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Learning Curve of Arthroscopic

Anatomic Glenoid Reconstruction:

Comparison to the Arthroscopic Bristow

Latarjet

Iustin Moga MD

George Konstantinidis MD, PhD

Cathy Coady MD, FRCS(C)

Ivan Wong MD, FRCS(C)

Orthopaedic Sports Medicine

Disclosures

Iustin Moga, MD No disclosures

George Konstaninidis, MD No disclosures

Catherine Coady, MD, FRCS(C) No disclosures

Ivan Wong, MD, FRCS(C) Smith and Nephew Depuy Mitek Stryker

Introduction

Surgical management of recurrent shoulder instability (RSI) due to bone loss:

• Arthroscopic Bankart Repair (ABR) - 35% long-term recurrence rate

• Arthroscopic Bristow-Latarjet Procedure (ABLP) - Excellent medium-term outcomes - complex and demanding procedure with long learning phase - should be performed by expert surgeons

• Arthroscopic Anatomic Glenoid Reconstruction (AAGR) - recently proposed alternative to ABLP and ABR - excellent short term clinical outcomes - learning curve not previously studied


Objective of the study

Investigate the learning curve of AAGR by

examining:

• surgical time

• outcome scores

• complication rates

and compare it to the ABLP with respect to

these metrics.

• AAGR will provide similar outcomes

while taking less time to learn and

perform

HYPOTHESIS


Materials and Methods • Single surgeon, retrospective review of patients managed

with either ABLP or AAGR for recurrent shoulder instability

• Data collected on:

• Surgical time

• Final graft and screw position (by CT scan)

• Intra op/ Post op complications

• Post op Western Ontario Shoulder Instability Index (WOSI)

• Study cohorts divided into three equal clusters of nine

patients

• primary outcome

- change in operative time over successive operations

• secondary outcome

- clinical outcome (WOSI)

- complication rates

- bone graft position


Surgical Steps

ABLP AAGR

Diagnostic Arthroscopy Diagnostic Arthroscopy

Subscapularis Split Allograft Preparation

Autograft Harvesting Preparation for graft placement

Graft positioning and fixation Graft positioning and fixation


Primary outcome • Surgical time

•AAGR: •Faster procedure •Optimal surgical time after seven cases

•ABLP •More complex surgery •Optimal surgical time after 17 cases


Secondary outcomes • WOSI score

78

76.5

83

74

50

65.9

Better mid term WOSI score for

AAGR


Secondary outcome • Complications and Revisions

ABL (n=11) AAGR (n=28)

Recurrent Instability requiring Revision Surgery

1 (9%) 1(4%)

Revision Surgery symptomatic non-union

2 (18%) 1(4%)

Axillary Neuropraxia or isolated sensory deficit

1 (9%) 0

Higher revision rate for ABLP

Infected allograft removed


0

2

4

6

8

10

1st cluster AAGR2nd cluster AAGR

3rd cluster AAGR

flush

medial

lateral

0

1

2

3

4

5

6

1st cluster ABLP2nd cluster

ABLP 3rd cluster ABLP

flush

medial

lateral

flush medial lateral

Secondary outcome • Graft positioning AAGR vs ABLP

Medial-lateral Superior-inferior

high medium low

0

2

4

6

8

1st cluster AAGR2nd cluster AAGR

3rd cluster AAGR

01234567

1st cluster ABLP2nd cluster

ABLP 3rd cluster ABLP

•Medial-lateral placement

more accurate with AAGR

•Low graft positioning with

both techniques


Conclusions

AAGR is easier to adopt, and suitable as a practical alternative to the ABLP

ABLP AAGR

Surgical time Mean optimal time = 116.6 min

Late plateau and deeper learning curve

Mean optimal time = 84 min

Plateaus early (after 7 cases)

Clinical outcomes Fair short term WOSI score Fair short term WOSI score

Better mid term WOSI score

complications Comparable revision rate for recurrent instability

Higher revision rate for other reason

Higher non union rate (25%)

One infection in cohort

Lower revision rate for other

reason

None non-union

Graft positioning

Greater intra-articular step off

Much better graft positioning


1. Faster than ABLP This study shows a learning curve advantage for AAGR vs ABLP

2. Anatomical advantages:

a) Spares the subscapularis muscle, avoiding potential adverse impact on range of motion and strength

b) Spares the capsule and labrum potentially improving long-term shoulder stability

3. Fewer complications with AAGR provides advantages to patients and healthcare systems

4. Shorter operative time creates a potential benefit to surgeons and healthcare systems

Advantages of AAGR

AAGR is a good alternative to ABLP

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• Cunningham G, Benchouk S, Kherad O, Lädermann A. (2016) Comparison of arthroscopic

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• Dauzère F, Faraud A, Lebon J, Faruch M, Mansat P, Bonnevialle N. (2016) Is

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Traumatol Arthrosc. 24(2):557-63.

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Long-term results after arthroscopic shoulder stabilization using suture anchors: an 8- to 10-

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