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Coracoid fracture following latarjet failure: a case report.

Recurrent anterior glenohumeral instability after attempted soft tissue stabilization can be secondary to failed repair, capsular redundancy, and more commonly from lack of bony support. The latter can be secondary to glenoid bone loss and concomitant articular bony deformities. (1) Isolated labral repair and capsular plication in patients with critical glenoid bone defects are often insufficient in preventing recurrent dislocation. Stabilization procedures to reconstitute structural deficits have been shown to reliably restore anterior stability. (2) The Latarjet procedure involves the transfer of the coracoid process with its soft tissue attachments, (3) thereby providing both bony and soft tissue articular reinforcement with a low incidence of postoperative failure. (4-7) However, complications, such as coracoid fracture, glenohumeral arthrosis, and screw migration, can be detrimental to articular anatomy. (5) In a patient with recurrent anterior instability after two attempts at soft tissue stabilization (arthroscopic labral repair followed by open inferior capsular shift), an open Latarjet procedure was performed with subsequent revision secondary to coracoid autograft fracture.

Case

A 45-year-old man presented for evaluation of persistent left shoulder anterior instability after two failed anterior reconstructive procedures at an outside institution. He had undergone arthroscopic superior labral anterior to posterior (SLAP) repair with anterior capsulorrhaphy in 2013. Owing to persistent instability, an open inferior capsular shift was performed in 2014. Following this second procedure, he continued to have recurrent instability. Upon his presentation to our institution, his examination demonstrated positive anterior apprehension and a positive relocation test with 2+ anterior instability. The patient had no evidence of generalized excessive joint laxity with a negative sulcus sign and no signs of posterior instability. Neurological exam of the extremity was otherwise normal.

Due to previous placement of a neurostimulator in the patient's back, magnetic resonance imaging (MRI) could not be performed. Left shoulder radiographs in anteroposterior (AP) internal rotation, AP external rotation, trans-scapular-Y, West Point, and axillary views suggested a small Hill-Sachs lesion without evidence of a concomitant Bankart lesion (Fig. 1). A three-dimensional computed tomography (CT) scan was obtained to further evaluate potential bony defects and revealed a small Hill-Sachs lesion as well as cortical irregularity along the anteroinferior glenoid rim without significant bony deficiency (Fig. 2).

At the time of surgery, examination under anesthesia revealed gross instability, primarily anteriorly with instability of 2+ to 3+ noted, as well as 2+ sulcus, and 2+ posterior instability. The patient was placed into the beach chair position and a Latarjet procedure was performed. A modified deltopectoral incision was utilized. The subscapularis muscle tendon was torn and retracted to the mid humeral level with a large tendinous stump laterally. This was separated from the capsule and tagged with #2 FiberWire[R] (Arthrex, Inc., Naples, FL). The pectoralis minor was elevated from the medial aspect of the coracoid, and the acromioclavicular (AC) ligament was incised at the level of the acromion to allow for adequate stump length to incorporate into the capsular repair. The coracoid drill holes were prepared using the Mitek Latarjet system (DePuy Mitek, Inc., Raynham, MA). The coracoid guide was placed followed by guidewires over which a cannulated reamer was utilized to prepare the coracoid drill holes. A curved oscillating saw was then utilized to cut the base of the coracoid, taking care not to damage the coracoclavicular ligaments. A vertical capsular incision was performed at the level of the glenohumeral joint followed by removal of the capsule at this level and medial along the anterior neck of the scapula. No major glenoid bone defects were noted. The coracoid graft was transferred and placed flush against the articular surface on the inferior glenoid from the 3:30 to 5 o'clock position. Two 36 mm screws were used to secure the graft. After graft insertion, shoulder stability was evaluated: the humeral head was maintained in position at 90[degrees] of abduction and 90[degrees] of external rotation. The coracoacromial ligament on the lateral aspect of the coracoid was incorporated into the capsular repair. The subscapularis muscle was then repaired via bone tunnels and suture anchors to the lesser tuberosity. Postoperatively, the patient was placed in an abduction brace in neutral shoulder rotation.

