Cirurgia de Bristow – Latarjet Artroscópica
Publicado em: 5 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Trabalhos Científicos - Ombro
Técnica artroscópica criada pelo Dr Jose Carlos para luxação do ombro.
Publicado nas revistas
” Arthroscopy” em 2012(Volume 28 número 6 pgs. e3-e4)
“Techniques in Shoulder and Elbow Surgery” em 2009:volume10, nº3 pgs 94-98.
Congresso da American Academy of Orthopaedic Surgeons
International Congress on Shoulder and Elbow Surgery:
AANA-Arthroscopy Association of North America Congress
Congresso Latino-Americano de Cirurgia de Ombro e Cotovelo
2009-Porto de Galinhas/Brazil
Congresso Latino-Americano de Artroscopia
Congresso Brasileiro de Ortopedia e Traumatologia:
Congresso Brasileiro de Cirurgia de Ombro e Cotovelo
Congresso Brasileiro de Artroscopia e Trauma do Esporte
Congresso de Ortopedia e Traumatologia do Estado de São Paulo
Esse Trabalho científico descreve a técnica de Bristow-Latarjet realizada 100% por artroscopia, a primeira descrição de Bristow Latarjet artroscópico das Américas. Essa técnica é a de escolha para graves luxações ou instabilidades anteriores do ombro. A luxação com perda óssea ( lesão de Bankart ósseo ) com fratura da glenóide com perda de mais de 25% da glenóide anterior. A primeira apresentação do Bristow Latarjet artroscópico foi feita no congresso de ortopedia do estado de São Paulo de julho de 2008 e no congresso latino-americano de cirurgia do ombro e cotovelo de agosto de 2008. A técnica foi publicada em 2009 no periódico Techniques in Shoulder and Elbow Surgery, a sua evolução e seguimento na Arthroscopy em 2012 e apresentada de forma oral no congresso mundial de cirurgia do ombro e do cotovelo de Edimburgo-Escócia em 2010 e na associação de Artroscopia da América do Norte em 2012. Nossa primeira cirurgia, sendo a primeira das américas data do final de 2007. Alguns serviços, principalmente na europa usam as técnicas de Bristow e Latarjet indiscriminadamente, nós entretanto usamos a cirurgia de Bankart artroscópica, caso não haja perda óssea de 25% ou mais da glenóide, devido aos excelentes resultados dessa técnica em nossas mãos. O Bristow-Latarjet artroscópico é um procedimento com ótimos resultados mas que deve ser usado com critério pelo cirurgião e bem explicado para o paciente.
Atualmente o n e follow-up são bem maiores que as primeiras descrições
Anterior shoulder instability is well known as a common pathology and many surgeons have chosen the arthroscopic Bankart procedure or other soft tissue procedures for its treatment. However using these techniques may result in unsatisfactory outcomes when an anterior glenoid fracture or bone loss is associated. These patients may achieve better and safer results by using a bony block procedures as the Bristow-Latarjet procedure. The intention of the study is to present the full arthroscopic Bristow-Latarjet procedure of the author and its implications in 21 patients.
We performed 21 arthroscopic bristow-latarjet procedures in patients presenting HAGL, soft tissue procedures failures, gross shoulder instability and anterior glenoid bone loss following the senior author’s technique. Patients were evaluated by UCLA score and comparative difference of external rotation, before and 6-month after surgeries.
Twenty one arthroscopic Bristow-Latarjet procedures have been performed, one lost the surgery because the breakage of the graft, 4 have less than 6 months post surgery. The remaining 16 were evaluated. In the 6-month postoperative evaluation, the UCLA score changed from 24,37 (before surgery) to 33,1. The average loss of external rotation was 12,5 degrees, compared with the normal shoulder. The only real failure was the breaking of the coracoid in 1 patient. In this case the author used successfully the arthroscopic conjoined tendon tenodesis (using anchors) in the anterior glenoid rim.
The coracoid and conjoined tendon transfer procedure is one of the most useful treatments for shoulder instability. Using this procedure many other shoulder surgeons have derived good and safe results. This procedure is strongly recommended for anterior glenoid bony loss, in contact athletes, gross anterior shoulder instability and failure of previous soft tissue procedures; however special attention is necessary to avoid limitation in external rotation. To improve surgical access and to make it easier to scope, the surgeon may use different portals to have a wide view and be able to work better. Compared with the open procedure, it is shown to be superior because of limited exposure, especially in young athletes with significant musculature. The arthroscopic technique is also advantageous in those cases in which the preoperative assessment fails to reveal a Humeral Avulsion of the Glenohumeral Ligament lesion or a large bony avulsion from the anterior glenoid rim. It also allows the surgeon to modify his plan intraoperatively. As to the graft placement and fixation, the arthroscopic technique provides better visualization for positioning the coracoid. This should minimize the risk of anterior overhang of the bone block and then, reduce the risk of osteoarthritis of the humeral head, a well-recognized complication of open procedures. There is also the advantage of the graft-shaving possibility. The absence of special devices was our challenge in creating this technique. The coracoid is horizontally positioned exposing the bone marrow and leading to a biological healing. Even with the advantages mentioned in the above, at this time, it does not seem evident that in long term the arthroscopic technique produces better results than the open surgery.
