Justin Arner:
Welcome everyone. I'm Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today, I have the pleasure of speaking with Dr. Brian Waterman, Professor, Fellowship Director and Chief of Sports Medicine at Wake Forest University in Winston-Salem, North Carolina. Dr. Waterman was a senior author of the article titled “Editorial Commentary: Suture Button Fixation May Have Advantages Over Screw Fixation for Glenoid Bone Grafting Procedures for Shoulder Instability,” which is in the January 2024 issue of the Arthroscopy Journal. Welcome Dr. Waterman and thanks so much for joining me.
Brian Waterman:
Hey Justin, thanks again. Longtime listener over here.
Justin Arner:
Yeah, I love it. Wanted to thank you for being a great contributor to this podcast. I made a comment before we started recording that. I thought this was your third, but it's actually your fourth, so I think you're the record holder here. So we really appreciate all of your support with the podcast and with AANA and really would like to thank you because all this couldn't happen without your support in pushing this forward, so appreciate that.
Brian Waterman:
Well, it's certainly an honor to be that high on the leaderboard, especially given all the honored guests that you've had. I hope to continue to come back. Definitely there is just an incredible amount of content and I really enjoy this format.
Justin Arner:
Yeah, it's fun to get everyone's thoughts and pick your brain a little bit. I know people like to hear that. So we've heard you speak about this topic before, and I've heard you give lectures at different meetings about this. So when I saw your editorial, I really wanted to do this podcast and appreciate you doing it. And I think a lot of us are thinking, "Hey man, it really would be great to get away from screws." But we are a little bit, I think, cautious to make that jump. Since you're so knowledgeable about this editorial and this literature, I'd recommend people really take a look at your commentary, but I wanted to ask if you could first talk to us a little bit about the systematic review, which you were commenting on here, which is out of St. Joseph's in New Jersey, which was “Screw Fixation for Latarjet Procedure May Reduce Risk of Recurrent Instability but Increases Re-operation Rate Compared to Suture Button Fixation: A Systematic Review. So can you tell us a little bit about your thoughts about that paper and little details that you thought were interesting?
Brian Waterman:
Yeah, sure. I'd be happy to. First off, with due credit to my co-author Jelle van der List who is one of our current fellows and that's just been an incredible asset through Wake Forest, I want to thank him for helping me to pen this editorial. He definitely has an unbridled passion for these types of evolving topics, so credit to him. Also, just like to acknowledge the author group that contributed this. I think this really helps to give an assessment of where we are with certain topics and Matt Kraeutler has certainly done more than his fair share of reviews and I think this one is incredibly helpful.
With that said, there is not an abundance of data available to compare these two and specifically we're looking at Latarjet and then looking specifically at screw and suture button fixation constructs. So they were able to assemble seven studies, 845 patients undergoing screw-based Latarjet procedure and then 279 with suture button fixation.
I think it's always really important in these studies and especially as you combine or evaluate these in aggregate to get a sense for what the age and activity level is, so please don't miss that table one when you show the demographics, but they show a fairly young population in both treatment arms. Twenty-one and 29 were the average years of age, and you can see there's a fairly wide-ranging follow-up, which we know continues to be an issue as we deal with these young fairly athletic but sometimes geographically transient patient populations.
So they had seven studies as I mentioned, and there were a comparison between these two methods. They did not perform a meta-analysis and we want to make sure we avoid inappropriate pooling and looking at these types of things. Jim Lubowitz and others have certainly drilled that into me. And the big variations that we described, surgical techniques, screw sizes, various different button fixations and types of implants. So when then they draw these studies together and granted there's one level two study and six level three studies, they're able to generate some at least ranges for the various different outcomes.
And what they show is of these, there was probably a trend towards higher re-operation with screw based fixation, and again, that range was somewhere between 0 and 7.7% as opposed to the suture button, it was 0 to 1.9%. However, when you look at recurrence rates, that was actually higher among the suture button fixation, and again, rates of that were about 0 to 8.3% versus the screw base, which is 0 to 2.5%. They do have some subgroup analyses and they do collect for various different patient reported outcome measures of which there are many, but I thought those were the biggest salient points and definitely the ones that will probably contribute meaningfully to this discussion that we have today about the relative merits of each one of those fixation constructs.