At 4 weeks postoperatively, the patient presented with sudden, persistent, severe pain. Plain radiographs showed fracture of the coracoid graft (Fig. 3). A CT scan confirmed eccentric coracoid drilling (Fig. 4).

The patient was brought back to the operating room for revision surgery. Intraoperatively the fragments were identified with the distal fragment still attached to the conjoint tendon. The conjoint tendon was scarred into the anteroinferior capsule and functioning as an anterior restraint. The proximal fragment was removed. No intra-articular damage was found. The two screws securing the coracoid to the glenoid were removed. The distal bony fragment was reattached to the anterior inferior portion the glenoid with two 3.0 mm PEEK suture anchors (Arthrex, Inc., Naples, FL), (Fig. 5). The sutures were passed through the remaining coracoid bone block and conjoint tendon and tied.

Postoperatively, the patient was kept in an abduction brace with the shoulder in neutral rotation for 6 weeks. Gentle passive pendulum exercises were started immediately. At 6 weeks postoperatively, shoulder abduction and external rotation were initiated. The patient was last seen at 6-months follow-up and had minimal pain with overhead activities. He did not report any instability and was satisfied with his result.

Discussion

In the setting of recurrent anterior shoulder instability, determining the extent of both bony and soft tissue defects is crucial for optimal operative management. Arthroscopic Bankart repair is an established option for patients with isolated soft tissue Bankart lesions, yet Burkhart and coworkers reported a near 70% instability recurrence rate following soft tissue stabilization with underlying bony Bankart or Hill-Sachs lesions. (8) More extensive soft tissue injuries, including capsular attenuation, also have a high association with recurrent instability following Bankart repair. (9) The Latarjet procedure, which was first described in 1954, (3) is becoming a popular option for surgeons managing patients with recurrent instability with or without significant bony defects. The known presence of significant anterior glenoid bone loss (generally beyond 25%) (10) from either a fracture or attritional bone loss can be successfully treated with Latarjet reconstruction. (11) An engaging Hill-Sachs defect, often in coexistence with a Bankart lesion, is also an indication for the procedure. (8) One can also advocate that a Latarjet procedure be used as the initial stabilization procedure in extremely active or athletic patients who do not have significant bone loss.

Latarjet stabilization successfully addresses the problem of recurrent instability in several ways. The most obvious benefit is from restoration of the glenoid contact surface area. Coracoid relocation to the anterior glenoid rim also increases the glenoid articular arc, allowing for more external rotation of the shoulder without engagement of a HillSachs lesion. The coracobrachialis functions as a static and dynamic stabilizer to the inferior part of the capsule during shoulder abduction and simultaneous elbow flexion. (12) This is otherwise known as the dynamic sling effect.

Most studies show positive outcomes with the open Latarjet procedure, with complications at rates as low as 1% (13) and predominately secondary to technical error. Perioperative complications may include musculocutaneous nerve palsy, hematoma formation, coracoid fracture, and coracoid graft osteolysis. (13) Protecting the coracobrachialis muscle during coracoid osteotomy and subsequent transfer can help prevent transient or permanent musculocutaneous nerve injury. (14) Coracoid fracture at the time of bony fixation can be secondary to using large screws, excessive compressive forces from screw overtightening, or eccentric screw placement in the coracoid as was seen in this case. Osteolysis of the coracoid graft is most likely secondary to insufficient vascularization or coracoid-glenoid contact and can lead to re-engagement of a Hill-Sachs lesion. (12) Screw loosening can cause symptomatic coracoid movement, while total screw displacement has been noted to cause major intra-articular damage. (15) Postoperative coracoid fracture, in addition to improper intraoperative technique, can be caused by trauma.

Glenohumeral arthrosis is a well-established long-term complication of Latarjet surgery, occurring with rates as high as 62%. The number one predisposing factor is improper coracoid graft orientation. The coracoid graft should ideally be fixed perpendicular to the scapular plane on the anterior glenoid rim. Additionally, lateral placement of the graft in the coronal plane can effectively create articular step-off and is strongly associated with glenohumeral arthrosis.

