Reconstruction of the Coracoacromial Ligament during a Modified Latarjet Procedure for the Treatment of Shoulder Instability: Clinical Outcome at Minimum 5 Years Follow-Up

Abstract

Objective The function of the coracoacromial ligament (CAL) in superior shoulder stability has been well established, and the release of the CAL with the Latarjet procedure leads to increased superior humeral translation. A surgical technique was developed recently to reconstruct the CAL during a modified Latarjet procedure, and the clinical outcome of this technique at medium-term follow-up is yet to be determined.

Methods Twenty-six patients with chronic post-traumatic anterior shoulder instability were included in this retrospective case-control study. Patients in group 1 (n = 12) were surgically treated with the classic congruent-arc Latarjet, where the CAL is sacrificed. In group 2 (n = 14), the CAL was reconstructed using a pectoralis minor fascia flap (PMFF). Primary outcomes were the return to sports activity and functional assessment based on the Western Ontario Shoulder Instability Index (WOSI) and the Constant Score (CS) at minimum 5 years follow-up. Patientʼs demographics, sport activities, duration of surgery, the rate of recurrent dislocations, and specific complications related to the surgical technique were recorded as secondary variables.

Results There was a decrease of the WOSI in both groups, indicating a decrease of symptoms at follow-up compared to the preoperative level. There was no statistically significant difference between groups 1 and 2 for the total WOSI as well as for all subscales. There was an increase of the CS in both groups in all four items at follow-up compared to preoperatively, indicating an increase in shoulder function at follow-up. There was a statistically significant difference between groups 1 and 2 for the total CS, as well as for the items power, mobility, and activity, but not for pain. Most patients (n = 20) returned to their preoperative sports activity, 13 at the same level. However, seven patients who used to perform their sports competitively chose to perform their activity at a noncompetitive level after the Latarjet procedure. All were younger than 35 years of age. Six patients did not return to their preoperative sports activity. All except one were over 35 years of age. The duration of surgery ranged from 75 to 125 minutes with a mean ± SD of 94.23 ± 15.06 minutes for both groups with no significant difference between the groups (p = 0.117). None of the patients had intra- or postoperative complications related to the surgical procedure. Especially, no patient had recurrent dislocations of the affected shoulder following the Latarjet procedure.

Conclusion The use of a PMFF is a safe technique for reconstruction of the CAL, which does not result in a longer surgery time or higher rate of complications. The reconstruction of the CAL during the modified Latarjet procedure may lead to better functional results in medium-term follow-up.

Zusammenfassung

Ziel Die Funktion des coraco-acromialen Ligaments (CAL) bei der superioren Schulterstabilität ist hinreichend gut bekannt. Die Resektion des CAL beim Latarjet-Verfahren führt zu einer erhöhten superioren Translation des Humeruskopfes. Daher wurde eine Operationstechnik entwickelt, um das CAL im Rahmen eines modifizierten Latarjet-Verfahrens zu rekonstruieren. Nun soll das mittelfristige klinische Ergebnis dieser Technik ermittelt werden.

Methoden 26 Patienten mit chronischer posttraumatischer ventraler Schulter-Instabilität wurden in diese retrospektive Fall-Kontroll-Studie eingeschlossen. Patienten in Gruppe 1 (n = 12) wurden mit dem klassischen Latarjet behandelt, bei welchem das CAL reseziert wird. In Gruppe 2 (n = 14) wurde das CAL mit einem „Pectoralis minor Fascia Flap“ (PMFF) rekonstruiert. Die primären Parameter waren die Rückkehr zur sportlichen Aktivität und die Funktionsbewertung auf der Grundlage des Western Ontario Shoulder Instability Index (WOSI) und des Constant Score (CS) nach mindestens 5 Jahren. Die demografischen Daten der Patienten, die sportlichen Aktivitäten, die Operationsdauer, die Häufigkeit rezidivierender Luxationen und spezifische Komplikationen im Zusammenhang mit der Operationstechnik wurden als sekundäre Variablen erfasst.

Ergebnisse In beiden Gruppen ist eine Abnahme des WOSI zu verzeichnen, was auf eine Abnahme der Symptome bei der Nachuntersuchung im Vergleich zum präoperativen Niveau hinweist. Es gibt keinen statistisch signifikanten Unterschied zwischen Gruppe 1 und 2 für den gesamten WOSI sowie für alle Subskalen. Es zeigt sich eine Zunahme des CS in beiden Gruppen in allen 4 Subskalen (Items) bei der Nachuntersuchung im Vergleich zu präoperativ, was auf eine Zunahme der Schulterfunktion bei der Nachuntersuchung hinweist. Es gibt einen statistisch signifikanten Unterschied zwischen Gruppe 1 und 2 für den Gesamt-CS, sowie für die Items Kraft, Mobilität und Aktivität, jedoch nicht für Schmerzen. Die meisten Patienten (n = 20) kehrten zu ihrer präoperativen sportlichen Aktivität zurück, 13 auf dem gleichen Niveau. 7 Patienten, die ihren Sport früher kompetitiv betrieben, entschieden sich jedoch dafür, ihre Aktivität nach dem Latarjet-Verfahren auf einem nicht-kompetitiven Niveau auszuführen. Alle waren jünger als 35 Jahre. Sechs Patienten kehrten nicht zu ihrer präoperativen sportlichen Aktivität zurück. Alle außer einem waren über 35 Jahre alt. Die Operationsdauer lag zwischen 75 und 125 Minuten mit einem Mittelwert ± SD von 94,23 ± 15,06 Minuten für beide Gruppen ohne signifikanten Unterschied zwischen den Gruppen (p = 0,117). Keiner der Patienten hatte intra- oder postoperative Komplikationen im Zusammenhang mit dem chirurgischen Eingriff. Insbesondere hatte kein Patient nach dem Latarjet-Verfahren wiederkehrende Luxationen der betroffenen Schulter.

Schlussfolgerung Die Rekonstruktion des CAL im Rahmen eines modifizierten Latarjet-Verfahrens kann zu besseren mittelfristigen funktionellen Ergebnissen führen. Die Verwendung eines PMFF ist eine sichere Technik zur Rekonstruktion des CAL, die nicht zu einer längeren Operationszeit oder einer höheren Komplikationsrate führt.

Key words

shoulder - instability - follow-up

Schlüsselwörter

Schulter - Instabilität - Nachuntersuchung

Publikationsverlauf

Artikel online veröffentlicht:
27. August 2020

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