Personal BACKGROUND 09/03/2018. L.Lafosse Alps Surgery Institute Annecy FRANCE. L.Lafosse : LATARJET GOUTALLIER
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1 L.Lafosse Alps Surgery Institute Annecy FRANCE L.Lafosse Alps Surgery Institute Annecy FRANCE Personal BACKGROUND : LATARJET GOUTALLIER 1984 : BANKART DUPARC 1985 : ALLOGRAFT ROY CAMILLE 1989 : LATARJET Private Surgeon ANNECY 1989 : FIRST SHOULDER ARTHROSCOPY. 1
2 1990 Arthroscopy taking off During the 1990's the technology and surgical experience advanced significantly with fluid pressure pumps shavers radiofrequency devices instruments and implants Shoulder Arthroscopy Instability GLENO HUMERAL JOINT 1982 First arthroscopic Bankart repair with staples by Johnson 1984 SLAP Andrews JR, Carson WG. The arthroscopic treatment of glenoid labrum tears in the throwing athlete. Orthop Trans.1984;8:44. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6: Transosseous repair Transosseous suture repair in 25 patients: Morgan CD, Bodenstab AB, Arthroscopic Bankart suture repair: technique and early results. Arthroscopy Caspari : Arthroscopic Shoulder reconstruction 1987 Arthroscopic Bankart repair with Anchors Eugene Wolf John Richmond 2
3 1992 Mitek G II Anchor 1995 Failures for Arthroscopic technique Gilles Walch Arthroscopic stabilization for reccurent anterior shoulder dislocation Result of 59 cases Arthroscopy 1995;11: «Of 59 patients, 49% had BAD result» RECURRENCE RATES ARTHROSCOPIC REPAIR % Geiger1997 Kandziora 2000 Cole 2000 Sperber 2001 Speer 1996 Laurencin 1996 Hayashida1998 Karlsson 2001 De Bernardino 2001 Bottoni 2000 Savoie 1997 Mishra 2001 Resch 1997 authors O'Neill 1999 Gartsman 2000 Larrain 2001 Kim2002 3
4 RECURENCIES 16.1 % Personal Serie 155 cases (74 GII+81 Panalok) 3 12 years TRAUMATIC ATRAUMATIC FU % ,5 DISLOCATION (GII) 4,9 4,9 4,9 0 SUBLUXATION DISLOCATION (GII) (PANALOK) DISLOCATION/SUBLUXATION RATE 3,7 SUBLUXATION (PANALOK) 2000 SFA SYMPOSIUM ANNECY SHOULDER ANTERIOR CHRONIC INSTABILITY 2000 SFA SYMPOSIUM ANNECY Indications for arthroscopic stabilisation can be more clearly defined... Arthroscopy + T I : if lesions are located on the glenoid side Arthroscopie +/ T II : if lesions are extended in the IGHL Arthroscopy T III : if lesions are extended on the humeral side 4
5 Tool of the Devil? HOW TO IMPROVE BANKART REPAIR? 2005 : Shrinkage Cadaver: Luke TA, Rovner AD, Karas SG, et al.: Shoulder Elbow Surg., 2004 Chen S, Haen PS, Walton J, Murrell GA: AJSM
6 CASSIOPEA : w 5 POINTS DOUBLE ROW FIXATION INSTABILITY Arthroscopy January 2006 w CASSIOPEA FIXATION 6
7 2006 : Glenoid Bone loss evaluation 2006 Open Iliac Crest Bone Graft (Eden Hybbinette, J Graft) Iliac Crest Bone Graft Original description used tibial autograft Contoured tricortical iliac crest graft Fixed with 3.5mm screws +/ sutures from Millett et al, Am J Sports Med, 2006 vol. 34 (2) pp Coracoid Transfer (Bristow, Latarjet) Vascularized bone graft Triple blocking effect Bone block (Butée) Soft tissue sling (conjoint tendon) Capsulolabral repair (Eventualy) Proven reliable technique 7
8 Bristow vs Latarjet Bristow Upright coracoid Only 1 screw fixation Small bony contact area No rotational stability Latarjet Lying coracoid Stable construct with 2 screws Greater increase surface area Rotation stability Latarjet: a French Technique I will do arthroscopic stabilization when it will be possible to do the Latarjet procedure Arthroscopicaly Gilles Walch 2007 : Arthroscopic Bristow 8
9 2007 : Arthroscopic Latarjet Lafosse L, Lejeune E, Bouchard A, Kakuda C, Gobezie R, Kochhar T. The Arthroscopic Latarjet Procedure for the Treatment of Anterior Shoulder Instability. Arthroscopy, 2007 ALPS: Arthroscopic Latarjet Procedure Surgery ALPS 3 M Arthroscopic Latarjet Procedure: My Personal Experience 27 Nice Shoulder Course May
10 Pain 28 Our Results 89 Shoulders 62 Pts (63 shoulders) available for followup NO RE DISLOCATION 1/63 subluxation 10
11 Xray 26 Months Follow up 4 Non union = 6% 3 Partial Osteolysis = 5% REVISIONS 4 Hardware Removals 1 Hybinette Results 26 Months Graft Position 11
