Dr. Rob H.: Welcome to the Arthroscopy Association's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or Arthroscopy Journal.
Greetings. I'm Dr. Rob Hartzler, from TSAOG Orthopedics in San Antonio. Today on the podcast, we have the honor of hearing from Dr. Johannes Barth, from Grenoble, France. Dr. Barth, welcome to the podcast or should I say [foreign language].
Dr. Johannes B.: [foreign language], Rob. Thank you very much for inviting me, here. It's a great honor for me to discuss with you about this podcast.
Dr. Rob H.: Dr. Barth currently serves as the Vice President of the French Society of Arthroscopy. He's a very productive researcher, having more than 35 scientific articles and a dozen book chapters to his name. He completed a clinical fellowship with Dr. Gilles Walch, an Asian traveling fellowship and a research fellowship with Dr. Stephen Burkhart.
So, Dr. Barth, we welcome you to the podcast, again. We're anxious to hear about your article from the July 2018 issue of the Journal, entitled Arthroscopic Latarjet Techniques: Graft and Fixation Positioning Assessed With 2D CT Is Not Equivalent With Standard Open Technique, which will give us a chance to take a broad look at shoulder instability surgery and some of the details of the Latarjet procedure.
So Dr. Barth, what's the take-home message of this article? Is arthroscopic Latarjet ready for widespread adoption?
Dr. Johannes B.: Yeah, that's the main question. I think we are optimistic about the arthroscopic Latarjet. I think it's probably the future. I shouldn't say it's “probably” the future; it is the future. But it is not as easy as we thought. We have analyzed from the past 10 years, that some surgeons started arthroscopic Latarjet and came back, which was not the case for the other procedures. We have to be very cautious with the technique and we have to probably improve ourselves, still improve ourselves with the technical steps, the different technical aspects of the procedure. For sure, it is going to be the future.
We wrote this article with Lionel Neyton. We were working for the French Society of Arthroscopy, for a symposium, under the direction of Gilles Walch and Laurent Lafosse. Our task, with Lionel was to try to see if we placed the coracoid bone graft as well with the arthroscopic technique as the open procedure. You can see that we thought that we did, but, actually, the placement is statistically, significantly different. We don't know the clinical impact of that, but what we showed is that the coracoid bone graft with the arthroscopic technique is significantly more lateral, in the axial plane, than for the open procedure.
Dr. Rob H.: Why do you think that, from a technical perspective, it resulted in a more lateral graft? Is there some visualization issue or is it a technical issue placing the graft?
Dr. Johannes B.: What we observed is that both arthroscopic technique, the technique as described by Laurent Lafosse with the arthro-screw or the technique as described by Pascal Boileau with the EndoButton, both techniques were significantly more lateral than the open procedure. This is a fact. It is difficult, I think, for the arthro-screw technique. The difficultly is to place the [implant] through the skin exposure and through the subscap split.
This is more difficult than the open approach, where you have a direct visualization of the anterior glenoid and you can place your coracoid graft very perpendicular toward the anterior glenoid. This is more difficult with the arthroscopic technique using the arthro-screw. We see that the screw were always more with a medial direction, whereas the open procedure is more parallel to the joint line.
Dr. Rob H.: Let's take just a step back and let me ask you, in your personal practice, how often are you doing the American style of an isolated arthroscopic Bankart repair for shoulder instability? What percentage of cases, in your practice, do you estimate?
Dr. Johannes B.: Well, it's approximately less than 10% because I follow the ISIS score. We have demonstrated with the French Society of Arthroscopy that with the ISIS score greater than two, the risk of re-dislocation [was] too high, so we use the cutoff of two points. You can imagine it's very rare that we can use the isolated arthroscopic Bankart for those patients, only for ISIS score inferior to two points.
Dr. Rob H.: How about arthroscopic Bankart repair with arthroscopic remplissage? Any indication, in your practice, for that operation?
Dr. Johannes B.: That will sound, probably, funny to for you because I use this technique only for my revision of Latarjet, but whenever I cannot match with an isolated arthroscopic Bankart, then I choose the open, the mini-open, Latarjet procedure.
Dr. Rob H.: Why do you think that arthroscopic Bankart repair isn't sufficient? Let's grant that in a typical, recurrent instability case, arthroscopic Bankart is not sufficient surgery. Is it because there's unrecognized capsular damage? Is the Bankart lesion not the essential lesion? What's your guess about that?
Dr. Johannes B.: It's probably multi-factorial problem. I'm not talking about arthroscopic Bankart, in association with other procedures, which I don't know because we did not analyze that. So I don't know about Bankart with remplissage or other procedure like that. For isolated Bankart we have well analyzed that. We think that it is not sufficient in many cases [crosstalk].
Dr. Rob H.: What I'm trying to ask you is why. If with address the Hill-Sachs lesion, would that be enough? Is there just capsular damage and stretch? Is the subscap insufficient?
Dr. Johannes B.: Well, I think it's combined problems that we have to treat. I think it's difficult to treat it with soft-tissue procedure.
