When to Do … A Latarjet versus Remplissage

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When to Do …
A Latarjet versus Remplissage
James C. Esch, M.D.
Orthopaedic Specialists of North County
Oceanside, CA
Latarjet v. Remplissage
The following financial relationships exist:
1. Stock options - KFX Medical
2. Consulting Income - Smith & Nephew Endoscopy
Latarjet or Remplissage ?
Church of Shoulder Surgery
High Failure of Labrum Repairs
with Glenoid or Humeral Bone Loss
Do You Believe This ?
20 yo male
20 yo male athlete
What Would You Do?
Another Instability Case
1:38
The Problem
Glenoid Bone Loss
Humeral Bone Loss
Hill-Sachs
Become Aware That Bone Loss Exists
And Leads to Higher Failure Rate in Younger Patients.
Teaching or Learning
• Confucius (551-479 BC)
– “To know what you don’t know is the first
stage of learning.”
• Oscar Wilde (1854-1900)
– “Education is an admirable thing, but it is
well to remember from time-to-time that
nothing that is worth learning can be
taught.”
Imaging
• Radiographs
• MRI arthrogram
• CT scan with 3 D reconstruction
Bone Loss Cases
Case 1: Latarjet Coracoid
Case 2
17 yo Football Linebacker
Bio-resorbable Anchors
Failed scope repair at 1.5 years
Etoi … Glenoid Track
Etoi … Glenoid Track
60
30
0
Etoi … Glenoid Track
Medial nonengage HS is at
84% of glenoid
width.
Treatment Choices
• Fill the humeral hole
– With bone
– With soft tissue = Remplissage
• Replace glenoid bone = Latarjet
• Create a sling
– Latarjet
– Bristol
Bone Loss
• Bony Bankart incorporate into repair
• Anterior Glenoid Bone Graft
– Ileac crest (Edin-Hybbinette)
– Tip of coracoid (Bristol)
– Larger coracoid (Latarjet) – 95+ success
– Allograft
• Large Hill-Sachs
– Bone allograft
– Remplissage
Shah, Karadsheh, Sekiay…Failure of Operative Treatment of
Glenohumeral Instability: Etiology and Management. JARR 2011
Bone Loss with Traumatic Anterior Instability
Repair Labrum ?
Anchor or Open
Labrum + Remplissage ?
When?
Bone Block Glenoid
Coracoid: Open (Walsh) or Scope (LaFosse)
Ileac crest: Open or Scope (Taverna)
Sling Operations
Coracoid of Walsh or Lafosse
Bristol: Open or Scope (Boileau)
Treatment of chronic glenoid defects in the setting of recurrent anterior
shoulder instability: a systematic review
• Inclusion criteria were all articles evaluating chronic glenoid
deficiency in the setting of recurrent anterior glenohumeral
instability.
• Six articles…level IV (case series)…5/6 retrospective.
• Techniques: coracoid transfer, allograft or autograft
• The 6 techniques reviewed here were all effective at
preventing recurrent instability.
Beran, Donaldson, Bishop: JSES 2010
Treatment of chronic glenoid defects in the setting of recurrent anterior
shoulder instability: a systematic review
• Conclusions
– Chronic glenoid deficiency in the setting of
recurrent anterior instability is an extremely
challenging problem.
– …a lack
of strong evidence guiding the
surgeon in the decision-making
process.
– Additional research ….
Beran, Donaldson, Bishop: JSES 2010
The Latarjet Procedure
The Sling + Widen Glenoid = “Latarjet”
What I did
Surgical treatment of anterior instability in rugby
union players: ….results of the Latarjet
• 37 shoulders in 34 rugby players
• Minimum 5 yrs follow-up
– Mean follow-up 12 yrs
• No recurrent dislocation or subluxation
– Apprehension 5 patients (14%)
– 11 patients (30%) minor arthritic changes
Neyton …Walch JSES 2012
• 45 shoulder
• 25% Complications
– 8% Recurrent Complications
– 10 % Nerve Injury
Latarjet Results
• Walsh > Primary instability operations … good results
• DeBeer > Primary in rugby players
• Warner > some nerve complications
• US Sports Surgeon – not a common procedure
• US Shoulder Surgeon – more comfortable with open surgery
How to do a Latarjet?
