The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair: a retrospective case series of forty-nine consecutive patients

Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review

Background

Primary shoulder stabilization is successful, but there continues to be a risk of recurrence after operative repair, particularly in the young athlete. It is important for surgeons to understand the outcomes after various revision stabilization techniques to best counsel patients and manage expectations.

Purpose

To analyze recurrent instability and revision surgery rates in patients who underwent revision anterior glenohumeral stabilization procedures with either arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction.

Study Design

Systematic review; Level of evidence, 4.

Methods

We performed a systematic review of level 2 to 4 evidence studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical studies of revision anterior glenohumeral stabilization (arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction) with a minimum 2-year follow-up were analyzed. The rate of recurrent instability, rate of revision surgery, patient-reported outcomes, and range of motion were extracted and reported. Study methodological quality was evaluated using the Downs and Black quality assessment score.

Results

A total of 37 studies met inclusion criteria and were available for analysis: 20 studies evaluated arthroscopic repair, 8 evaluated open repair, 5 evaluated Latarjet procedure, 3 evaluated bone block, and 2 evaluated capsular reconstruction. There was 1 study included in both arthroscopic and Latarjet procedures, for a total of 1110 revision cases. There was 1 level 2 study, and the remainder were level 3 or 4 with poor Downs and Black scores. Participants analyzed were most commonly young (weighted mean age, 26.1 years) and male (78.4%). The weighted mean clinical follow-up after revision surgery was 47.8 months. The weighted mean rate of recurrent instability was 3.8% (n = 245) after the Latarjet procedure, 13.4% (n = 260) after open repair, 16.0% (n = 531) after arthroscopic repair, 20.8% (n = 72) after bone block, and 31.0% (n = 35) after capsular reconstruction. The weighted mean rate of additional revision surgery was 0.0% after bone block, 0.02% after the Latarjet procedure, 9.0% after arthroscopic repair, 9.3% after open repair, and 22.8% after capsular reconstruction. Patient-reported outcomes and objective measures of range of motion and strength improved with all revision techniques.

Conclusion

The current review identifies a deficiency in the literature pertaining to consistent meaningful outcomes and the effect of bone loss after revision shoulder stabilization. Published studies demonstrate, however, that revision shoulder stabilization using arthroscopic, open, coracoid transfer, or bone block techniques yielded satisfactory objective and patient-reported outcomes. The Latarjet procedure exhibited the lowest recurrent instability rate. This study confirms that recurrent instability remains a common problem, despite revision shoulder stabilization. The quality of research in revision shoulder stabilization remains poor, and higher quality studies are needed to establish best practices for treatment of this complex problem.

Bankart versus Latarjet operation as a revision procedure after a failed arthroscopic Bankart repair

Background

An arthroscopic Bankart operation is the most common operative procedure to treat shoulder instability. In case of recurrence, both Bankart and Latarjet procedures are used as revision procedures. The purpose of this study was to compare the re-recurrence rate of instability and clinical results after arthroscopic revision Bankart and open revision Latarjet procedures following failed primary arthroscopic Bankart operations.

Methods

Consecutive patients operatively treated for shoulder instability at Turku University Hospital between 2002 and 2013 were analyzed. Patients who underwent a primary arthroscopic Bankart operation followed by a recurrence of instability and underwent a subsequent arthroscopic Bankart or open Latarjet revision operation with a minimum of 1 year of follow-up were called in for a follow-up evaluation. The re-recurrence of instability, Subjective Shoulder Value, and Western Ontario Shoulder Instability index were assessed.

Results

Of 69 patients, 48 (dropout rate, 30%) were available for follow-up. Recurrent instability symptoms occurred in 13 patients (43%) after the revision Bankart procedure and none after the revision Latarjet procedure. A statistically and clinically significant difference in the Western Ontario Shoulder Instability index was found between the patients after the revision Bankart and revision Latarjet operations (68% and 88%, respectively; P = .0166).

Conclusions

The redislocation rate after an arthroscopic revision Bankart operation is high. Furthermore, patient-reported outcomes remain poor after a revision Bankart procedure compared with a revision Latarjet operation. We propose that in cases of recurring instability after a failed primary Bankart operation, an open Latarjet revision should be considered.

Latarjet Procedure for Anterior Glenohumeral Instability: Early Postsurgical Complications for Primary Coracoid Transfer Versus Revision Coracoid Transfer After Failed Prior Stabilization

BACKGROUND

The Latarjet procedure (coracoid transfer) is often used to successfully treat failed instability procedures. However, given the reported increased complication rates in primary Latarjet surgery, there is a heightened concern for complications in performing the Latarjet procedure as revision surgery.

PURPOSE

To evaluate the early outcomes and complications of the Latarjet procedure as primary surgery compared with revision surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 157 patients were included and retrospectively reviewed: 103 patients in the revision group and 54 patients in the primary group. Patients were evaluated by physical examination findings as well as by documentation of complications and reoperations extracted from their electronic medical records.

RESULTS

The mean follow-up was 7.8 ± 11.0 months for the primary group and 7.0 ± 13.2 months for the revision group. There were no significant differences in overall complication rates between the primary and revision groups (16.7% vs 8.7%, respectively; P = .139). The complication rate was significantly higher in patients in the revision group who had undergone a prior open procedure compared with those who had undergone only arthroscopic procedures (30.0% vs 4.1%, respectively; P < .001). Of those patients who sustained a complication, 7 of the 9 underwent a reoperation in the primary group (13.0%), and 7 of the 9 did so in the revision group (6.8%); the risk of reoperations was not different between groups (P = .198). There were 4 patients in the primary group (7.4%) and 5 patients in the revision group (4.9%) who experienced recurrent dislocations during the follow-up period (P = .513). There was no difference in postoperative range of motion.

CONCLUSION

The Latarjet procedure is a reasonable option for the treatment of failed arthroscopic instability repair with an early complication rate similar to that found in primary Latarjet surgery.

Revision anterior glenohumeral instability: is arthroscopic treatment an option?

Background

The purpose of this study was to determine the short-term outcomes for patients who underwent revision surgery for shoulder instability, including both revision arthroscopic repair and Latarjet.

Methods

This study included patients who underwent revision of a prior arthroscopic labral repair to arthroscopic labral repair or Latarjet at our institution from 2012 to 2017. After collection of preoperative demographic data, preoperative 3-dimensional imaging was reviewed to determine percent glenoid bone loss (%GBL) and to determine whether each shoulder was on-track or off-track. Patients were contacted to obtain postoperative patient-reported outcome metrics including visual analog scale pain, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and instability recurrence (full dislocation, subluxation, or subjective apprehension) data at a minimum of 2 years postoperatively.

Results

Of 62 patients who met criteria, 45 patients were able to be contacted. Of them, 21 underwent revision arthroscopy and 24 underwent a Latarjet procedure. In the revision arthroscopy group, 5 of 15 had %GBL >20% and 4 of 21 were contact athletes. In the Latarjet group, 11 of 22 had %GBL >20% and 5 of 24 were contact athletes. Of 21 revision arthroscopy patients, 8 underwent concomitant remplissage. Eight of 21 patients in the revision arthroscopy group and 7 of 21 patients in the Latarjet group reported instability postoperatively. Three of 21 patients in the revision arthroscopy group and 2 of 21 patients in the Latarjet group reported full dislocations postoperatively. Zero patients in the revision arthroscopy group and 1 of 21 patients in the Latarjet group underwent reoperation.

Conclusion

Our results suggest that both revision Latarjet and arthroscopic stabilization can be of benefit in select circumstances. However, in revision settings, postoperative instability symptoms are common with both procedures.