Justin Arner:
Yeah, that's a great summary and good advice regarding these systematic reviews and meta-analyses. It is hard. They really have to be done correctly and it's trickier than sometimes we think at the surface. So one thing I wanted, since you're so knowledgeable about this topic, can you just give the listeners a little bit of background? You mentioned the suture button versus screw fixation. Can you get a little more detailed regarding types of different buttons or anchors that people have described and reviewed in the literature and the different types of screws and just give us your thoughts about what's really out there regarding these fixation option.
Brian Waterman:
Yeah, certainly, and I think you have to be a student of history in order to avoid reproducing the mistakes of the past, and this obviously has a very long history. Michel Latarjet and many of our European colleagues have innovated in this space since the '40s and '50s, and they initially used maleollar screws. This has been modified and modernized maybe moving from Bristow to a more sizable piece of the coracoid and transferring in various different formats, whether that's a European technique or the congruent arc. And we've seen the screws adapt over time, so there's definitely been use of cortical screws and cancellous screws. There's a discussion about partially and fully threaded screws, and then there are many different commercial systems that utilize a cannulated based system.
I think it's important to realize that what we're aiming to achieve with maybe some of the newer fixation construct is to try to avoid the dreaded hardware complications. For any of us that have ever had to remove screws from an intra-articular space or a Latarjet that's failed, we know that this is a disastrous complication and catastrophic failure or fatigue failure in bending or breakage of these screws can be quite a cumbersome problem. In Matt Provencher's data from the NFL Combine, and this is a high-demand subset, they showed 46% hardware-related complications and about 100% of them hard to believe had evidence of radiographic arthritis based on the Samilson-Pareto classification.
When you look at rates of resorption around screws and when you look at rates of non-union and other things that can make this somewhat of a tricky procedure and definitely a tricky revision procedure, I think that is the impetus for trying to move away from screw-based constructs. In the earnestness to do that, I think that we've certainly seen some areas for improvement and many of us have seen how maybe these things perform well biomechanically in a lab with cyclical loading, but then when you put into the arms of our patients, maybe they behave a little bit different. And so I would say we're very much in the toe of the use of suture button fixation and maybe we can talk a little bit about specifically what types there are there here in a minute.
Justin Arner:
Yeah, I think that would be great. That's a great summary and always learning from you. That's great. Tell us your thoughts about the solid versus cannulated screw fixation. I know it's an age-old debate and you could probably talk about it for hours, but what are your thoughts about that?
Brian Waterman:
I think any of those in the wrong patient or with inappropriate technique can fail. I've been in somewhat of an evolution on this topic. I've traditionally used cannulated based systems because one of the take home messages that has been beaten into me is that you need to be flush and you need to have really an ideal trajectory for your screws. The alpha angle is something that we perseverate on, and that's the angle basically that your screws go on trajectory versus the articular surface. And ideally, that should be colinear with the articular surface.
As you get more and more into this oblique pattern, you lose some of your time zero fixation, and I think you also put yourself at bigger risk for neurovascular injury and potentially loss of fixation. So that is one where I feel like a utilization of a cannulated base system has been helpful for me, but admittedly that also can be potentially at risk for hardware breakage, and I've recently started to transition to using a solid 4.0 screw two of those. Again, shooting for a very colinear position and typically that's with direct visualization. I like to place the graft intraarticular and I do use the French technique to maximize apposition of the bone block to the glenoid surface.
Justin Arner:
Yeah, that's a nice summary. I've always have had similar thoughts in training. Everyone says to use, or not everyone, but many people talk about using solid screws because of hardware breakage, but if you're not putting the screw in the right trajectory or location, this isn't done as commonly in the states. It's not that simple. So I think that's a really great explanation, especially to a lot of our listeners who are younger folks, so thanks for that. You mentioned before and give us a little teaser about the different non-screw options. Tell us a little bit about technology wise, some basics about what's out there, non-screw wise.
