ARTHROSCOPIC LATARJET PROCEDURE: TECHNIQUE-RELATED CHARACTERISTICS, MID-TERM FUNCTIONAL RESULTS

Введение. Посттравматическая нестабильность плеча широко распространена в популяции и имеет высокую социальную значимость. Невысокая эффективность лечения нестабильности плеча определила развитие свыше 300 хирургических методов лечения. Цель – изучить среднесрочные функциональные результаты артроскопической операции по Латарже по лечению нестабильности плеча при наличии значительных дефектов переднего края суставного от ростка лопатки и головки плечевой кости. Методология. В клинике No 2 Всероссийского центра экстренной и радиационной медицины им. А.М. Никифорова МЧС России (СанктПетербург) с 2013 по 2017 г. выполнены 68 артроскопических операций по Латарже. Проанализировали время выполнения операции, положение трансплантата клю вовидного отростка по отношению к гленоиду, функциональную оценку результатов лечения. Результаты. Средняя продолжительность операции составила (91 ± 12) мин, при этом с приобретени ем навыков выполнения процедуры время сокращалось. В 88 % случаев трансплантат располагался в кор ректном положении (в диапазоне 02.30–05.30 ч мнимого циферблата). Отмечен один эпизод рецидивного вывиха плеча через 9 мес. Ограничение наружной ротации плеча в среднем составило 7° (от 5 до 14°). Заключение. Среднесрочные клинические результаты артроскопической операции по Латарже под твердили, что процедура может быть надёжной, безопасной в исполнении и функционально выгодной. Ключевые слова: травматология, травма плеча, нестабильность плеча, костное повреждение Бан карта, повреждение Hill–Sachs, артроскопическая операция по Латарже, артроскопия.

MedicoBiological and SocioPsychological Problems of Safety in Emergency Situations.2018.N 2

Introduction
Shoulder instability is defined as a symp tomatic abnormal motion of the humeral head relative to the scapula articular process during active shoulder motion [5].Treatment of this polyetiologic disease has been up todate and widely discussed over the last decade due to its high spread among young people and social significance [1,16].Over 300 surgical methods and their variants have been developed for treatment of shoulder in stability, including shoulder capsule surgeries, accessory ligaments creation, musculoplasty, bone autoplasty with coracoid process or free block graft [13].
However, some surgeries which can be traumatic and technically difficult to perform result in considerable limitation of external shoulder rotation, extension of patients' inca pacity period or development of arthrosis de formans.Besides, chronic shoulder instability is often followed by a significant bone defect in the anterior part of the scapula articular process or by bipolar damages of the humeral head and glenoid leading to recurrent shoul der dislocation.Thus, osteoplastic surgeries present a considerable advantage over soft tissue surgeries [8].
Surgeries with auto and allografts are used for anatomic restoration of the scapula articular process defect.Iliac crest internal surface is more frequent among autografts applied.Authors note that such surgeries result in high rate of development of gleno humeral joint osteoarthritis deformans, bone graft nonunion and resorption while the num ber of postoperative recurrences amount to 10 % [2,12].
Osteoplastic surgery for treatment of shoulder instability suggested by Michel Latarjet came into common use among trau matologistsorthopedists in 1954 [6].The modern variation of the Latarjet procedure consists in transferring the coracoid process Methodology.68 arthroscopic Latarjet surgeries were performed over the period of 2013-2017 in the clinic No.2, Nikiforov Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia (St.Petersburg).There were analyzed the duration of surgery, the position of the coracoid process graft relative to the glenoid, functional evaluation of the treatment results.
Results.The average duration of a surgery was (91 ± 12) minutes.The time for the procedure reduced with the acquisition of skills.The graft was placed in the correct position (in the range of 02.30-05.30o'clock of the imaginary dial) in 88 % of cases.Only one episode of recurrent shoulder dislocation occurred in 9 months.The limitation of external shoulder rotation averaged to 7° (from 5 to 14°).-третий стабилизирующий эффект обеспечи вается натяжением суставноплечевых связок, об разуемым при фиксации капсулы сустава к транс плантату клювовидного отростка или гленоиду [18].
It should be noted that studies em phasize the primary significance of the slingeffect in stabilization of the glenohu meral joint at Latarjet procedure [20].
An open approach of Latarjet surgery demonstrated excellent and reliable results published by various authors [7,15].Lau rent Lafosse and his coauthors described in 2003 a procedure where a screw fixa tion of the coracoid process to the anterior part of the scapula articular process was performed in al fully arthroscopical man ner [11].This kind of surgery is technically difficult and requires that the surgeon has a good knowledge of glenohumeral joint anatomy.Thus, there is little data on clinical and radiological results of this method in scientific literature [4].The advantages of this treatment method include [3,11,14]: -Good visualisation from different ar throscopic portals for accurate placement of the bone graft on the glenoid; -Low risk of damaging large nerves provided with a constant control over their position; -Low probability of postoperative contracture due to a limited damage of soft tissues and visual control over split formation; -Low intensity of postoperative pain syndrome; -Short terms of inpatient stay in hospi tal; -Earlier mobility in the shoulder joint and quicker rehabilitation in postopera tive period; -рентгенографию в прямой проекции и косую проекцию 20° по Garth; -магнитнорезонансную томографию плече вого сустава без контрастирования; -компьютерную томографию (КТ) с 3Dрекон струкцией обоих суставов.