Relationship between the Thickness of the Coracoid Process and Latarjet Graft Positioning-An Anatomical Study on 70 Embalmed Scapulae

Background: The Latarjet procedure is a popular technique with the aim of the reconstruction of glenoid cavity bone defects in patients with chronic anterior shoulder instability. Studies have shown that the Congruent arc Latarjet procedure is better able to reconstruct larger defects than the Classic Latarjet, but there is a lack of information on the limitations of both methods. Methods: The dimensions of the glenoid width and the native coracoid process of two groups with 35 Formol-Carbol embalmed scapulae each were measured using a digital caliper. The relationship between the coracoid graft and the anterior-posterior diameter of the glenoid cavity was calculated to determine the maximum defect size of the glenoid cavity width, which can be treated by both Latarjet techniques. Results: The average restorable defect size of the anterior segment of the glenoid cavity was 28.4% ± 4.6% (range 19.2%–38.8%) in the Classic Latarjet group, and 45.6% ± 5.2% (range 35.7%–57.1%) in the Congruent arc Latarjet group. Based on our results, the feasibility of the Classic Latarjet procedure to reconstitute the anatomical width of the glenoid cavity was 86% in a 25% bone loss scenario, and only 40% in a 30% bone loss scenario. Conclusion: Based on our results we are unable to define a clear threshold for the optimal Latarjet graft position. In glenoid cavity defects <20%, the Classic Latarjet technique usually provides enough bone stock for anatomical reconstruction. Defects ≥35% of the glenoid cavity width should only be treated with a coracoid graft in the Congruent arc position. In the critical area between 20% and 35% of bone loss, we suggest the preoperative assessment of coracoid dimensions, based on which the graft position can be planned to restore the anatomical anterior-posterior diameter of the glenoid cavity.

Outcomes of the Latarjet Procedure for the Treatment of Chronic Anterior Shoulder Instability: Patients With Prior Arthroscopic Bankart Repair Versus Primary Cases

BACKGROUND

It remains unclear whether results differ between a Latarjet procedure performed after a failed arthroscopic Bankart repair and one performed as the primary operation.

PURPOSE

To compare the postoperative outcomes of the Latarjet procedure when performed as primary surgery and as revision for a failed arthroscopic Bankart repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter retrospective comparative case-cohort analysis was performed for all patients undergoing a Latarjet procedure for recurrent anterior shoulder instability. Patients were separated into 2 groups depending on if the Latarjet procedure was performed after a failed arthroscopic Bankart repair (group 1) or as the first operation (group 2). Outcome measures included recurrent instability, reoperation rates, complications, pain, Walch-Duplay scores, and Simple Shoulder Test.

RESULTS

A total of 308 patients were eligible for participation in the study; 72 (23.4%) did not answer and were considered lost to follow-up, leaving 236 patients available for analysis. Mean follow-up was 3.4 ± 0.8 years. There were 20 patients in group 1 and 216 in group 2. Despite similar rates of recurrent instability (5.0% in group 1 vs 2.3% in group 2; P = .5) and revision surgery (0% in group 1 vs 6.5% in group 2; P = .3), group 1 demonstrated significantly worse pain scores (2.56 ± 2.7 vs 1.2 ± 1.7; P = .01) and patient-reported outcomes (Walch-Duplay: 52 ± 25.1 vs 72.2 ± 25.0; P = .0007; Simple Shoulder Test: 9.3 ± 2.4 vs 10.7 ± 1.9; P = .001) when compared with those patients undergoing primary Latarjet procedures.

CONCLUSION

Functional outcome scores and postoperative pain are significantly worse in patients undergoing a Latarjet procedure after a failed arthroscopic Bankart repair when compared with patients undergoing primary Latarjet. The assumption that a failed a Bankart repair can be revised by a Latarjet with a similar result to a primary Latarjet appears to be incorrect. Surgeons should consider these findings when deciding on the optimal surgical procedure for recurrent shoulder instability.

Previous arthroscopic Bankart repair is an independent risk factor for an inferior outcome after Latarjet procedure

BACKGROUND

There is limited evidence that the Latarjet procedure has a worse outcome as a revision operation, after a failed stabilization surgery, compared with when it is the primary procedure for posttraumatic anteroinferior instability of the shoulder joint.

PURPOSE

To compare the results from Latarjet as a primary operation vs. revision surgery after a failed arthroscopic Bankart repair for posttraumatic anteroinferior shoulder instability. In addition, to assess the effect of preoperative bony pathology on outcome.

PATIENTS AND METHODS

Ninety-nine patients who underwent the Latarjet procedure (47 primary, 52 revision after failed Bankart repair) were analyzed after an average of 3.8 (SD 2.3, range 1-11) years of follow-up. All patients underwent either computed tomography or magnetic resonance imaging preoperatively. Glenoid and humeral bone defects were measured to assess whether the Hill-Sachs lesion was on- or off-track. Clinical outcome measures included the Western Ontario Shoulder Instability Index (WOSI), subjective shoulder value (SSV), and recurrence of instability (dislocation, subluxation, or any perception of instability).

RESULTS

There were no cases of recurrent dislocation in either group. Four patients in the primary surgery group and 13 in the revision group had at least one subluxation or perception of instability after the Latarjet procedure. Patients with a previous arthroscopic Bankart repair had worse outcomes than those undergoing primary Latarjet when assessed by the WOSI: 76 (SD 22) vs. 85 (SD 15), difference in means -9 (95% CI -17 to -1, p=0.02); SSV: 80 (SD 18) vs. 88 (SD 13), difference in means -8 (95% CI -15 to -2, p=0.01); and the recurrence percentage (25% vs. 9%, p=0.03). A multivariate linear regression model adjusted for the length of follow-up, glenoid bone defect size, Hill-Sachs lesion size, and the frequency of preoperative bipolar bone defects (on/off track Hill-Sachs lesions) further increased the difference in WOSI to -12 (95% CI -21 to -4, p=0.005).

DISCUSSION

A previous failed arthroscopic Bankart repair was a significant independent risk factor for inferior outcome. Preoperative bony pathology did not explain the worse outcome from the revision vs. primary Latarjet procedure.

LEVEL OF EVIDENCE

IV, cohort observational study.

A pilot study of blood supply of the coracoid process and the coracoid bone graft after Latarjet osteotomy

Latarjet osteotomy is still one of the most reliable and commonly used surgeries in treating recurrent anterior shoulder dislocation. The coracoid process (CP) is the main structure of this surgery. However, the blood supply of CP is not fully understood, and the extent of destruction of blood supply of coracoid bone graft after Latarjet osteotomy procedure is still controversial. Five embalmed cadaveric upper limbs specimens were employed for macro observation of the blood supply of CP. The conjoint tendon (CT) and CP interface were dissected for histology. Sixteen fresh frozen shoulder specimens were used for perfusion and micro CT scanning. Eight specimens were used to present the whole vessel structure of CP. The other eight underwent Latarjet osteotomy procedure. The coracoid bone grafts in both groups were scanned to clarify the remnant blood supply. It was found that the CP was nourished by supra-scapular artery (SSA), thoracic-acromial artery and branch from second portion of the axillary artery (AA). After Latarjet osteotomy procedure, no artery from CT was detected to penetrate the CP at its attachment. Only in one specimen the blood vessel that originated from the CT penetrated the bone graft at the inferior side. Therefore, most of the blood supply was destroyed although there is a subtle possibility that the vessels derived from the CT nourished the inferior side of the CP. In a nutshell, CP is a structure with rich blood supply. The traditional Latarjet osteotomy procedure would inevitably cut off the blood supply of the coracoid bone graft.