Brian Waterman:
Yeah, I think we've also seen evolution in this space and many of our listeners may not be as familiar with some of the emerging options. We've certainly seen I would call suture button fixation as a disruptive technology. You can extrapolate many of these fixation constructs from other areas of the body, and you think about how this has changed the game for thinking syndesmotic fixation or AC joint fixation, and now it's really evolved to a lot of different areas, ACL reconstruction, Lisfranc, so many different types of procedures have been made better by the use of suture button fixation. I think it also decreases the potential for non-anatomic reduction, but the biggest thing that we know from it is that there's lower rates of secondary hardware failure, although it's not completely devoid of that. We know that the sutures can experience fatigue and compromise. So the suture button fixation I think was the first type.
The second that you've seen an emergence of is use of all suture anchors with retensionable technology, and then the last is utilizing a tape-cerclage type of method. And that mimics what I think many of us have gone to in long bones, whether it's for the femur or for the humerus. I often use it in a revision setting for arthroplasty, but it's been extrapolated to the shoulder. Unfortunately, many of these are really only featured in technique-based articles, and so there's not beyond some simple biomechanical data, there's not a lot that look at this clinically and have shown a lot of reproducibility about this.
A couple of key features that I think we need to focus on, one is the retention ability. I think that that is key to be able to oscillate between one to two of these non-screw based constructs. And then another thing that I think is really a game changer is the use of a tensiometer in order to standardize that load. We've seen how that can have definitely benefit to compress and avoid either rotational or translational displacement of these free bone blocks, but those may also come with certain risks.
Certainly using a tensiometer I've over-compressed bone blocks and for anybody that's had breakage of their bone block intraoperatively, it's obviously a pretty harrowing experience, and so you definitely want to have the ability to work around that. I think we also need to take into account the biology, the technique, the reproducibility, the technical difficulty of this. There's been great biomechanical data that's performed by many different authors, but there's recent systematic review on this very topic as well by Brett Ponce and Manfredi and their colleagues, and they showed that there was really no measurable difference between screw-based constructs and suture button. So I think I find encouragement of that. They also showed that in the saw bones model with similar results, and as long as you're focusing on colinearity, there actually could be some measured benefits to the suture button-based construct.
Justin Arner:
Yeah, that's a nice summary of advantages and disadvantages, and you're right, getting back to sometimes we get so focused on this technology, but the technique is really, really the key. It's a great solution or great discussion. I find it hard not to ask you, do you have any tricks? You hear different people talk about different things, but any thoughts if you would break your bone block and you're in that circumstance, any kind of bailouts that you've found to be helpful?
Brian Waterman:
Yeah, there's a couple different options, and I think much of this can be anticipated and avoided. So for instance, they always say the best offense is a good defense or vice versa, and I would say that make sure you're harvesting the appropriate amount of block for what you need. I generally like a coracoid of 20 to usually a minimum of 25 millimeters, and so that's going all the way to the base of the CC ligaments. It should go right to the genu or that down sloping arm at the base of the coracoid, and so maximize your harvest.
Secondly is I prefer to use a rim plate in order to dissipate forces. I think that that is a game changer for me, but washers also serve that same purpose. There's also top hats that are utilized in various different proprietary systems. I think when you encounter that, trying to assess whether a washer affords you the opportunity to still maintain that fixation, and if not, move more towards a single screw construct. If that's ineffective, then you can push forward with some form of suture anchor based fixation and delayed rehabilitation. Lastly, if you're really into a difficult situation and you experience that, then converting to a Bristow and then potentially considering just a conjoint transfer to the front part of the rim almost like a dynamic stabilizer.
Justin Arner:
Right, with a nice capsular shift and open Bankart a lot of people are historically that had some good literature, so certainly a tough day when you're almost done with a case and that happens. So great tips to have in your back pocket, so appreciate that. Tell us a little bit about your thoughts regarding fixation with different types of bone blocks and these adjustable loop buttons. I talked to you before and heard you speak about if you have a coracoid transfer versus a distal clavicle autograft or an iliac crest autograft versus an allograft, whether it be fresh or frozen. Tell us a little bit about your thoughts. Do you think the fixation method maybe matters in those or it's not really a consideration?