Materials and Methods
Latarjet procedure was indicated in the fol lowing cases: -Bone loss of the scapula articular pro cess exceeded 25 % of the joint square, when glenoid takes the "inverted pear" shape (Fig. 1); -Bone mass deficit was less than 25 %, but only patients: participate in combat sports or were, less than 20 years old [6,17]; -There were bipolar damages of the hu meral head and glenoid with a total volume of bone tissue loss and Hill-Sachs lesion over 3×3 cm.The study group included 31 females (46 %) and 37 males (54 %), aged 18-42 (average age -22.3).According to CT scans 53 patients (78 %) had bone loss over 25 % of the joint square, 8 patients (12 %) prac ticed sport with bone mass deficit less than 25 %, 7 patients (10 %) were younger than 20 years old.All examined had bipolar dam ages of the humeral head and glenoid with a total volume of bone tissue loss and Hill-Sachs lesion over 3×3 cm.
There were analyzed the surgery duration (from the moment of skin incision to its su turing), accuracy of bone graft placement and intraoperative complications or ad verse events.In sagittal section the place ment was considered perfect in the range of 02.30-05.30o'clock; in horizontal sec tion -flush and congruent placement on the glenoid [10].Functional objective evalua tion was done according to the scales Rowe, WOSI (Western Ontario Shoulder Instability) and Walch-Duplay [9].
Stage 5: Through the portal 3 (Fig. 2) which is located above the coracoid process the dualbarrel guide for wires was introduced in parallel to the longitudinal axis, on the mid line of the coracoid process.The wires were inserted via the guide through the coracoid process.The drills were created over them using threestep drill.Special plates were in serted into the drills to prevent fractures of the coracoid process.Coracoid process osteoto my was performed; the coracoid surface was smoothed with burr; Stage 6: From standard posterior portal a retractor was inserted through the split in the subscapular muscle frontward onto skin; this instrument was used to form the anterior portal 4 (Fig. 2).Twochannel holder was in serted into the portal and fixed to the coracoid process.Through the split in the subscapu lar muscle the coracoid process was pulled to the anterior part of the scapula articular process by achieving the necessary position relative to the glenoid.The caracoid process was fixed by cannulated screws at the site of wires inserted beforehand.In addition to the surgery there was a procedure on glenoid lip restoration with anchoring in case it was pre served.
During the next 4 weeks after the surgery the motion of the shoulder joint was limited using soft orthesis like Desault's bandage.

Results and their Analysis
The duration of surgeries was from 63 to 124 min., average -(91 ± 12) min.It is neces sary to note that the time for the arthroscopic Latarjet procedure reduced with the acquisi tion of skills, and the last 10 surgeries were performed in less than 70 min.
In midterm observation period which at the moment does not exceed 5 years only one episode of recurrent shoulder disloca tion occurred in 9 months after the surgery due to screws migration and damage of au togenous bone lysis.
Movement amplitude analysis has shown the average limitation of external shoulder rotation is 7° (from 5 to 14°) and there is no significant difference in shoulder internal ro tation, abduction and bending.All examina tions have showed that the limitation of rota tion have not influenced the functional result.
Midterm functional result was from 61 to 100 points, average -(83 ± 13) points according to the Rowe scale; from 50-100 points, average -(82 ± 12) points according to the Walch-Duplay scale; average WOSI in dex -334.6 units.This result corresponds to the evaluation range as "excellent".
Discussion.Arthroscopic Latarjet pro cedure for shoulder instability with defect in the scapula articular process over 25 % and for young people and sportsmen al lows effective stabilization of the shoulder joint.The advantage of the method is good visualization for accurate caracoid process placement, i. e. fundamental for restoration of anatomisity of humeral head and glenoid contacting.Constant control over large nerves position allow excluding their dam age during the surgery.The method strength points also include such characteristics as minimal invasiveness, earlier joint mobility and good cosmetic effect typical for all ar throscopic procedures.
The observed fracture of the caracoid graft has probably appeared due to incorrect determination of place for fixing screws in sertion.

Conclusions
Arthroscopic Latarjet procedure is a diffi cult, but reliable method for shoulder insta bility treatment.Perfect knowledge of shoul der joint anatomy and Latarjet technique decreases intraoperative complications and surgery duration.

Литература (References)
Arthroscopic Latarjet procedure has shown good midterm results with minimal complications: midterm functional result was (83±13) points according to Rowe scale, (82 ± 12) points according to Walch-Duplay scale, average WOSI index -334.6units.This result corresponds to the evaluation range as "excellent".

Fig. 1 .
Fig. 1.Diagnostics of injuries of the humeral head and the scapula articular process: а -Defect of the anterior glenoid, 25 % of diameter; b -3Dprints of a fragment of the humeral head and the scapula articular process.

Fig. 2 .
Fig. 2. Arthroscopic shoulder joint Latarjet surgery.а -Anterior arthroscopic portals location; b -Diagnostic arthroscopy, a significant Hill-Sachs lesion; c -Preparation and opening of the rotator interval, biceps short head tendon; d -Decortication of the inferior glenoid surface; e -Split creation in the subscapular muscle; f -Сoracoid process osteotomy; g, h -Сoracoid process fixation to the glenoid; i -External view of postoperative wounds.
Latarjet surgery have confirmed that the procedure can be reliable and safe for performance as well as functionally advantageous.