Conjoint Tendon Tenotomy for Glenoid Exposure in the Setting of Previous Coracoid Transfer

Surgical exposure of the glenoid after previous coracoid process transfer is technically challenging as a result of distorted anatomy, obliterated soft-tissue planes, and adhesive scar tissue, which poses additional risk to adjacent neurovascular structures. The purpose of this article is to present a technique for glenoid exposure following coracoid transfer that involves tenotomy of the conjoint tendon to minimize the risk for neurovascular injury while leaving the well-healed coracoid bone graft in place.

Long-term Results of the Open Latarjet Procedure for Recurrent Anterior Shoulder Instability in Patients Older Than 40 Years

BACKGROUND

Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy.

PURPOSE

To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up.

RESULTS

No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly (P < .001). In total, 36 patients rated their result as excellent, 3 as good. Further, 6 patients (15%) underwent joint-preserving reoperation, and 1 patient (3%) had reverse total shoulder arthroplasty for severe dislocation arthropathy. Dislocation arthropathy was severe in 14 patients (37%) and had progressed by at least 2 grades in 17 patients (45%). Patients with severe dislocation arthropathy had already shown degenerative changes preoperatively as opposed to those who ultimately had no or moderate dislocation arthropathy (n = 24) (P < .001). Progression of dislocation arthropathy was associated with lateral (>1 mm) graft positioning (P < .001) and older age at surgery (r = 0.58; P < .001).

CONCLUSION

The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.

Management of the Failed Latarjet Procedure: Outcomes of Revision Surgery With Fresh Distal Tibial Allograft

BACKGROUND

Patients with recurrent anterior glenohumeral instability after a failed Latarjet procedure remain a challenge to address. Complications related to this procedure include large amounts of bone loss, bone resorption, and issues with retained hardware that necessitate the need for revision surgery.

PURPOSE

To determine the outcomes of patients who underwent revision surgery for a recurrent shoulder instability after a failed Latarjet procedure with fresh distal tibial allograft.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All consecutive patients who underwent revision of a failed Latarjet procedure with distal tibial allograft were prospectively enrolled. Patients were included if they had physical examination findings consistent with recurrent anterior shoulder instability. Patients were excluded if they had prior neurologic injury, a seizure disorder, bone graft requirements to the humeral head, or findings of multidirectional or posterior instability. History of shoulder instability was documented, including initial dislocation history, duration of instability, number of prior surgeries, examination findings, plain radiographic and computed tomography (CT) data, and arthritis graded with Samilson and Prieto (SP) classification. All patients were treated with hardware removal, capsular release with subsequent repair, and fresh distal tibial allograft to the glenoid. Outcomes before and after revision were assessed according to the American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), and Western Ontario Shoulder Index (WOSI) and statistically compared. All patients underwent a CT scan of the distal tibial allograft at a minimum 4 months after surgery.

RESULTS

There were 31 patients enrolled (all males), with a mean age of 25.5 years (range, 19-38 years) and a mean follow-up time of 47 months (range, 36-60 months) after revision with distal tibial allograft. Before distal tibial allograft augmentation, the mean percentage glenoid bone loss was 30.3% (range, 25%-49%). All patients after their Latarjet stabilization had recurrent shoulder dislocation (11/31, 35.5%) or subluxation (20/31, 64.5%), and all patients had symptoms consistent with recurrent shoulder instability upon physical examination. Radiographs demonstrated 2 fixation screws in all cases, mean SP grade was 0.5 (range, 0-3), and CT scans revealed that a mean 78% of the Latarjet coracoid graft had resorbed (range, 37%-100%). Patient-reported outcome scores improved significantly pre- to postoperatively for ASES (40 to 92, P = .001), SANE (44 to 91, P = .001), and WOSI (1300 to 310, P = .001). There were no cases of recurrence, and a final CT scan of the distal tibial revision demonstrated a complete union at the glenoid-distal tibial allograft interface in 92% of patients.

CONCLUSION

The majority of the failed Latarjet procedures included in this study had near-complete resorption of the coracoid graft and hardware complications. At a minimum follow-up time of 36 months, patients who underwent revision treatment for a failed Latarjet procedure with a fresh distal tibial allograft demonstrated excellent clinical outcomes and near-complete osseous union at the glenoid-allograft interface. Although patients evaluated with recurrent anterior shoulder instability after a failed Latarjet procedure remain a challenge to address, fresh distal tibial allograft augmentation is a viable and highly effective revision procedure to treat this patient population.

Analysis of complication after open coracoid transfer as a revision surgery for failed soft tissue stabilization in recurrent anterior shoulder instability

BACKGROUND

The coracoid transfer represents a treatment option for patients with recurrent shoulder instability. Only a few studies exist about the complication rate of the coracoid transfer as a revision surgery following failed soft tissue stabilization. The purpose of this study was to analyze the results and complication rate after coracoid transfer as a revision surgery.

METHODS

In this study 38 patients (4 females, 34 males, mean age 27 years) were included of whom 29 patients were available for follow-up after a mean of 27 months. Previous shoulder stabilization procedures were predominantly arthroscopic (n = 25). Complications were divided according to their timely appearance into early (< 3 months) and late (> 3 months) postoperatively as well as need for revision. Clinical scores [Constant Score (CS), Rowe Score (RS), Walch-Duplay-Score (WDS), WOSI and Subjective-Shoulder-Value (SSV)] were evaluated preoperatively and at final follow-up.

RESULTS

In this patient cohort, the overall complication rate was 27.6%, all of them occurred > 3 months postoperatively. In seven of eight cases (24.1%) a repeat surgical procedure was conducted. Recurrent instability occurred in three patients (10.3%) of which two received a revision surgery (n = 1 iliac-crest bone graft, n = 1 labral repair). Due to persistent pain five patients underwent an arthroscopic implant removal. The complication rate was with 40% higher in patients with two or more previous surgeries (n = 4 out of 10 patients) compared to patients with one previous surgery (21%, n = 4 out of 19 patients). The scores increased significantly comparing pre- to postoperative [CS 74-90 points, RS 27-91 points, WDS 16-89 points, WOSI 40-76% and SSV 41-82% (p < 0.05)].

CONCLUSION

The open coracoid transfer as a revision surgery after failed soft tissue stabilization leads to satisfying clinical results. However, the complication rate is high though comparable to data in the literature when used as a primary surgery. The indication for a coracoid transfer should be judged carefully and possible alternatives should be considered.

Open Shoulder Stabilization for Instability: Anterior Labral Repair With Capsular Shift

Although anterior shoulder instability is most commonly treated with arthroscopic fixation, open labral repair with capsular shift may be best for select patients and in cases of revision stabilization without significant bone loss. The technique described in this article uses the deltopectoral interval; it involves careful dissection of the subscapularis from the anterior capsule, repair of the Bankart lesion, and a lateral and superior capsular shift using all-suture anchors in the humeral head. Advantages of this technique include meticulous control of anchor placement and the ability to provide additional stability via a lateral and superiorly directed capsular shift. This operation can be performed in a reliable, efficient, and reproducible manner.

Intraoperative and anatomic dimensions of the coracoid graft as they pertain to the Latarjet-Walch procedure

BACKGROUND

Our objective was to study the anatomic and intraoperative coracoid measurements with an aim to closely replicate the Latarjet-Walch technique and find the similarities and dissimilarities in our population.

METHODS

In the cadaveric study, 20 shoulders in 10 fresh cadavers were dissected, and the coracoid length, width, and thickness were measured. In the intraoperative study, 10 patients underwent the classic Latarjet procedure according to the Walch technique. The harvested coracoid graft was analyzed for the length of the coracoid, the distance of the inferior hole from the lateral margin of the coracoid graft, and the width of the coracoid graft at the inferior and superior hole.