Brian Waterman:
Yeah, I think irrespective of whatever fixation construct we choose or bone block we choose, we need to be mindful of the potentially the second operation that may come later. We need to try to obviate the need for hardware removal. We need to be mindful of how difficult it is to remove bent or broken hardware. We know that secondary arthritis has a high point prevalence, and this is at mid to long-term outcomes. It's up to 66% in Bankarts. Latarjets are described as up to 30%. Iliac crests, somewhere between 17 to 40%, and for a distal tibial allograft, we really don't know as of yet. So I think we need to be mindful of the role, potentially the cumbersome role of screw based fixation.
So then taking that and moving forward and looking at how that plays into the graph debate, we know based on the available literature that at least suggests that button-based fixation performs better with autograft. That can include the iliac crests where there's abundant data both here and internationally, and that's the Eden-Hybbinette procedure. And then additionally, there's an evolving role for the distal clavicle, and distal clavicle autograft is another great locally based option where a single button fixation can be of benefit. I'd be remiss if I didn't describe the clinical series from Pascal Boileau where he shows a single button-based fixation in upwards of 200 individuals. Most of these were Latarjets, but now he's transitioned in many cases to a distal clavicle with excellent results, excellent healing, and I think that biology does quite well.
Certainly Ivan Wong has given us a lot of food for thought as it relates to his anatomic glenoid reconstruction technique, and the AGR has been a game changer for many of us that are looking to transition to a free bone block type fixation. But the cautionary tale that he shared from his robust experience was that with button-based fixation and a frozen distal tibial allograft, that his rate of failure was 39% and that was with near complete resorption of the graft. So that's very concerning, especially in these individuals that have a fairly complex problem and often have had prior operative intervention.
I was in communication with him about this study which he had presented in many different venues, and he's since gone back to screw-based fixation as a result of that based on his graft of choice. So I think that that is an important perspective when you consider use of buttons. Button perform well with autograft. I think if you have the technical faculties to pursue an arthroscopic Latarjet, which is not an easy procedure, but there are many thought leaders that have really showed reproducibility and a learning curve of about maybe about 50 cases. I think that that's a very executable procedure and it can be done through a subscap split with relative ease. But for those that are looking for free bone block options, I think again, I would probably lean more heavily if you're looking for button-based fixation towards iliac crests or considering that distal clavicle.
Justin Arner:
Yeah, that's a great summary and great point. Something we don't really think about because it's not in the next few years, but people in earlier portions of their career, especially if you're going to be seeing that person with arthritis 15 or 20 years later, hopefully not that soon or ever, certainly a difficult arthroplasty. One thing I wanted to ask you about, just personally, the distal clavicle and Latarjet autograft options, in your practice, are there times where you say that maybe they have less bone loss that you will do a single button distal clavicle or is there a role that plays in your practice versus Latarjet? Just tell us how you approach some of the bone block procedures.
Brian Waterman:
I think much of this plays into a discussion about the bone loss morphology. I think 3D CT scans certainly or MRI as Matt Provencher has shown us, can be very helpful for characterizing that degree of bone loss, but it tends to be fairly flat and not serrated in a traditional pattern. Now, some of these postage stamp fractures may be a little bit different morphology, but in general, I have not migrated towards that distal clavicle as an option. For me, I think that would serve more of a Bristow type of technique and I would probably use a single screw in the current application. Where the bone block fits in my current algorithm, it's usually for those subcritical areas of bone loss, so I'm thinking about it in greater than 15% isolated glenoid bone loss and then obviously taking into account the bipolar dynamic bone loss situation and seeing how that might contribute. For button-based fixation, I'm probably more interested in the cerclage medalist techniques. There are some great data out of Barcelona. Dr. Hashem has shown us excellent early results with some of his techniques, and so I'm really interested in moving that direction.
Justin Arner:
Yeah, it's really interesting. In Europe, they've certainly pushed the envelope here and really taught us so much. It's pretty exciting. I've spoken with a few different people regarding, sometimes maybe a Bristow and you have a minimal amount of bone loss is a quick procedure that's kind of falling out of favor, but with Dr. Jobe's experience and some of those folks that trained with him, they found good data. It's a complicated thing for sure. One thing I wanted to ask you about, and you spoke with me about before is sometimes the screws, it's maybe more like absolute stability, it's maybe stiffer. Do you think there's some advantage to have micro motion with anchors or buttons or cerclage, do you think that would benefit healing or do you think it makes more sense to have a stiffer construct that will say a screw?
