar as no significant differences were observed in the func-tionalscorebetweenpatientswithbonelesionoftheinferior glenoidgreaterthanorlowerthan20%;furthermore,no func-tional or recurrence differences were observed among the various groups ofparticipants stratified by levels of activ-ity.

Inlightoftherecurrenceratesobservedinisolated arthro-scopic capsulolabral repair in instabilities associated with

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glenoidbonelesions,andconsideringtheefficacy,functional results, and the absence of recurrences inthis study with 102 patients who underwent the modified Bristow-Latarjet operation,the authorsrecommend itsapplication to situa-tionsofrecurrenttraumaticanteriorglenohumeralinstability witherosiveglenoid bonelesions ofany degree.Giventhe verysatisfactoryfunctionalresults(andevensuperiorto sev-eralserieswithisolatedcapsulolabralrepairsininstabilities withoutbonedefects); theabsence ofrecurrences; andthe reduced rate of complications and development of gleno-humeral osteoarthrosis, regardless ofthe degree of sports practice,theauthorsbelievethatthis surgicalprocedure to beanexcellent option forthetreatment ofthesepatients. Thus,patientsinthesecondandthirddecadesoflife,involved in risky sports and with erosive glenoid bone lesions or without adequate bone fragments for glenoid reconstruc-tion,are theidealcandidatesforbonetransfersurgery; an isolatedcapsulolabralrepairwouldnotbesufficientforthe resolution of instability. Nonetheless, the increase in the follow-up timeofthe present study may lead tothe iden-tification of more cases that are typically observed in the longtermwithsignsofglenohumeralosteoarthritisandother complications.15,23,30

Theauthorsconsiderthattheverysatisfactoryresultsand the reduced rate ofcomplications observedin the present studymayberelatedtothelongexperienceofthissurgical teamandthemodiﬁcationsintroducedintheoriginalsurgical technique,particularlyintermsofboneblockﬁxation, sub-scapularisapproach,andtheglenohumeralstabilityobtained. TheU-openingofthesubscapularis,preservingitslowerthird, allowsanexcellentvisualizationoftheglenoidandminimizes theriskofinjurytothe axillarynerve.Moreover,thelower aggressivenessofthisincisioninthesubscapulariswhen com-paredwithitsdeinsertionintheoriginaltechniquemayalso beresponsiblefortheverysatisfactoryfunctionalresultsand mobilityofthe operatedshoulders.13 _If _necessary, _in_cases

of a lax articular capsule that still allows some abnormal mobilizationofthehumeralheadafterclosure,thismuscular incisionalsoallowsasubscapularisshorteningorretention,a veryimportantfactorthatensuresglenohumeralstabilityand reducestheriskofdislocationrecurrence.Theadaptationof theconcavesurfaceofthecoracoidboneblock,corresponding totheinferiororposterioraspectofthecoracoidapophysis atits anatomicalsite, allowsamorecongruent adaptation totheconvexsurfaceofthelowerthirdoftheglenoid.The fixationisusuallyperformedusingaself-tappingmalleolar screwafteradequateroughingupoftheglenoidcoracoidbone blocksurfaces,inordertostimulatetheconsolidationofthe bonetransfer.Theauthors considerthis fixationmethodto besimple,inexpensive,stable,andefficient,asobservedin thepresentstudy,inwhichnocasesoffixationfailurewere observed.

The main limitations of the present study were its retrospectivenature,whichdidnotallowarigorous preop-erativefunctionalevaluation,ashortfollow-upperiod,anda non-normaldatadistribution,whichrequiredtheuseof non-parametrictests.Inturn,thefactthatthesurgerieswereall performedbythesameteamoforthopedistsusingthesame surgicaltechnique reducedsomebiases arising from these factors.

Conclusion

Thepresentstudydemonstratedthat,inthemedium-term, themodiﬁedBristow-Latarjetsurgeryisaveryeffectiveand safeprocedurewithreducedcomplications,presentingvery satisfactory functional results in the treatment of recur-rentanteriorglenohumeralinstabilityassociatedwithglenoid bonelesions.

Conﬂicts

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Theauthorsdeclarenoconﬂictsofinterest.

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