RESULT

The average distance from the tip of the coracoid to the trapezoid insertion was 25.4 mm (standard deviation [SD], 1.7 mm). The mean width of the undersurface of the coracoid was 14.2 mm. The average length of the graft after harvesting was 25.1 mm (SD, 1 mm). The average distance between the lateral border and the inferior hole was 5.5 mm (SD, 1.1 mm). We used 25-mm malleolar screws in 3 shoulders and 30-mm malleolar screws in 7 shoulders.

CONCLUSION

The"7-mm" rule of Walch could be followed in our population. The medial surface width of the coracoid in our Indian morphology was an average of 7 mm; hence, malleolar screws of 30 and 25 mm were used to fix the graft on the glenoid.

Comparative Systematic Review of Fixation Methods of the Coracoid and Conjoined Tendon in the Anterior Glenoid to Treat Anterior Shoulder Instability

BACKGROUND

Coracoid process transfer for the treatment of recurrent glenohumeral dislocations is a safe and reliable procedure; however, there is no consensus as to which is the best method, the Bristow or Latarjet procedure.

PURPOSE

To analyze the results of coracoid process transfer for the treatment of recurrent glenohumeral dislocations and to compare the results of this transfer between the Bristow and Latarjet techniques.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The databases surveyed for this review included J-STAGE; Cochrane Bone, Joint and Muscle Trauma Group Specialized Register; Cochrane Controlled Register of Trials; MEDLINE; Ovid; Embase; Google Scholar; and CINAHL. Inclusion criteria consisted of (1) studies related to anterior glenohumeral dislocations treated with transfer of the coracoid process to the anterior glenoid rim and (2) studies that could provide data to perform at least 1 meta-analysis or other statistical evaluation. Titles and abstracts were reviewed for inclusion; thereafter, outcomes and the risk of bias were extracted. Statistical analyses were performed according to the nature of the data. When possible, the 95% CI was included.

RESULTS

Of the 779 studies found, 63 were able to provide data assessing 3395 shoulders. There were no randomized, blinded, or double-blinded trials. The recurrence of dislocations was assessed in 41 studies that used the Bristow technique (n = 2346 shoulders; percentage redislocations [mean ± SE], 1.00% ± 0.20%) and 18 studies that used the Latarjet technique (n = 930 shoulders; percentage redislocations, 2.13% ± 0.49%) (P = .04). The mean loss of external rotation was 12.91° for the Bristow procedure (n = 1440 shoulders) and 11.70° for the Latarjet procedure (n = 243 shoulders). The mean quality-of-life outcome scores were as follows for the Bristow and Latarjet procedures, respectively: Rowe score, 92.06 and 89.33; Western Ontario Shoulder Instability Index score, 16.44% and 19.68%; Japanese Orthopaedic Association score, 93.28 and 92.00; and American Shoulder and Elbow Surgeons score, 91.00 and 89.90.

CONCLUSION

Transferring the coracoid to the anteroinferior border of the glenoid through the subscapularis tendon is effective, regardless of the technique. When comparing the Bristow and Latarjet techniques, the recurrence of dislocations was the only outcome that could undergo a meta-analysis, and it presented a statistically significant difference in favor of the Bristow procedure. All other outcomes presented no clinically significant differences between their effect sizes. More studies presenting better methodology are still needed to achieve more robust conclusions.

Bone block procedures for glenohumeral joint instability

Glenoid bone loss is a well established cause of instability and long term morbidity if not adequadely addressed. Anterior glenohumeral instability due an anterior glenoid defect is significantly more common, and for many years has been well treated with open anterior bone block augmentation procedures, most commonly the latarjet procedure. However, with refinement of this technique and some interest in reducing morbidity associated with iliac crest bone harvest, arthroscopic bone block procedures with allograft has become more popular. In this article we will review some of the key available evidence. We will also review management of the less common and more challenging posterior glenoid defects associated with posterior instability.

Ninety-day complications following the Latarjet procedure

BACKGROUND

The purpose of this study was to describe the rate and type of complications occurring within 90 days following the Latarjet procedure for anterior glenohumeral instability.

METHODS

Consecutive patients undergoing the Latarjet procedure by fellowship-trained surgeons from a single institution between 2007 and 2016 were included for analysis. Indications for the Latarjet procedure included primary or recurrent anterior instability with clinically significant anterior glenoid bone loss and/or failed prior arthroscopic stabilization. Patients undergoing the Latarjet procedure after prior glenoid bone grafting were excluded. All complications that occurred within 90 days of surgery were analyzed and correlated with demographic factors.

RESULTS

A total of 146 consecutive patients (146 shoulders) were included. Of these patients, 11 were lost to follow-up and 2 were excluded for having undergone prior open bone grafting. Among the remaining 133 patients (average age, 28.5 ± 11.8 years; 75% male patients), 10 total complications occurred within 90 days of surgery, for an overall short-term complication rate of 7.5%. Of these 10 complications, 6 required subsequent surgery, with recurrent instability in 2 cases (overall rate, 1.50%), infection in 2 (overall rate, 1.50%), musculocutaneous nerve palsy in 1 (overall rate, 0.75%), and postoperative pain in 1 (overall rate, 0.75%). The remaining 4 complications were transient, resolving with nonoperative treatment. No cases of hardware failure or graft osteolysis were reported.

CONCLUSIONS

The overall 90-day complication rate following the Latarjet procedure for anterior shoulder stabilization was 7.5%. In 6 of the 10 cases, complications led to subsequent surgery, including recurrent instability in 2, while in the remaining 4 cases, the complications were transient and resolved with nonoperative treatment.

Comparison Between Modified Latarjet Performed as a Primary or Revision Procedure in Competitive Athletes: A Comparative Study of 100 Patients With a Minimum 2-Year Follow-up

Background:

The literature lacks evidence comparing outcomes between the Latarjet procedure performed as a primary procedure versus a revision procedure in competitive athletes.

Purpose:

To compare return to sport, functional outcomes, and complications of the modified Latarjet performed as a primary or revision procedure in competitive athletes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between June 2008 and June 2015, a total of 100 competitive athletes with recurrent anterior shoulder instability underwent surgery with the congruent arc Latarjet procedure without capsulolabral repair. There were 46 patients with primary repairs and 54 with revisions. Return to sport, range of motion (ROM), the Rowe score, a visual analog scale (VAS) for pain in sport activity, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed by computed tomography.

Results:

The mean follow-up period was 58 months (range, 24-108 months). A total of 96 patients (96%) returned to competitive sports; 91% returned to their preinjury level of play. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, VAS, and ASOSS scores showed statistically significant improvements after surgery (P < .001). The Rowe score increased from a preoperative mean of 43.8 to a postoperative mean of 96.1 (P < .01). Subjective pain during sports improved from a preoperative VAS score of 3.3 to a postoperative score of 1.2 (P < .01). The ASOSS score improved significantly from a preoperative mean of 46.3 to a postoperative mean of 88.1 (P < .001). No significant differences in shoulder ROM and functional scores were found between patients who underwent a primary versus a revision procedure. No recurrence of shoulder dislocation or subluxation was noted. The bone block healed in 91 patients (91%).

Conclusion:

In competitive athletes with recurrent anterior glenohumeral instability, the modified Latarjet procedure produced excellent functional outcomes, with most athletes returning to sport at the same level they had before surgery and without recurrence, regardless of whether the surgery was performed as a primary or a revision procedure.