Veja em: http://www.arthroscopyjournal.org/article/S0749-8063(12)00351-9/fulltext
Techniques in Shoulder and Elbow Surgery
The anterior shoulder instability is a common pathology, and its gold standard treatment is the arthroscopic Bankart procedure. However, when associated with an important anterior glenoid fracture, either the Latarjet or Bristow procedures can achive better results. For those cases, the author has used a combination of both the Latarjet and the Bristow procedures through arthroscopy, which provides the advantages of both the minimally invasive techniques and the classical procedures.
At this time, it does not look evident that the arthroscopic technique produces better results than open surgery, although it surely provides better protection to the deltoid muscle.
The improvement of the arthroscopic skills when using the arthroscopic Bristow-Latarjet-like procedure will certainly lead to its acceptance and adoption in the future. It is highly recommended in special cases where there is more than 25% of loss of anterior glenoid bone associated to gross shoulder instability.
Veja o artigo na íntegra clicando em: http://journals.lww.com/shoulderelbowsurgery/Fulltext/2009/09000/Arthroscopic_Bristow_Latarjet_like_Procedure_.2.aspx
PAPER NO. 609
Jose C. Garcia Jr, MSc, PhD, Sao Paulo, Brazil
INTRODUCTION: In 2009, a surgical technique was created to allow the Bristow-Latarjet procedure to be minimally invasively performed by using just regular arthroscopic devices and one large screw. The author has evolved this technique and presents the 22 shoulders that underwent the arthroscopic Bristow-Latarjet procedure with two years follow up and 30 with one year follow up.
METHODS: This is a retrospective study, however, 15/22 patients with more than two-year post surgery and 23/30 with more than one-year post surgery were assessed prospectively. The patients assessed were those presenting bony Bankart lesion compromising 25% or more of the glenoid, HAGHL lesion, failure of previous labrum reconstructions, or patients in high-demand sports. The sample size was calculated based in the baseline data through an adaptive protocol. Assessments made in the baseline: UCLA and passive external rotation. Six months after surgery: UCLA, SST, Rowe, passive external rotation. Two years after surgery: UCLA, SST, Rowe, passive external rotation. Rowe was compared with the cutoff point 75, UCLA with the baseline. Data was assessed in intention to treat as possible; UCLA was assessed in ITT.
RESULTS: The author used 22 patients with more then two years follow up. Considering it reasonable that the minimal significant difference of UCLA can be at least 4, the number of patients calculated was 19. Data are paired and presented negative results to the normality tests, therefore were assessed by Wilcoxon matched-pairs signed rank test. For two year PO, the pre-surgical UCLA mean changed from 25.45±0.9437 (SD 4.426) to 33.14±0.7793 (SD 3.655), the p value for a two-tailed curve was <0.0001. The Rowe mean was 92.75±2.913 (SD 13.03). Comparing with the cutoff p was <0.0001. The SST mean was 11.25±0.3898 (SD 1.743). Answers were presented in the following frequency:1=19/20, 2=18/20, 3=20/20, 4=19/20, 5=20/20, 6=20/20, 7=20/20, 8=19/20, 9=20/20, 10=17/20, 11=15/20, and 12=18/20. The mean of external rotation losses in adduction was: 11.50±2.325o (SD 10.40). For patients with one year or more PO, the pre-surgical UCLA mean changed from 25.57±0.7009 (SD 3.839) to 32.97±0.5219 (SD 2.859), the p value for a two-tailed curve was <0.0001. The Rowe mean was 92.96±2.189 (SD 11.37). Comparing with the cutoff p was <0.0001. The SST mean was 11.22±0.3173 (SD 1.649). Answers were presented in the following frequency: 1=26/27, 2=23/27, 3=27/27, 4=26/27, 5=27/27, 6=27/27, 7=27/27, 8=25/27, 9=27/27, 10=24/27, 11=19/27, 12=24/27. The mean of external rotation losses in adduction was: 12.78±1.395 (SD 7.250). Adverse events were cocaroid breakages, osteolysis, anterior impingement, one frozen shoulder. No recurrences have been found.
CONCLUSION: Despite all the possible post-surgery complications, UCLA, SST, DER recurrence rates, and Rowe scale have shown that the arthroscopic Bristow-Latarjet procedure was effective in treating anterior shoulder instability. In the authors’ opinion regarding inherent possible complications associated to this technique, the best indication for the Bristow-Latarjet procedure, open or arthroscopic, remains as follows: patients presenting bony Bankart lesion compromising 25% or more of the glenoid, HAGHL lesions, failure of previous labrum reconstructions, and patients with high demand sports. More data and prospective trials will be important in the future to better understand possible
advantages and disadvantages of this procedure. Multicentric trials and new devices can be decisive to consolidate this procedure as a viable option for treating the anterior shoulder instability.