Brian Waterman:
Yeah, you can definitely make pros and cons out of it. I think some of the initial premise, and this is drawing from our AO experience, we're all orthopedists first. A little bit of motion is probably good, but certainly I think we fall prey to this concept of trying to make it completely anatomic. We love to see those bony surfaces compressed together, but I think a certain amount of micro motion, knowing that it's an imperfect science for preparation of those mating surfaces, a little bit of micro motion probably is not bad, and I think it's probably a little bit more forgiving for subtle degrees of either malposition or micro adjustments.
Certainly that has to be offset with the discussion that relates to suture based implants. And I know you and I have discussed a little bit about, and we mentioned this in our article, the concept of windshield wipering in and bungee effect of these suture based constructs. We see this around the AC joint fixation where you see some lysis and that may be from toggling the suture based implants based on that micro motion. So I think with a potential beneficial effect may also come to problems. That's not to say you won't get that with suture anchors with screw based constructs, but it is another dynamic to consider when discussing micro motion. What do you think?
Justin Arner:
Yeah, I agree with you. I think I probably don't have much to add, but we love that bone compressing, but is that really better? You love feeling that screw being so solid and the excellent purchase, but yeah, we don't know. I think that's a great summary of it. I wanted to ask you, with some of these buttons and anchors, do you worry about windshield wiping of the implants or tunnels enlarging if they loosen or do you have any thoughts about that or experience?
Brian Waterman:
I haven't. Really, again, extrapolate a lot of my experience from other areas. I think that having a broad base button so that you don't have sintering or subsidence of these implants on the cortical surface, because I think that the interface is so small and that's one of the benefits of these suture based fixation is that it consumes a small amount of bone at the interface. It's fairly small. Those small drill pins or suture size openings leave a really robust surface for healing. So I don't worry about the windshield wiping as much, especially I think if you're observing the time-honored and more maybe conservative or moderate rehabilitation protocol. But I do think the utilization of these so-called top hats, the washers or potentially even the rim plates may be beneficial. And then also as you're thinking about some of these all suture constructs, something that's fairly broad-based that is going to sit capably on that cortical surface prior to healing probably has some benefit.
Justin Arner:
Yeah, that makes a lot of sense. One thing that I think that we probably don't think enough about is cost. And you mentioned that in your editorial here. Can you just give us a little summary about cost of implants?
Brian Waterman:
In a single-use culture? Right. The consumable costs are quite considerable. So as you think about implants, you also have to think about kits and everything around that, and everything is boiling down to a value-based discussion these days as it should be. I'm at an academic center, but we're taught to be mindful of these types of things, especially as it relates to different payers when we're in an ACS environment. It's hard to dispute the overall value of a $65 screw, especially some of these more basic non-cannulated screws. But the value proposition probably is not just at the time of surgery, it's how they do. It's their quality of life, adjusted years. It's their avoidance of re-operation, it's their time loss to injury or recovery process. And so certainly there've been studies that have shown cost-effectiveness of an arthroscopic bone block procedure. I think what we need is probably more long-term data to see if the overall initial upfront expense, which can vary significantly depending on your distributorship or vendor, whether that bears out for better value in the long-term for our patients, and that'd be a really interesting avenue of study.
Justin Arner:
Yeah, something in the United States that's certainly a big problem, healthcare costs. So all these things are important. So as we wrap up here, I just wanted to see what closing thoughts you may have about this technology and where we are in 2024, where do you think this is going or where do you see in five or 10 years? Will we be having these same discussions or do you think we're going to, a lot of us will make the jump and progress will continue to be made in this front?
Brian Waterman:
Yeah, no, you can obviously see it's something we're passionate about. I've focused a lot of time and energy on trying to consider where we can get better for our patients and especially trying to make things more reproducible. I think without question, we are moving to a medalist technique and a free bone block with avoidance of the subscapularis compromise. JT Tokish boldly predicts that the Latarjet will be dead in five years. I've learned not to question him in anything he says.
Justin Arner:
That's smart.
Brian Waterman:
And I would say that many of his contemporaries have called for the same thing. But I think we need to make sure we have ease of access and cost of grafts. So if we are using free grafts, donor grafts, we need to consider how we can drive that cost down and make them more easily accessible. And that's not just in the United States. We need that also for our international colleagues. This helps them to avoid the donor site morbidity that's commonly seen with such things as iliac crests and potentially even the distal clavicle.