A reduction in the rate of nerve injury after Latarjet: a before-after study after neuromonitoring

BACKGROUND

Neurologic dysfunction is a known complication after the open Latarjet procedure. Although the reported clinical incidence is variable, a prior neuromonitoring study demonstrated a significant incidence of nerve dysfunction during surgery, presumably from nerve stretch. We aimed to determine whether a nerve stretch-reduction protocol reduced the incidence of neurologic injury after the open Latarjet procedure.

METHODS

In a nonrandomized study, 38 patients (group 1) who underwent surgery before our neuromonitoring study were compared with 48 patients (group 2) who underwent surgery after this study. Follow-up was at least 3 months or until documented resolution of nerve dysfunction.

RESULTS

There were no significant demographic differences between the groups. In group 1, there were 7 nerve injuries, of which all but 2 recovered. In group 2, there were 3 nerve injuries, of which all but 1 recovered. The overall incidence of nerve injury was 18.4% (group 1) vs. 6.3% (group 2); however, the incidence of permanent motor dysfunction was 5.3% (group 1) vs. 2.1% (group 2). These differences were not significant, likely due to the small number of patients included.

CONCLUSIONS

We observed a reduction of nerve injury with the implementation of a nerve stretch-reduction protocol during the Latarjet procedure; however, we could not demonstrate statistical significance. This trend represents an important finding that modification of surgical technique can reduce the incidence of nerve injury with the Latarjet procedure.

The bra strap incision in the open Latarjet procedure

Background

The anterior deltopectoral approach is the standard approach for performing the open Latarjet procedure. Through the use of a more medial and vertical skin incision, the scar can be cosmetically covered by the bra strap in women. We call this incision the bra strap incision.

The intention of this study was (1) to elaborate if the bra strap incision is considered beneficial by female patients, (2) to find reproducible landmarks to indicate how the bra strap incision has to be oriented, and (3) to evaluate preliminary clinical results of patients in whom the bra strap incision was used.

Methods

In 18 patients with a mean follow-up of 21 (range, 12–31) months treated with an open Latarjet procedure through the bra strap incision, the clinical results (scar satisfaction, Constant and Murley score [CMS], and subjective shoulder value [SSV]) were retrospectively analyzed.

To assess the typical course of the bra strap, anatomical landmarks were assessed in 100 consecutive female patients as the distance from the bra strap center to (1) the tip of the coracoid process, (2) the superior end of the anterior axillary fold, and (3) the acromioclavicular joint.

Results

All (18 of 18) patients stated that they would prefer the bra strap incision if the same procedure had to be performed on the opposite shoulder; 16 women were satisfied with the scar. The mean CMS was 83 (range 64–96) points and the mean SSV was 85 (range, 60–100) %.

The mean distances from the bra strap center to the acromioclavicular joint, coracoid tip, and axillary fold were 28 (range, 5–60) mm, 15 (range, 2–17) mm, and 30 (range, 2–55) mm.

No combination of distance measures and demographic variable revealed a linear relationship.

Conclusion

This analysis shows that the bra strap incision appears to be highly welcomed by female patients and does not compromise the clinical outcome, when compared to previously published data. However, even though the typical location of the bra strap can be determined, the large variations in the distances make it more preferable to preoperatively mark the incision for optimal placement.

Trial registration

The study is approved by the Ethical Committee Zurich. (Cantonal Ethical Committee number: ZH-Nr.2017–00891).

Clinical Outcomes and Recurrence Rates After Arthroscopic Stabilization Procedures in Young Patients With a Glenoid Bone Erosion: A Comparative Study Between Glenoid Erosion More and Less Than 20

PURPOSE

To evaluate the clinical outcomes and recurrence rates of arthroscopic stabilization procedures in young patients who had recurrent anterior shoulder instability with a glenoid bone erosion more than 20%, and to compare with those in patients with a glenoid bone erosion less than 20%.

METHODS

A total of 161 patients who underwent an arthroscopic stabilization procedure for recurrent anterior shoulder instability with anterior glenoid bone erosions and at least 2 years of follow-up were included. Patients were divided into 2 groups based on the glenoid defect size (group I [32 patients]: erosion >20%, group II [129 patients]: erosion <20%). The clinical outcomes were compared using the American Shoulder Elbow Surgeons (ASES) score, Rowe score, and sports/recreation activity level between the 2 groups. Postoperative complications including instability recurrence were documented.

RESULTS

The mean glenoid defect size was 22.1 ± 2.1% in group I, and 12.2 ± 3.7% in group II. In group I, clinical outcomes were significantly improved after operation (ASES score: 57.9 ± 14.3 at initial, 88.9 ± 6.2 at the last visit, P = .001; Rowe score: 42.1 ± 15.6 at initial, 87.4 ± 7.6 at the last visit, P = .001). These results were inferior to the clinical outcomes of patients in group II (ASES score: 91.5 ± 12.7, P < .001; Rowe score: 89.3 ± 12.4, P = .01). Postoperative recurrences occurred in 5 patients (15.6%) in group I, whereas patients in group II showed 5.4% of recurrence rate (P = .05). Competent recoveries to sports/recreation activity were achieved in 84.4% of patients in group I.

CONCLUSIONS

Arthroscopic stabilization procedures for recurrent anterior shoulder instability in young patients with glenoid bone erosions more than 20% showed satisfactory clinical outcomes and recurrence rate, although these results were inferior to those of patients with glenoid erosions less than 20%. Arthroscopic stabilization procedures can be applied as the primary treatment of recurrent anterior shoulder instability with a large glenoid bone erosion for functional restoration and return to previous sports activity level.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Coracoid graft union: a quantitative assessment by computed tomography in primary and revision Latarjet procedure

BACKGROUND

The goal of the Latarjet procedure is restoration of shoulder stability enabled by accurate graft positioning and union. This study aimed to establish a reproducible method of quantitatively assessing coracoid graft osseous union percentage (OUP) using computed tomography (CT) scans and to determine the effect of other factors on the OUP.

MATERIALS AND METHODS

Postoperative CT scans of 41 consecutive patients treated with the open Latarjet procedure (37% primary, 63% revision) for anterior glenohumeral instability were analyzed for the OUP, position of the graft, and screw type and angle. Two musculoskeletal radiologists independently examined the images 2 times, and intraobserver and interobserver reliability was calculated using intraclass correlation coefficient (ICC).

RESULTS

Mean OUP was 66% (range, 0%-94%) using quantitate methods, with good intraobserver reliability (ICC = 0.795) and interobserver reliability (ICC = 0.797). Nonunion and significant graft resorption was found in 2 patients. No significant difference was found in the mean OUP in the primary (63%) vs. revision Latarjet procedure (67%). Grafts were flush in 39%, medial in 36%, and lateral in 8%. The medial and neutral graft position was associated with slightly higher OUP (72% and 69%) compared with lateral (65%). OUP was higher when the superior screw angle was less than 17° and the inferior screw angle was less than 24°. This difference did not reach statistical significance. Screw type was not associated with significant difference in OUP.

CONCLUSION

Quantitative assessment of osseous union of the graft using a reproducible method that we introduced showed similar OUP in the primary and revision Latarjet procedure.

Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization

BACKGROUND

Recurrent anterior instability following a failed Bankart repair in the shoulder represents a challenging clinical scenario. Few studies have examined the role of arthroscopic revision anterior stabilization as a treatment option in these cases. The purpose of this study was to evaluate the outcomes of arthroscopic revision anterior stabilization for patients with recurrent instability after a failed index procedure.

