Learning Curve of Arthroscopic Anatomic Glenoid Reconstruction: Comparison to the Arthroscopic Bristow Latarjet
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1 Learning Curve of Arthroscopic Anatomic Glenoid Reconstruction: Comparison to the Arthroscopic Bristow Latarjet Iustin Moga MD George Konstantinidis MD, PhD Cathy Coady MD, FRCS(C) Ivan Wong MD, FRCS(C)
2 Disclosures Iustin Moga, MD George Konstaninidis, MD Catherine Coady, MD, FRCS(C) Ivan Wong, MD, FRCS(C) No disclosures No disclosures No disclosures Smith and Nephew Depuy Mitek Stryker
3 Introduction Surgical management of recurrent shoulder instability (RSI) due to bone loss: Arthroscopic Bankart Repair (ABR) - 35% long-term recurrence rate Arthroscopic Bristow-Latarjet Procedure (ABLP) - Excellent medium-term outcomes - complex and demanding procedure with long learning phase - should be performed by expert surgeons Arthroscopic Anatomic Glenoid Reconstruction (AAGR) - recently proposed alternative to ABLP and ABR - excellent short term clinical outcomes - learning curve not previously studied
4 Objective of the study Investigate the learning curve of AAGR by examining: surgical time outcome scores complication rates and compare it to the ABLP with respect to these metrics. HYPOTHESIS AAGR will provide similar outcomes while taking less time to learn and perform
5 Materials and Methods Single surgeon, retrospective review of patients managed with either ABLP or AAGR for recurrent shoulder instability Data collected on: Surgical time Final graft and screw position (by CT scan) Intra op/ Post op complications Post op Western Ontario Shoulder Instability Index (WOSI) Study cohorts divided into three equal clusters of nine patients primary outcome - change in operative time over successive operations secondary outcome - clinical outcome (WOSI) - complication rates - bone graft position
6 Surgical Steps ABLP Diagnostic Arthroscopy AAGR Diagnostic Arthroscopy Subscapularis Split Allograft Preparation Autograft Harvesting Preparation for graft placement Graft positioning and fixation Graft positioning and fixation
7 Primary outcome Surgical time AAGR: Faster procedure Optimal surgical time after seven cases ABLP More complex surgery Optimal surgical time after 17 cases
8 Secondary outcomes WOSI score Better mid term WOSI score for AAGR
9 Secondary outcome Complications and Revisions Recurrent Instability requiring Revision Surgery Revision Surgery symptomatic nonunion Axillary Neuropraxia or isolated sensory deficit ABL (n=11) AAGR (n=28) 1 (9%) 1(4%) Infected allograft removed 2 (18%) 1(4%) 1 (9%) 0 Higher revision rate for ABLP
10 Secondary outcome Graft positioning AAGR vs ABLP Medial-lateral Superior-inferior flush medial lateral 1st cluster AAGR 2nd cluster AAGR 1st cluster ABLP 2nd cluster ABLP 3rd cluster AAGR 3rd cluster ABLP flush medial lateral flush medial lateral Medial-lateral placement more accurate with AAGR Low graft positioning with both techniques high medium low 1st cluster AAGR st cluster ABLP 2nd cluster AAGR 2nd cluster ABLP 3rd cluster AAGR 3rd cluster ABLP
11 Conclusions Surgical time ABLP Mean optimal time = min Late plateau and deeper learning curve AAGR Mean optimal time = 84 min Plateaus early (after 7 cases) Clinical outcomes Fair short term WOSI score Fair short term WOSI score Better mid term WOSI score complications Comparable revision rate for recurrent instability Higher revision rate for other reason Higher non union rate (25%) One infection in cohort Lower revision rate for other reason None non-union Graft positioning Greater intra-articular step off Much better graft positioning AAGR is easier to adopt, and suitable as a practical alternative to the ABLP
12 Advantages of AAGR 1. Faster than ABLP This study shows a learning curve advantage for AAGR vs ABLP 2. Anatomical advantages: a) Spares the subscapularis muscle, avoiding potential adverse impact on range of motion and strength b) Spares the capsule and labrum potentially improving long-term shoulder stability 3. Fewer complications with AAGR provides advantages to patients and healthcare systems 4. Shorter operative time creates a potential benefit to surgeons and healthcare systems AAGR is a good alternative to ABLP
13 References Burkhart SS, De Beer JF (2000).Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 16(7): Castagna A, Garofalo R, Melito G, Markopoulos N, De Giorgi S (2010). The role of arthroscopy in the revision of failed Latarjet procedures. MusculoskeletalSurgery.94(1): S Cunningham G, Benchouk S, Kherad O, Lädermann A. (2016) Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc. 24(2): Dauzère F, Faraud A, Lebon J, Faruch M, Mansat P, Bonnevialle N. (2016) Is the Latarjet procedure risky? Analysis of complications and learning curve. Knee Surg Sports Traumatol Arthrosc. 24(2): Paladini P, Merolla G, De Santis E, Campi F, Procellini G (2012). Long-term subscapularis strength assessment after Bristow-Latarjet procedure: isometric study. J Shoulder Elbow Surg. 21(1):42-7 Van der Linde JA, van Kampen DA, Terwee CB, Dijksman LM, Kleinjan G, Willems WJ (2011). Long-term results after arthroscopic shoulder stabilization using suture anchors: an 8- to 10- year follow-up. Am J Sports Med.39(11): Wong IH, Urquhart N. Arthroscopic Anatomic Glenoid Reconstruction Without Subscapularis Split. Arthrosc Tech Sep 21;4(5):e449-56
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