Chronic anterior instability with hyperlaxity treated by arthroscopy using the Trillat technique with endobutton fixation: results for 14 cases

BACKGROUND: Recurrent anterior instability associated with hyperlaxity remains a difficult challenge. In 1954, Trillat proposed osteoclasis of the coracoid process in order to make it more distal and more medial to place the conjoint tendon just in front of the humeral head. The conjoint tendon lowers and reinforce the stabilizing action of the subscapularis muscle in abduction. This open surgery technique has provided satisfactory results in patients with chronic anterior glenohumoral instability associated with massive irreparable rotator cuff tears. We hypothesized that this procedure could be arthroscopy-assisted with the use of an endobutton to treat anterior glenohumoral instability with hyperlaxity without engaging bone defects. METHODS: This is a prospective study on 14 patients (9 females, 5 males; average age 25 years) who underwent surgery between 05/2014 and 12/2016. These were patients with anterior instability with hyperlaxity (external rotation > 85° / positive sulcus sign and no associated bone lesions). Arthroscopic surgery consisted of an antero-inferior capsuloplasty with Bankart repair combined with coracoid osteoclasis and fixation with an endobutton with a self-locking mechanism. The results were evaluated using SSV, Walch-Duplay, Rowe and Constant scores. Standard X-rays and a CT scan with 3D reconstructions were also performed at follow-up. RESULTS: With an average follow-up of 26 months (24 to 32 months), no recurrent instability was reported, but persistent apprehension was found in 2 cases. The average Walch-Duplay score was 85 points, Rowe 89 points, the SSV 91% and adjusted Constant score 95.8%. The average VAS score was 0.8 points. The mean preoperative active anterior elevation of 178° decreased to 165° postoperatively and similarly, external rotation with the elbow at side decreased from 90° to 57°. At the last follow-up, all osteotomies healed. No complications were reported. CONCLUSION: Arthroscopy-assisted Trillat technique with the use of an endobutton appears to be a reliable technique for the treatment of hyperlaxity associated with chronic anterior glenohumoral instability without bone defect. Stabilization and adjustment of coracoid osteoclasis are provided by the endobutton; lowering and medial placement of the coracoid causes lowering of the subscapularis muscle by the conjoint tendon in abduction and thereby reinforces anterior capsuloplasty. Longer follow-up is required to confirm the reliability of this technique.