Allografts to Humerus and Glenoid
Jeffrey Sodi, MD
Brian Cole MD
The Remplissage Procedure
• We present an arthroscopic technique used to treat traumatic
shoulder instability in patients with glenoid bone loss and a
large Hill-Sachs lesion
Fill the Hole =
“Remplissage”
How to Do the Remplissage
Larry Field MD
1:12
Remplissage + Bony Bankart
3:28
Some Remplissage Literature
• 35 patients … 2 yrs … moderate bone loss
• Failure rate
– Primary case = 0%
– Revision case = 36%
• Aggressive capsulolabral reconstruction with remplissage in
traumatic instability patients with moderate bone loss and
engaging humeral Hill-Sachs lesions yields acceptable outcomes for
primary instability surgery.
• A significantly higher failure rate occurred when arthroscopic
reconstruction with remplissage was performed in the revision
setting.
• 6 cadaver shoulders in a testing machine
• Converts engaging Hill-Sachs to non-engaging Hill Sachs
• The addition of the remplissage procedure combined with Bankart repair for
treatment of large Hill-Sachs lesions had no statistically significant effect on ROM
or translation, but altered the kinematics of the glenohumeral joint.
• Thus, by addressing the humeral bone defect following an anterior shoulder
dislocation, the remplissage technique with concurrent Bankart repair may be a
relatively minimally invasive option for converting engaging Hill-Sachs lesions to
non-engaging and promoting shoulder stability, though further biomechanical
and clinical studies are warranted.
• 7 pairs of cadavers
• Bankart lesion repair associated with remplissage restored
intact joint stiffness contrary to Bankart lesion repair alone.
• This increase in stiffness was associated with a decrease in
external rotation.
• 6 studies … 167 patients … f/u 12-43 months
• 5.8 % Recurrence rate
• Postoperative clinical outcome scores were generally good to excellent
following arthroscopic remplissage. No studies indicated a significant loss
of shoulder motion following the procedure. The failure rate following HillSachs remplissage compared favorably with previously published rates for
patients without clinically important Hill-Sachs lesions who underwent
arthroscopic Bankart repair alone. The overall complication rate across the
studies was low, further supporting the use of this technique along with
Bankart repair in the treatment of glenohumeral instability with a
concurrent osseous defect of the humeral head.
• 8 cadavers
• In the treatment of shoulder instability with a humeral head
bone defect and an intact glenoid rim, this study supports
the use of both the remplissage and Latarjet
procedures. Clinical studies and larger cadaveric studies
powered to detect differences in instability rates are needed to
evaluate these procedures in terms of their comparative
efficacy at preventing dislocation, as any differences between
them seem likely to be small.
• 10% of 459 patients underwent arthroscopic Bankart repair
combined with Hill-Sachs remplissage with use of suture
anchors.
• All had a large Hill-Sachs lesion (Calandra grade III), engaging
over the glenoid rim, without substantial glenoid bone loss.
• A potential solution for patients with a large engaging humeral
head bone defect but no substantial glenoid bone loss.
• Is not indicated for patients with glenoid bone deficiency.
Summary
• Both procedures seem to work
• Remplissage
– Converts engaging to a non-engaging Hill-Sachs
– I am surprised by the good early results.
– Boileau > Only for Hill Sachs with glenoid intact
– Field, others > Works for glenoid bone loss too
• Latarjet
– Widens glenoid and creates a sling effect
– A long term solid procedure
– Preferred by French patients and rugby players
– Difficult and significant complications
Thank You
James C. Esch, M.D.
Orthopaedic Specialists of North County
Oceanside, CA

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