METHODS

Ninety-two patients underwent arthroscopic revision anterior stabilization after a failed index (open or arthroscopic) stabilization procedure. Sixty-five patients with a minimum of 2 years of follow-up were included in this study. The mean age at the time of revision surgery was 26 years (range, 15 to 57 years). The rate of recurrent instability and risk factors for failure were evaluated; the mean duration of follow-up was 4.7 years (range, 2 to 10.8 years). Glenoid and humeral bone loss were quantitatively assessed using preoperative T1-weighted magnetic resonance arthrograms to determine if the lesions were on-track or off-track.

RESULTS

Twenty-seven (42%) of the patients experienced recurrent instability at a mean of 2.3 years after arthroscopic revision anterior stabilization. On multivariate analysis, the presence of an off-track lesion, an age of <22 years, and ligamentous laxity were independent predictors of recurrence (p = 0.022, 0.028, and 0.031, respectively). Among a cohort with these risk factors excluded, the failure rate was 19%.

CONCLUSIONS

Arthroscopic revision anterior stabilization is associated with a high rate of recurrent instability, and patient selection is of critical importance in order to minimize recurrence.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Learning Curve for the Latarjet Procedure: A Systematic Review

Background

Anterior shoulder instability, including recurrent instability, is a common problem, particularly in young, active patients and contact athletes. The Latarjet procedure is a common procedure to treat recurrent shoulder instability.

Purpose

To identify the reported learning curves associated with the Latarjet procedure and to determine a point on the learning curve after which a surgeon can be considered to have achieved proficiency.

Study Design

Systematic review; Level of evidence, 4.

Methods

Three online databases (Embase, MEDLINE, PubMed) were systematically searched and screened in duplicate by 2 independent reviewers. The search included results from the inception of each database to January 23, 2017. Data regarding study characteristics, patient demographics, learning curve analyses, and complications were collected. Study quality was assessed in duplicate.

Results

Two level 3 studies and 3 level 4 studies of fair methodological quality were included. Overall, 349 patients (350 shoulders) with a mean age of 25.1 years (range, 14-52 years) were included in the final data analysis. Patients were predominantly male (93.7%). After 22 open and 20 to 40 arthroscopic Latarjet procedures, surgeons achieved a level of proficiency as measured by decreased operative time. For open procedures, complication rates and lengths of hospital stay decreased significantly with increased experience (Spearman ρ = -0.3, P = .009 and Spearman ρ = -0.6, P < .0001, respectively).

Conclusion

With experience, surgeons achieved a level of proficiency in performing arthroscopic and open Latarjet procedures, as measured by decreased operative time, length of hospital stay, and complication rate. The most commonly reported difference was operative time, which was significant across all studies. Overall, the Latarjet procedure is a safe procedure with low complication rates, although further research is required to truly characterize this learning curve.

Editorial Commentary: Computed Tomography-based Analysis of the Arthroscopic Latarjet Procedure Suggests Graft Positioning Is More Variable than Expected

The Latarjet operation is one of the most successful techniques for the treatment of recurrent anterior shoulder instability, which has recently been translated into the arthroscopic field. Several studies suggest that its arthroscopic variant is safe and reproducible and report promising short-term and mid-term results. Some authors claim that, in addition to less soft tissue damage, positioning of the coracoid graft is more accurate during arthroscopic control. There is currently no evidence of superiority of the arthroscopic or the open technique. As with the open procedure, the arthroscopic Latarjet operation requires a substantial learning curve; therefore the arthroscopic technique should be reserved for experienced arthroscopists treating a large number of shoulder instabilities.

Modified Latarjet Procedure Without Capsulolabral Repair for Failed Previous Operative Stabilizations

The optimal management of recurrent anterior shoulder instability with significant glenoid bone loss continues to be a challenge. The high recurrence rates seen in arthroscopic Bankart repair in the presence of significant glenoid bone loss have led many surgeons to choose bony reconstructions to manage these injuries. The Latarjet procedure acts through the combination of 3 different mechanisms: the coracoid bone graft restores and extends the glenoid articular arc, the conjoint tendon acts as a dynamic sling on the inferior subscapularis and anteroinferior capsule when the arm is abducted and externally rotated, and the effect of repairing the capsule to the stump of the coracoacromial ligament. However, in patients with multiple recurrences and previous surgeries, the anteroinferior labrum and capsule are often very deficient or practically destroyed. This Technical Note provides a detailed description of the modified Latarjet procedure without capsulolabral repair for patients with failed previous operative stabilizations.

Shoulder Instability: Common Problems and Solutions

Operative treatment of the unstable shoulder historically has a high success rate. However, the complication rate has risen. This article reviews the pearls and pitfalls to attempt to elucidate the etiology for these complications and failures. Preoperative assessment of the unstable shoulder ultimately is critical to avoid complications, including history, physical examination, and key radiographic features. Intraoperative techniques include appropriate soft tissue mobilization, multiple points of fixation, avoidance of hardware-related problems, and appropriate management of the capsule and bone defects. Finally, postoperative rehabilitation is equally important to regain physiologic range of motion in a safe, supervised fashion.

Modified Latarjet Procedure Without Capsulolabral Repair for the Treatment of Failed Previous Operative Stabilizations in Athletes

PURPOSE

To analyze time to return to sport, functional outcomes, and recurrences of the modified Latarjet procedure without capsulolabral repair in athletes with recurrent anterior shoulder instability after a failed previous operative stabilization.

METHODS

We included athletes with recurrent anterior shoulder instability with a previous failed operative stabilization treated with the modified Latarjet procedure without capsulolabral repair with a minimum of 2-year follow-up. Return to sports, range of motion, the Rowe score, a visual analog scale for pain in sport activity, and the Athletic Shoulder Outcome Scoring System were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed with computed tomography.

RESULTS

Between June 2008 and June 2015, 68 athletes were treated with the modified Latarjet procedure without capsulolabral reconstruction for recurrent shoulder instability after a previous failed stabilization surgery. The mean follow-up was 44 months (range, 24-108 months), and the mean age at the time of operation was 26.8 years (range, 17-35 years). All the patients returned to sports, and 95% returned to the same sport they practiced before the surgery, all to the same level. No significant difference in shoulder range of motion was found between preoperative and postoperative results. The Rowe score, visual analog scale, and Athletic Shoulder Outcome Scoring System showed statistical improvement after operation (P < .001). There was no recurrence of shoulder dislocation or subluxation. The bone block healed in 92% of patients. There were 8 complications (12.3%) and 2 reoperations (3%).

CONCLUSIONS

In athletes with previous failed operative stabilization procedures, the modified Latarjet without capsulolabral repair produced excellent functional outcomes with most athletes returning to sport at the same level they had before the surgery without recurrences.

LEVEL OF EVIDENCE

Level IV, therapeutic, case series study.

Treatment of recurrent anterior shoulder instability with the Latarjet or Bristow procedure in older patients

BACKGROUND

The coracoid transfer procedure is commonly and successfully used to treat shoulder instability in young patients. However, there is concern that the outcome of this procedure might be inferior in older patients because of decreased bone graft quality and the potential concomitant presence of irreparable rotator cuff tears (RCTs).

METHODS

All patients older than 40 years treated with a coracoid transfer procedure between 1998 and 2013 because of anterior shoulder instability were included. Surgical indication criteria were anterior glenoid bone defects and/or the presence of an irreparable yet functionally compensated RCT. Of 27 consecutive patients, 25 (93%) were followed up after an average of 9 years (2-15 years) clinically as well as by means of computed tomography scans. Mean age at surgery was 62 years (40-85 years).

RESULTS

Nine patients (36%) were revised during the follow-up period. The average Western Ontario Shoulder Instability Index of the nonrevised patients was 556; Rowe score, 77; American Shoulder and Elbow Surgeons score, 75; Constant score, 65; and subjective shoulder value, 70%. The average preoperative instability arthropathy score of 0.7 increased to 2.0 (P < .001). An irreparable RCT showed no significant effect on the clinical outcome scores or revision rate but was associated with the development of cuff arthropathy (R = 0.89; P = .01). An increased grade of preoperative cuff arthropathy was associated with a higher revision rate (R = 0.55; P = .04).

