Grant Garrigues, MD

The paper by Bradley S. Schoch, MD, and colleagues compares a newer method of coracoid graft fixation using buttons to a more traditional approach with screws. The Latarjet procedure can be technically challenging, especially when performed arthroscopically. The rigidity of screw fixation requires an approach through a very medial portal that traverses in proximity to the axillary artery and brachial plexus.  Button fixation is intriguing as it would allow placement of the fixation buttons through more traditional portals, and may obviate the need to go far medial.  In addition, while not addressed here, button constructs can be used to shuttle other allograft or autograft options beyond the coracoid through the rotator interval—not providing the sling effect of the latarjet but avoiding the difficulty of the subscapularis split.  One concern, however is the decreased rigidity, especially in torsion, for single button constructs when compared to the traditional two screws. 

In the current study, the authors compare button with screw fixation in a mix of arthroscopic and mini-open Latarjet cases.  They showed that the complications are different between the two devices, with a lower rate of recurrent dislocation with screw fixation and, interestingly, also a lower rate of reoperation.  This may relate to the pain that can occur when the superior aspect of the graft resorbs leaving a prominent screw head.  More data is needed to address this topical question, but as one of the first to compare the button to the screw for Latarjet this paper is impactful.

John M. Tokish, MD

The paper by Bradley S. Schoch, MD, and colleagues is an intriguing paper because it offers a potential new way to perform fixation of bone blocks in a much simpler and potentially safer fashion. One of the reasons that the Latarjet procedure is not widely adopted in the U.S. is due to the complication rates have been published to be high in some studies. The surgery is a technically challenging procedure, especially arthroscopically. One of the big reasons for this is that the fixation of the graft with a screw requires a "straight in" trajectory, and thus a very medial starting point. In the current study, the authors offer a different mode of fixation. This is intriguing as it would allow placement of the fixation buttons through more traditional portals, and may obviate the need to go far medial. The current study compared these techniques in Latarjet, but perhaps the more intriguing application is the use of these button constructs for free bone grafts. Such an application would allow a bone graft to be placed through the rotator interval using traditional portals, removing the most difficult part of the arthroscopic Latarjet, the subscapularis split. Secondly, the hardware prominences that we see with the screws can be eliminated potentially by the buttons. If the authors’ data are right and the two procedures end up being equivalent, then I think this will change the face of how we do instability surgery with bone loss.