The case presented specifically highlights the need to appropriately identify the "bony margins" of the coracoid prior to drilling to make certain that drill holes are not eccentrically placed. The soft tissue attachments to the coracoid (lateral coracoacromial ligament stump and medial pectoralis minor tendon) need to be adequately elevated off the coracoid to visualize the bony margins and appropriately center the drill guide.

Disclosure Statement

Laith M. Jazrawi, M.D., receives research support from Arthrex, Inc. (Naples, FL) and DePuy Mitek (Raynham, MA). None of the other authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

(1.) Tauber M, Resch H, Forstner R, et al. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 2004 May-Jun; 13(3):279-85.

(2.) Boileau P, Villalba M, Hery JY, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006 Aug; 88(8):1755-63.

(3.) Latarjet M. [Treatment of recurrent dislocation of the shoulder]. Lyon Chir. 1954 Nov-Dec; 49(8):994-7.

(4.) Hovelius LK, Sandstrom BC, Rosmark DL, et al. Long-term results with the Bankart and Bristow-Latarjet procedures: recurrent shoulder instability and arthropathy. J Shoulder Elbow Surg. 2001 Sep-Oct; 10(5):445-52.

(5.) Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998 Jun; 80(6):841-52.

(6.) Hovelius L, Sandstrom B, Sundgren K, Saebo M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I--clinical results. J Shoulder Elbow Surg. 2004 Sep-Oct; 13(5):509-16.

(7.) Spoor AB, de Waal Malefijt J. Long-term results and arthropathy following the modified Bristow-Latarjet procedure. Int Orthop. 2005 Oct; 29(5):265-7.

(8.) Burkhart SS, De Beer JF. 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. 2000 OcU6(7):677-94.

(9.) Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995 Oct; ll(5):600.

(10.) Itoi E, Lee SB, Amrami KK, et al. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med. 2003 JanFeb; 31(1):112-8.

(11.) Beran MC, Donaldson CT, Bishop JY Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elbow Surg. 2010 Jul; 19(5):769-80.

(12.) Di Giacomo G, Costantini A, de Gasperis N, et al. Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients. J Shoulder Elbow Surg. 2011 Sep; 20(6):989-95.

(13.) Young AA, Maia R, Berhouet J, Walch G. Open Latarjet procedure for management of bone loss in anterior instability of the glenohumeral joint. J Shoulder Elbow Surg. 2011 Mar; 20(2 Suppl):S61-9.

(14.) Levigne C. [Long-term results of anterior coracoid abutments: apropos of 52 cases with homogenous 12-year follow-up]. Rev Chir Orthop Reparatrice Appar Mot. 2000 Sep; 86 Suppl 1:114-21.

(15.) Zuckerman JD, Matsen FA 3rd. Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am. 1984 Feb; 66(2):175-80.

Brian Capogna, M.D., William E. Ryan, Jr., B.S., Alan W. McGee, M.D., and Laith M. Jazrawi, M.D., Division of Sports Medicine, Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York.

Correspondence: Laith M. Jazrawi, M.D., Division of Sports Medicine, NYU Hospital for Joint Diseases, 333 East 38th Street 4th Floor, New York, New York 10016; laith.jazrawi@nyumc.org.

Caption: Figure 1 Left shoulder radiographs in AP internal rotation, AP external rotation, transscapular-Y, West Point, and axillary views.

Caption: Figure 2 A, 3D CT of the left shoulder showing the glenoid. B, 3D CT of left shoulder showing anterior margin of glenoid. C, 3D CT of left shoulder showing Hill-Sachs lesion. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 3 Plain films showing coracoid fracture.

Caption: Figure 4 3D CT showing eccentric reaming. To view this figure in color, see www. hjdbulletin.org.

Caption: Figure 5 Open revision fixation of coracoid fragments with suture anchors. To view this figure in color, see www.hjdbulletin.org.

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Author:Capogna, Brian; William, Ryan E., Jr.; McGee, Alan W.; Jazrawi, Laith M.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Date:Oct 1, 2016
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