CONCLUSION

The coracoid transfer procedure represents a joint-preserving treatment option for anterior shoulder instability in older patients with glenoid bone defects or concomitant irreparable yet functionally compensated RCTs. However, bone graft- and hardware-related complications as well as required revision operations are frequent.

Arthroscopically-assisted Latarjet: an easy and reproducible technique for improving the accuracy of graft and screw placement

BACKGROUND

The effectiveness of the Latarjet largely depends on accurate graft placement, as well as on proper position and direction of the screws. We present our technique for an arthroscopically-assisted Latarjet comparing radiological results with the open technique.

METHODS

We retrospectively reviewed the postoperative computed tomography scans of 38 patients who underwent a Latarjet procedure. For 16 patients, the procedure was performed with the open technique and, for 22 patients, it was performed using an arthroscopically-assisted technique. An independent radiologist evaluated graft and hardware position, as well as graft integration or resorption. Postoperative complications were also documented.

RESULTS

The graft was correctly placed in only 18.8% of cases in the open group and 72.7% of cases in the arthroscopically-assisted group. There were no postoperative complications in the arthroscopically-assisted group, whereas one patient had a recurrence and two required hardware removal in the open group.

CONCLUSIONS

The Latarjet procedure is a challenging procedure for which a key point is the correct placement of the coracoid graft onto the glenoid neck and correct position of the screws. The present study substantiates a clear benefit for the use of a guide with an arthroscopically-assisted technique in terms of graft and hardware placement. At short-term follow-up, there appears to be a benefit for graft integration and avoidance of resorption.

Clinical Outcomes Following the Latarjet Procedure in Contact and Collision Athletes

BACKGROUND

Few studies have evaluated the success of the Latarjet procedure for recurrent anterior glenohumeral instability in the contact or collision athlete. The purpose of this study was to evaluate the return-to-sport and functional results of the Latarjet procedure in this select group.

METHODS

One hundred and nine consecutive contact or collision athletes (112 shoulders) treated with an open Latarjet procedure for recurrent anterior glenohumeral instability were retrospectively identified. Seventy-three shoulders in 73 patients (67%) were evaluated at a mean follow-up of 52 months (range, 24 to 120 months). The average age at surgery was 25.8 years (range, 15 to 54 years). The primary outcomes were the scores on the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Surgeons (ASES) questionnaire, a visual analog scale (VAS) for pain, and return to sport. Predictors of return to sport were analyzed.

RESULTS

Six (8%) of the 73 patients experienced ≥1 postoperative dislocations. Ten additional patients (14%) experienced a perception of instability without a dislocation. The median postoperative WOSI and ASES scores were 382 (range, 0 to 2,016) and 93.3 (range, 21.7 to 100), respectively. The median postoperative VAS pain score was 0 (range, 0 to 10). Forty-nine percent (36) of the 73 patients returned to their preoperative sports level, 14% (10) decreased their activity level in the same sport, 12% (9) changed sports, and 25% (18) decreased their level of activity and changed sports or stopped participating in sports altogether. Patients with ≥2 stabilization procedures prior to the Latarjet procedure demonstrated a lower likelihood of returning to their original sport (p = 0.019; relative risk = 2.84; 95% confidence interval = 1.34 to 6.06). The percentage of glenoid bone loss showed no association with the return-to-sport rate (p = 0.507).

CONCLUSIONS

The outcome of the Latarjet procedure in high-risk contact or collision athletes is variable. Patients who have fewer prior stabilization surgical procedures are more likely to successfully return to their original sport.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modified Bristow-Latarjet procedure for treatment of recurrent traumatic anterior glenohumeral dislocation

Objective

Retrospective case–control study of authors experience in the modified Bristow-Latarjet procedure for treatment of recurrent traumatic anterior glenohumeral dislocation with glenoid bone injury.

Methods

Sample with 102 recurrent glenohumeral dislocation cases submitted to modified Bristow-Latarjet procedure. Indications included situations of recurrent traumatic anterior glenohumeral instability with more than two dislocation episodes and with glenoid bone attritional or fragmentary injuries, without possibility of reconstruction. Mean follow-up time was 5.33 ± 2.74 years (minimum 1; range 1–13).

Results

The mean Walch-Duplay Score at the last evaluation was 91.23 ± 11.46 (range 15–100). The functional score of patients with glenoid bone loss greater than 20% did not show a significant difference in comparison with patients with glenoid bone loss lower than 20% (90 vs. 92, respectively). The functional score also did not show a significant difference between sports practice categories and between recreational and competitive practice, being excellent (greater than 90) in every category. There were no dislocation recurrences and the only complications were a case of persistent instability and a screw revision. Mild glenohumeral osteoarthrosis imaging signs were identified in 7.84% of the patients; however, their functional scores were not significantly different in comparison to other patients.

Conclusion

The modified Bristow-Latarjet procedure is a very effective procedure with few complications in the medium-term, showing very satisfactory functional outcomes in the treatment of recurrent traumatic anterior glenohumeral dislocation associated with glenoid bone injury.

Review of Latarjet (1954) on the treatment of recurrent shoulder dislocations

This classic discusses the original publication ‘Treatment of recurrent dislocation of the shoulder’ on the Latarjet procedure. This surgical technique that has become one of the basics in shoulder-stabilising surgery, introduced by Latarjet in 1954 in the journal Lyon Chirurgical. Inspired by publications of colleagues in the field of shoulder surgery, Latarjet introduced a technique that transfers the coracoid process to the anterior glenoid rim in patients with anterior shoulder instability. Although being outrun in popularity by the Bankart repair for several decades, improved knowledge regarding long-term outcomes, surgical techniques and patient characteristics such as bone loss and participation in contact sports has led to renewed interest in the Latarjet procedure. This especially accounts for patients with significant glenohumeral bone loss or patients with a previously failed soft tissue repairs. Whereas the increase in popularity has led to many studies focussing on various aspects, the 15 basics of the initial procedure have virtually remained unchanged.

Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up

PURPOSE

This study investigated the long-term results of arthroscopic Bankart repair in terms of rates and timelines of recurrence of instability, with special interest in young adult patients aged ≤20 years.

METHODS

Between 2000 and 2005, 186 shoulders [182 patients, 50 women, median age 26 (range 15-58) years] were operated on at a university hospital using arthroscopic Bankart repair because of instability after traumatic anteroinferior shoulder dislocation. Medical records were retrospectively reviewed and patients were assessed using postal questionnaires or telephone interview after a minimum of 10 years of follow-up [median 12.2 (range 10-16) years]. The primary outcome measure was recurrence of instability (assessed from 167 shoulders), other outcome measures included Oxford instability score (OIS), subjective shoulder value (SSV), and Western Ontario instability index (WOSI) (assessed from 157 shoulders).

RESULTS

At the end of follow-up, 50/167 shoulders (30%) had recurrence of instability and 30/167 (18%) were subjected to reoperation due to instability symptoms. Twenty-six (52%) failures occurred within ≤2 years, 11 (22%) within 2-5 years, and 13 (26%) >5 years after surgery. Failure rate was 19/35 (54%) for patients aged ≤20 years and 31/132 (24%) for patients aged >20 years; reoperation rates were 11/35 (31%) and 19/132 (14%), respectively. Mean OIS was 20 (SD 9, range 12-50), SSV 83% (SD 21, range 10-100), and WOSI score 80 (SD 22, range 33-100).