12 The Vast Majority of patients do well. in 15%-20% of Patients Concerns Arise Concerns Graft Placement 6 Months A. Too High B. Too Low C. Too Lateral Non Union Osteolysis Stiffness/Lack of ER TOO HIGH 12
13 TOO LOW 6Months Post OP TOO LATERAL DUE TO BAD SCREW POSITIONING : Too lateral Too oblique LEADS TO : Pain Restriction of ER Arthritis +++ NEEDS: HARDWARE REMOVAL +++ LATARJET 5 YEARS FOLLOW UP 13
14 «Whatabout the excision of the anterior capsule which does not allow the capsule and labrum repair?» Difference only in Pure Abduction NO Difference in ABERPosition «Whatabout the exision of the anterior capsule which does not allow the capsule and labrum repair?» 2.5 years Post op Open Latarjet French Arthroscopic Society Laurent Lafosse & Gilles Walch J Barth, P Boileau, R Brzoska, P Clavert, D Haeni, J Leuzinger, G Nourissat, L Neyton, B Villain 14
15 Fondamental Questions 1. Compared to open, giving the usual advantages of arthroscopy? 1. Do we do as well? 2. Do we do better? 2. What are the difficulties Latarjet? (learning curve) 3. What are the complications Latarjet? (morbidity) 4. Any alternative technique? 5. What about the futur Latarjet? 1. Should we keep on or should we stop? 2. Which improvement should we bring? IRB committee Population of 5 studies learning curve : 125 first cases ( 5 x 25 ) RETROSPECTIVE P. Métais G. Nourissat P. Clavert J. Leuzinger R. Brzoska Latarjet : Operative difficulties : 151 cases PROSPECTIVE 3. Clinical, X Ray & CT scan post op study. : 390 patients PROSPECTIVE SERIES # 1 March 2013 => June Latarjet : 222 Endo Bouton : 64 Open Latarjet : Functional study on WOSI score : 184 patients PROSPECTIVE SERIES # 2 July 2014 => December Latarjet : 99 Open Latarjet : Complications Latarjet Exhaustive study : 1555 patients RETROSPECTIVE Operative difficulties 151 cases The technique L. LAFOSSE (2003) 15
16 Operative difficulties 1. Subscapularis Split level 2. Passing through the subscapularis 3. Conditions of visualization 4. Positioning of the screws SERIES # I : 390 cases There is no significant difference between Open Latarjet or open provides a stable shoulder Series cases Major Post op Complications SFA 2015 Global Series Recurrence Neurol.Compl Lavage 0,8 % 0,8 % 2 0,5 % 1,4 % 1% Latarjet C.O. 0% 0% 1% Endo Bouton 3 % 0 % 0 % 16
17 Position of the graft Transversal plan : Open is more medial is more proud (1mm) Sagital with screw is the highest (55%) 71% of open are below equator, endobouton is the lowest (82%), Angulation of glenoid tunels Endobouton is the most parallel to the gelnoid and reproductible. Open is screw is the most variable with higher extremes (>30 ), Series I 390 cas EVOLUTION OF THE BONE GRAFT RESORPTION : ½ SUP > ½ inf SUP OSTEOLYSE : Open Inf osteolysis > open Very little impact on Clinical result Independant to the vertical position More important if more medial Complications on 1555 cases since each surgeon 1 Latarjet NB NEURO INF HEMAT FRACT GRAFT RECUR DISLOC REVISION LL JL RB PC GN PM Total ,2% 10 0,6% 7 0,4% 14 1% 30 2% 58 3,7% 17
18 2015 Conclusion of the and Open Latarjet Effective Reproducible Low rate complication SREWS vs ENDOBUTTON Endo Bouton Graft Stability Forces: 18
19 Graft Stability Forces: Bending load I x = π r 4 / 4 Graft Stability Forces: Bending load Graft Stability Forces: Bending load Shear load S x = π r 2 19
20 Graft Stability Forces: Bending load Shear load Graft Stability Forces: Bending load Shear load Tension load Graft Stability 20
21 Graft Stability
22 22
23 ` Indications for Bankart/A Acute trauma, even with glenid bony lesion Labrum detachment without any dislocation No bony lesion (humerus &/or glenoid) No ligamentous evident lesion No labrum tear Low risk population Indications for Latarjet/A Recurrent dislocations Glenoid bone loss >10% High risk population < 25 y High risk sport (Rugby etc.) Engaging Hill Sachs lesion HAGL lesion 23
24 THANK YOU! 24
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