I think the way that we can continue to innovate in this space is by showing benefit of the fresh frozen grafts such as that Ivan Wong and many of our colleagues now in North America are using with the AGR technique. I think there's also a role for biologics and biomimetic scaffolds. We've definitely seen different vendors and tissue providers get into this space, and we are heavily involved here at Wake with the Wake Forest Institute of Regenerative Medicine and looking at ways that we can bioprint these scaffolds and it may be ideally suited in a less of a load bearing joint such as the glenoid. So trying to find ways that we can populate these scaffolds with the right amount of biologic milieu to create healing and incorporation and development into subchondral bone.
And so that's where I think we're all going. I'm in the infancy of transitioning to an arthroscopic free bone block technique with screw-based fixation. I think there's merit to that. There is morbidity in the approach. The systematic reviews and pooled data suggest that an open base Latarjet, while I think probably more reproducible in everybody's hands than an arthroscopic, probably is associated with scarring, some level of subscap compromise and lower rates of return to sports. So that's my call to action to get better and innovate. And Ivan's been a great leader in this space along with many of our international colleagues, Pascal Boileau, Laurent Lafosse, and so many others.
So the future is bright, but I don't know if we have a consensus on this space. I think we also need to figure out who needs a free bone block, who doesn't, and really I think having some more continued studies that robustly compare the benefits of Bankart remplissage versus a bone block. That's the other area you and I were just discussing that recently in the past couple days.
Justin Arner:
Right. Yeah, you had a nice editorial commentary talking about that, and it's tricky circumstance. It's exciting though. Like you mentioned, there's some good data coming out and smart people like yourself that are really leading the way. So this is certainly beyond the discussion here, but are you a remplissage believer in people that have less bone loss? Do you think that more and more those will be done and less and less bone blocks will be performed?
Brian Waterman:
I think time will tell on that. I'm certainly a believer. We've done so much to make that very easy and reproducible. We were chatting a little bit about for those individuals that have the appropriate Hill Sachs lesion and you need to avoid the over-medialized ones, you need to avoid that in a throwing or overhead athlete. You need to avoid those that are in a real cephalad position. But even those kind of disclaimers notwithstanding, I think it's a great technique if there's really modest to limited degree of bone loss anteriorly on the glenoid. That's what I believe in my heart. If you look at trend lines over time, I think the utilization has continued to escalate rapidly. Historically, for me, it was somewhere around 10%. Now, I would estimate we're probably out on the order of 30% for remplissage in our instability arthroscopic treatments.
So I think we'll continue to see that to escalate with I think very low morbidity. When you look at the pooled data, it suggests that while there's nominal losses in external rotation, probably less than 15% in full adduction, you don't see a lot of issues and it probably is more related to a posterior tethering effect rather than truly filling that defect.
Justin Arner:
Right. It certainly have a lot of improvements in the way we do it, just like you mentioned makes it just so much better. Appreciate those comments. So thanks again for your time tonight. I appreciate you doing this over and over again for us and your commitment to AANA and arthroscopy and everything, and really want to thank you for your time. Appreciate it.
Brian Waterman:
Thanks, Justin. It's truly an honor. Thanks everybody.
Justin Arner:
Dr. Waterman's article in Editorial Commentary titled “Suture-Button Fixation May Have Advantages Over Screw Fixation for Glenoid Bone Grafting Procedures for Shoulder Instability” is in the January 2024 issue of the Arthroscopy Journal and is available online at arthroscopyjournal.org. Thank you so much for joining us.
Justin Arner:
This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
Medical Disclaimer:
The information and opinions discussed herein, including but not limited to text, graphics, images, and other material contained in this podcast and its referenced paper are for informational and educational purposes only. No material in this podcast or its referenced paper is intended to be a substitute for professional medical advice, diagnosis or treatment. Specifically, all content and information in this podcast and its referenced paper does not constitute medical advice. Always seek the advice of your physician and/or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you were exposed to from this podcast or its referenced paper. The information discussed in this podcast and its referenced paper may not apply to every individual and may cause harm.