This document discusses the management of bone defects in shoulder instability. It reviews several studies on the long-term outcomes of arthroscopic Bankart repair and open Latarjet procedures. The key points made are that bone loss, especially over 20%, is a major risk factor for recurrence of instability. The Latarjet procedure is likely the most reliable option for significant bone loss or patients with multiple risk factors. While arthroscopic Latarjet is becoming more common, complications rates remain high, similar to the open technique. Further improvements and standardization of graft placement are still needed to reduce risks. In complex cases of bone loss, the Latarjet may provide the best chance of avoiding recurrent instability.

1. Gonzalo Samitier
Hospital General de Villalba (Madrid)
MANEJO DE LOS DEFECTOS ÓSEOS EN LA INESTABILIDAD

4. Am J Sports Med. 2009 Apr;37(4):669-73
Long-term follow-up of acute arthroscopic Bankart repair for
initial anterior shoulder dislocations in young athletes.
Owens BD1, DeBerardino TM, Nelson BJ, Thurman J,
Cameron KL, Taylor DC, Uhorchak JM, Arciero RA.
Arthroscopy. 2013 May;29(5):920-33
Long-term outcomes after Bankart shoulder stabilization.
Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM,
Cole BJ, Bach BR Jr, Romeo AA, Verma NN.

5. Balg F, Boileau P. The instability Severity Index
Score (ISIS score). A rationale approach for patient
selection in arthro- scopic Bankart repair. J Bone
Joint Surg (Br) 2007;89:1470—7.
NO TIENE EN CUENTA:
- Pobre calidad de los tejidos
- Laxitud de los tejidos
- Número de recurrencias
- No cuantifica el grado de
pérdida ósea

6. FRENCH
NON FRENCH
BOILEAU LAFOSSE WALCH

7. 0 104 653 7

8. 0 104 653 7

9. Itoi et al. JBJS Am 2000
Burkhart et al. Arthroscopy 2002
Yamamoto, Itoi et al. JBJS 2010
25%
17%

12. Di Giacomo G, Itoi E, Burkhart SS.
Arthroscopy. 2014 Jan;30(1):90-8.
- Evolving concept of bipolar bone loss and the
Hill-Sachs lesion: from "engaging/non-engaging"
lesion to "on-track/off-track" lesion -

13. Algorithm treatment

14. TREATMENT OPTIONS
• GLENOID BONE LOSS
– Latarjet Open
– Iliac crest vs
– Fresh allograft Arthroscopic
• HUMERAL BONE LOSS
– Remplissage
– Fresh allografts

15. Arthroscopy. 2014 Sep;30(9):1184-211
Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder
dislocation: systematic review and quantitative synthesis of the literature.
Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V.

16. Journal of Arthroscopy 2009 Vol 25, No 4 (April), 2009: pp 446-452
Anatomic Osteochondral Glenoid Reconstruction for Recurrent
Glenohumeral Instability With Glenoid Deficiency Using a
Distal Tibia Allograft
LCDR Matthew T. Provencher, M.D., MC, USN, Neil Ghodadra, M.D.,
Lance LeClere, M.D., MC, USN, CDR Daniel J. Solomon, M.D., MC, USN,
and Anthony A. Romeo, M.D.

17. LATARJET

18. BONE BLOCK EFFECT (BUTÉE)
SLING EFFECT

19. What are the Indications …?

21. LAURENT LAFOSSE

22. ANNECY

23. WHY ARTHROSCOPIC ??!!!

24. What a man can do another man can do ...

27. VIDEOTECHNIQUE

29. Operative
difficulties
1. Subscapularis Split level
2. Passing through the subscapularis
3. Conditions of visualization
4. Positioning of the wires

30. RESULTS
High satisfaction index (>95%)
Extremely low recurrence rate (1.5%)
__
- Problems & Complications (25%)
- Revision rate is low (3.7%)
- ER limitation
- OA ?

31. COMPLICATIONS
• Breakage
• Neuro-vascular damage
• Malpositioning
• Coracoid graft osteolysis
• Non Union
• Mobilization of the screws
• Limited external rotation
• Infection
• Glenohumeral arthrosis

32. Complications 337 cases
–8 malunion
–3 stiffness
–4 Recurrent Instability
–32 screw removals
–3 revision by Iliac crest

33. SFA 2015
Complications on 1555 cases
since each surgeon first @Latarjet
1st @
Latarjet
NB NEURO INF HEMAT FRACT
GRAFT
RECUR
DISLOC
REVISION
LL 2003 500 2 2 4 4 5 17
JL 2007 145 0 2 1 2 6 20
RB 2009 246 0 0 2 0 2 4
PC 2009 240 1 1 0 2 3 3
GN 2010 202 0 0 0 4 4 4
PM 2010 222 1 5 0 2 10 10
Total
1555
4
0,2%
10
0,6%
7
0,4%
14
1%
30
2%
58
3,7%

34. George S. Athwal, M.D., F.R.C.S.C., Robert Meislin, M.D., Charles Getz, M.D., David
Weinstein, M.D., and Paul Favorito, M.D.
Short-term Complications of the Arthroscopic Latarjet Procedure: A North American
Experience
“The rate of adverse events reported in this
arthroscopic series is not insignificant and is
similar to that reported with the traditional open
Latarjet”

35. Superior osteolysis
Massive osteolysis

36. TOO HIGH
TOO PROUD
TOO MEDIAL
TOO LOW

37. TOO SUPERFICIAL
TOO MUCH !!

38. NON-UNION

39. SCREW MOBILIZATION
BREAKAGE SCREWS

40. SUMMARY
-
Bone loss is probably single most important factor for recurrence of instability
-
Preoperative bone loss quantification is critical
-
Bone loss <10% Bankart
-
Bone loss >20% Latarjet
-
10-20% look for other significant risk factors: age, activity-overhead, off track,
# dislocations, revision, intraoperative factors (soft tissue quality/laxity)
-
With significative bone loss or moderate + risk factors, Latarjet is probably the most
reliable operation to avoid recurrence
-
Personal preference Arthroscopic/Open: Complication/Recurrence rate is not
insignificant both

41. SUMMARY
•
Arthroscopic Latarjet is only since 2007 and is here to stay … Improvement of the
Procedure and Devices is still needed
•
- In shoulder instability there is no procedure without risk or complications …
INACTION IS AN ACTION ITSELF
•
Most patient do Well with minimal recurrencies
•
Complication rate is high but not higher than open surgery
•
Complication = Revision (3.7%)
•
Unanswered Questions Remain … Indications, graft placement, Osteolysis
•
Doable/Learning Curve
•
“When in doubt … Chicken out” … conversion to Open surgery is possible at any
stage

42. … Gracias