Long-term prevalence and impact of glenohumeral osteoarthritis after Latarjet-Patte procedure for anterior instability.

INTRODUCTION: The Latarjet procedure provides satisfactory functional results, with low rates of recurrence. It is, however, sometimes claimed to induce osteoarthritis due to the positioning of the bone-block and hardware. The aims of the present study were to assess the long-term prevalence of osteoarthritis following the procedure, to determine risk factors and assess clinical impact. The study hypothesis was that osteoarthritis risk can be reduced by good bone-block positioning. The secondary objective was to assess long-term recurrence of instability. MATERIALS AND METHODS: Out of a cohort of 102 patients (106 shoulders) operated on between 1984 and 1998, 77 had complete radiology files for analysis in a previous study published in 2003. Forty-four of these patients were seen again for clinical and radiological assessment at a mean 22 years' follow-up, to be compared to results previously reported at 8 years. Clinical assessment comprised range of motion and Constant and Walch-Duplay scores. X-rays were taken systematically to determine Samilson osteoarthritis stage; 31 patients also underwent CT. RESULTS: In the 44 patients, the rate of osteoarthritis was 34.1%. 90.9% of patients were satisfied. Mean Constant score was 83.5±14 and mean Walch-Duplay score was 71.6±23.4. Advanced age at surgery and at assessment, length of follow-up and age >30 years at first episode of instability were the main factors for onset of osteoarthritis, independently of surgery. Lateral bone-block overhang correlated with onset of osteoarthritis: 71.4%, versus 16.7% in medial or flush bone-block (p=0.0004). Humeral notch, glenoid bone defect and number of preoperative episodes of instability were unrelated to onset of osteoarthritis. Lateral bone-block overhang was the only risk factor related to surgery. The clinical impact of the osteoarthritis was significant only in advanced stages (Samilson 3 and 4). CONCLUSION: Lateral bone-block overhang was the only surgical risk factor for osteoarthritis in the long-term. Strict coracoid positioning is therefore essential, and could be facilitated by specific instrumentation and by arthroscopy. LEVEL OF EVIDENCE: IV; retrospective study.

Endoscopic treatment of insertional Achilles tendinopathy: A cadaver feasibility study.

INTRODUCTION: One treatment option in insertional Achilles tendinopathy is open reconstruction of the insertion, resecting the enthesophyte and posterosuperior calcaneal prominence and reinserting the tendon using anchors. Although classically performed as an open procedure, the necessary subcutaneous release and dissection can entail problems of healing in at-risk patients. HYPOTHESIS: It is possible to perform Achilles disinsertion-reinsertion with posterosuperior calcaneal prominence resection endoscopically, without iatrogenic risk, enabling complete resection of the enthesophyte and posterosuperior calcaneal prominence and satisfactory reinsertion. MATERIAL AND METHODS: An operative technique was developed, consisting in Achilles disinsertion-reinsertion with resection of the posterosuperior calcaneal prominence and enthesophyte endoscopically via 5 portals. A feasibility study was conducted in an anatomy laboratory on 10 foot specimens, assessing iatrogenic impact. Bone resection quality was assessed under endoscopic and fluoroscopic control. Reinsertion quality was assessed endoscopically and on dissection of the specimens. RESULTS: In the 10 procedures, there were no failures. Resection of the calcifications and the calcaneal prominence was complete in all cases. Reinsertion was satisfactory in all cases. There were no iatrogenic neural lesions. DISCUSSION/CONCLUSION: It was possible to perform endoscopic Achilles disinsertion-reinsertion with resection of the posterosuperior calcaneal prominence and enthesophyte. The procedure did not seem to increase iatrogenic risk, and enabled complete bone resection and satisfactory reinsertion. This endoscopic technique now needs to be validated clinically, with comparison versus open surgery. LEVEL OF EVIDENCE: IV; cadaver study.

Arthroscopic Bankart Repair Versus Immobilization for First Episode of Anterior Shoulder Dislocation Before the Age of 25: A Randomized Controlled Trial.

BACKGROUND: The risk of recurrence after the first episode of anterior shoulder dislocation is high with nonoperative treatment in younger patients. PURPOSE/HYPOTHESIS: The aim of this study was to compare the results of arthroscopic Bankart repair and nonoperative treatment for shoulder dislocation in patients younger than 25 years, with a minimum of 2 years of follow-up. The hypothesis was that surgery would decrease the risk of recurrence. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: We included patients aged between 18 and 25 years after a first episode of anterior shoulder dislocation and divided them into 2 groups. The first group was treated surgically with an arthroscopic Bankart repair within 2 weeks after the dislocation; the second group was treated nonoperatively. Both groups were immobilized for 3 weeks in internal rotation and followed the same physical therapy protocol. Standard radiography and computed tomography were performed immediately after reduction of the dislocation, and follow-up was performed at 3, 6, 12, and 24 months. The primary outcome measure was instability recurrence, defined as another anterior shoulder dislocation requiring closed reduction by another person (the patient was unable to reduce the dislocated joint themselves), a subluxation, or a positive apprehension test. Secondary outcome measures included range of motion, return to sport, and functional scores such as the short version of the Disabilities of the Arm, Shoulder and Hand score the Walch-Duplay score, and the Western Ontario Shoulder Instability Index (WOSI). RESULTS: A total of 20 patients were included in each group. The mean ± SD age was 21 ± 1.8 years, and there were 33 men (82.5%) and 7 women (17.5%) in the total sample. Recurrence of instability was significantly decreased in the surgical treatment group compared with the nonoperative group (2 [10%] vs 14 [70%], respectively; P = .0001). Fewer patients in the surgical treatment group versus the nonoperative group had another episode of dislocation (0 vs 6 [30%], respectively), subluxation (2 [10%] vs 13 [65%], respectively; P = .003), or a positive apprehension test (1 [5%] vs 11 [58%], respectively; P = .0005). The Walch-Duplay score (88.4 vs 70.3 points; P = .046) and WOSI (11.5 vs 17.7 points; P = .035) were significantly better in the surgical group versus the nonoperative group after a 2-year follow-up. Level of sport was the same or better in 89% of the surgical treatment group vs 53% of the nonoperative treatment group (P = .012). No surgical complication was recorded. We did not find any significant difference in range of motion. CONCLUSION: In patients with first-time shoulder dislocations, arthroscopic labral repair (Bankart procedure) reduced the risk of secondary shoulder dislocation and improved functional outcome versus nonoperative treatment after a 2-year follow-up. Surgical treatment after a first episode of shoulder dislocation could be offered as a primary treatment option in a younger population if these results are confirmed by larger studies with a longer follow-up. REGISTRATION: NCT03315819 (ClinicalTrials.gov identifier).