Dr. Rob H.: Would you say that you're holding out room that arthroscopic Bankart repair with a remplissage may be sufficient treatment for typical, recurrent-
Dr. Johannes B.: Oh, yes.
Dr. Rob H.: ... instability patient?
Dr. Johannes B.: Then, we need to have evidence with long term follow-up, but why not? Yes.
Dr. Rob H.: For me, I think that's the big unanswered question in shoulder instability surgery. Is Latarjet the answer or Bankart plus remplissage?
Dr. Johannes B.: Yes.
Dr. Rob H.: Is that fair?
Dr. Johannes B.: That's totally true. I agree with that and have no answer to give you because I don't have the evidence about that, but I'm very interested by the result of this combined procedure.
Dr. Rob H.: Yeah, that'll be really interesting to see how that plays out in the next 5 to 10 years, probably.
Dr. Johannes B.: Yes.
Dr. Rob H.: So for you, the vast majority of instability surgery is mini-open Latarjet?
Dr. Johannes B.: Yes.
Dr. Rob H.: Currently, any indication, for you, for arthroscopic Latarjet? Are you using that at all, in your practice?
Dr. Johannes B.: Well, I used to try the arthroscopic technique as described by Laurent Lafosse, but, at that time, I was not so happy with the results because the patients were a little bit more painful, a little bit more stiff and the placement of the coracoid was not as satisfactory as with the mini-open approach. I tried to stop this procedure, but, now, I'm thinking about doing the arthroscopic Latarjet with the technique as described by Pascal Boileau with the EndoButton, which seems to be more reproducible, with a completely different technical approach that might be more satisfactory.
Dr. Rob H.: You think from the prospective of graft positioning, though, that they EndoButton technique is going to win out and be good enough, in terms of an appropriate graft position for arthroscopic Latarjet?
Dr. Johannes B.: Yes, that's what we observed. We proved that it was a slightly more lateral, than the open procedure, but we don't know the clinical relevance about that. What we saw with the EndoButton technique, it was the more reliable procedure. What do I [mean] when I say that? That means that the dispersion of the value was the shortest. Whereas the arthro-screw technique were very variable, sometimes very too medial or very too lateral. You understand what I mean?
Dr. Rob H.: Yes.
Dr. Johannes B.: The variability of the positioning was less reproducible than the EndoButton technique. This is what I'm saying, but I cannot say more than that.
Dr. Rob H.: Do you have any advice for US surgeons or surgeons who don't have much experience in arthroscopic Latarjet in going about adopting the procedure?
Dr. Johannes B.: That's a very good question, Rob. I think that we learned that from the open Latarjet it was, also, a very difficult technique. From the prospective of the published series, especially coming from North America where we see so many complications, we see that the technique needs to be learned through a surgeon who really knows the technique. We have to transmit the technique by teaching all the different points, all the different pearls of the technique.
We can really reduce the complication rate, as it was shown by Gartsman and Bradley Edwards, who was a fellow with Gilles, with the complications rate under 5%. For open procedure, it's the reality, but, I think, it's even more true for the arthroscopic technique. I think it's a very, very demanding procedure that needs to be learned with a mentor that will teach all the different pearls of the technique. Once this is done, the surgeon probably has to train on cadaver labs and, then, progressively start with the technique.
I would probably recommend to do it, first, with the open approach to perfectly understand the anatomy. Because the difference between the other techniques, like a rotator cuff repair or Bankart procedure, most of these technique are all inside the box, so it's intra-articular procedure. But when you do a Latarjet it's an outside the box procedure. You have to deal with other anatomy that we are not used to do, like the plexus and all those kind of stuff, which are quite difficult to manage. I think it's more important to know it perfectly to do open first and, then, to switch to arthroscopic Latarjet.
Dr. Rob H.: What do you think is the learning curve? I've heard Pascal Boileau say 50 is the learning curve for arthroscopic Latarjet. Do you think that's accurate?
Dr. Johannes B.: Yes, he's probably right because, as I told you, I went back from the arthroscopic Latarjet, so I will just start now the technique of Pascal Boileau. I hope I will go faster because I went to see him, I went to see him practice this technique. Then, I trained in the cadaver lab and I tried to work. I know the anatomy because I'm doing a lot of open cases, probably 60 cases per year. I think I can do it, now, I hope, probably faster. I hope 20 cases would be enough because in France we are more comfortable with the Latarjet technique, only the Latarjet technique.
Dr. Rob H.: Well, it sounds like if we want to learn the technique we have to come to France.
Dr. Johannes B.: Maybe. And we will be very happy to welcome you.
Dr. Rob H.: Good! Anything else you can think of?
Dr. Johannes B.: Well, I just want to thank you for inviting me. I hope I was clear enough to talk about this topic. We'll see in the future what the American surgeon will do, if they will follow the French way, with the Latarjet open or arthroscopic. We'll see that in 5 or 10 years.
Dr. Rob H.: This article from the July 2018 issue of the Journal, entitled Arthroscopic Latarjet Techniques: Graft and Fixation Positioning Assessed With 2D CT Is Not Equivalent With Standard Open Technique can be found on the Arthroscopy Journal's website at ArthroscopyJournal.org. Don't forget to join us next time.