CONCLUSIONS

Nearly one-third of patients had recurrence of instability after arthroscopic Bankart repair after a minimum of 10-year follow-up. Patients aged ≤20 years did poorly with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients.

LEVEL OF EVIDENCE

IV.

Conjoined Tendon Transfer for Traumatic Anterior Glenohumeral Instability in Patients With Large Bony Defects and Anterior Capsulolabral Deficiency

PURPOSE

To report outcomes of a conjoined tendon transfer procedure in a small case series of young active patients of various activity levels with recurrent traumatic anterior shoulder instability.

METHODS

A retrospective chart review identified 10 consecutive patients who underwent conjoined tendon transfer (8 open and 2 arthroscopic) for anterior glenohumeral instability from January 2009 through December 2012. The indications were traumatic anterior shoulder instability with 25% or greater anterior glenoid bone loss, engaging Hill-Sachs lesion, or absent anterior-inferior labral tissue with anterior capsular tissue that did not readily hold sutures or a combination of these deficiencies. Patients did not undergo the procedure if they had healthy capsulolabral tissue and small bony defects or if they competed in high-level collision sports or were overhead throwers. The American Shoulder and Elbow Surgeons (ASES) questionnaire and a physical examination were completed preoperatively. Postoperatively, patients answered questions about shoulder stability and completed ASES and Western Ontario Shoulder Index questionnaires. A physical examination was performed postoperatively to assess range of motion.

RESULTS

Of 10 patients, 9 were available for follow-up. The mean age was 33.0 years (range, 18-51 years) at the time of surgery. Eight of nine patients underwent a physical examination at 31.3 ± 10.5 months (range, 24-58 months) postoperatively. There were no revisions or complications except for recurrent instability in 1 patient who underwent the arthroscopic procedure and reported gross deviation from the postoperative protocol. The ASES score improved significantly (62.8 ± 21.2 at baseline vs 89.2 ± 11.5 at final follow-up, P = .01). The postoperative Western Ontario Shoulder Index score was 74.5 ± 19.7. No significant change was found in external rotation in 90° of abduction (80.6° ± 12.9° at baseline vs 88.4° ± 6.1° at final follow-up, P = .11) or in flexion (145.6° ± 14.9° at baseline vs 153.1° ± 16.4° at final follow-up, P = .19). All patients returned to their previous activity level.

CONCLUSIONS

Stability was restored and no significant range-of-motion loss was observed in noncollision athletes who underwent conjoined tendon transfer. Recurrent instability occurred in 1 patient who underwent the arthroscopic procedure. There were no other complications.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Can a Drill Guide Improve the Coracoid Graft Placement During the Latarjet Procedure? A Prospective Comparative Study With the Freehand Technique

Background

One of the factors that can affect the success of the Latarjet procedure is accurate coracoid graft (CG) placement.

Hypothesis

The use of a guide can improve placement of the CG and screw positioning in the sagittal and axial planes as compared with the classic open ("freehand") technique.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 49 patients who underwent a Latarjet procedure for the treatment of recurrent anterior shoulder instability were prospectively included; the procedure was performed with the freehand technique in 22 patients (group 1) and with use of a parallel drill guide during screw placement in 27 patients (group 2). All patients underwent a postoperative computed tomography scan with the same established protocol. The scans were used to evaluate and compare the position of the CG in the sagittal and axial planes, the direction of the screws (α angle), and overall contact of the graft with the anterior surface of the glenoid after the 2 surgical techniques.

Results

The CG was placed >60% below the native glenoid equator in 23 patients (85.2%) in group 2, compared with 14 patients (63.6%) in group 1 (P = .004). In the axial plane, the position of the CG in group 2 patients was more accurate (85.2% and 88.9% flush) at the inferior and middle quartiles of the glenoid surface (P = .012 and .009), respectively. Moreover, with the freehand technique (group 1), the graft was in a more lateral position in the inferior and middle quartiles (P = .012 and .009, respectively). No differences were found between groups 1 and 2 regarding the mean α angle of the superior (9° ± 4.14° vs 11° ± 6.3°, P = .232) and inferior (9.5° ± 6° vs 10° ± 7.5°, P = .629) screws. However, the mean contact angle (angle between the posterior coracoid and the anterior glenoid surface) with the freehand technique (3.8° ± 6.8°) was better than that of the guide (8.55° ± 8°) (P = .05).

Conclusion

Compared with the classic freehand operative technique, the parallel drill guide can ensure more accurate placement of the CG in the axial and sagittal planes, although with inferior bone contact.

Evaluation and Management of Failed Shoulder Instability Surgery

BACKGROUND

Failed shoulder instability surgery is mostly considered to be the recurrence of shoulder dislocation but subluxation, painful or non-reliable shoulder are also reasons for patient dissatisfaction and should be considered in the notion.

METHODS

The authors performed a revision of the literature and online contents on evaluation and management of failed shoulder instability surgery.

RESULTS

When we look at the reasons for failure of shoulder instability surgery we point the finger at poor patient selection, technical error and an additional traumatic event. More than 80% of surgical failures, for shoulder instability, are associated with bone loss. Quantification of glenoid bone loss and investigation of an engaging Hill-Sachs lesion are determining facts. Adequate imaging studies are determinant to assess labrum and capsular lesions and to rule out associated pathology as rotator cuff tears. CT-scan is the method of choice to diagnose and quantify bone loss. Arthroscopic soft tissue procedures are indicated in patients with minimal bone loss and no contact sports. Open soft tissue procedures should be performed in patients with small bone defects, with hiperlaxity and practicing contact sports. Soft tissue techniques, as postero-inferior capsular plication and remplissage, may be used in patients with less than 25% of glenoid bone loss and Hill-Sachs lesions. Bone block procedures should be used for glenoid larger bone defects in the presence of an engaging Hill-Sachs lesion or in the presence of poor soft tissue quality. A tricortical iliac crest graft may be used as a primary procedure or as a salvage procedure after failure of a Bristow or a Latarjet procedure. Less frequently, the surgeon has to address the Hill-Sachs lesion. When a 30% loss of humeral head circumference is present a filling graft should be used.

CONCLUSION

Reasons for failure are multifactorial. In order to address this entity, surgeons must correctly identify the causes and tailor the right solution.

Arthroscopic Revision Surgery for Failure of Open Latarjet Technique

PURPOSE

To evaluate the efficacy in treating pain, limited range of motion, and continued instability of the Latarjet open technique via the use of arthroscopy.

METHODS

A retrospective review of patients who underwent arthroscopic capsule plication after failure of an open Latarjet technique was performed. Revision surgery was indicated in cases of recurrent instability and associated pain. Only patients with a glenoid defect <25% were considered. The Constant and Rowe scores were administered, whereas pain was assessed with a visual analog scale before the reoperation and at 24 months after operation. Radiographs, computed tomography, and CT arthrography scans were performed.

RESULTS

Twelve patients met the inclusion criteria. All patients had capsular distension and consequently were subjected to a capsuloplasty. Shoulder function, stability, and pain had all improved significantly at 24 months after arthroscopic revision (P < .0001). In particular, the Constant score increased from 44.9 (standard deviation [SD] 7.10) to 89.3 (SD 12.6) points, the Rowe score improved from 49.5 (SD 10.1) to 80.9 (SD 10.9), whereas the visual analog scale pain score decreased from 6.75 (SD 1.17) to 1.38 (SD 1.06).

CONCLUSIONS

Primary open Latarjet with a glenoid bone defect <25% that failed due to capsular redundancy is amenable to successful treatment with arthroscopic capsuloplasty.

CLINICAL RELEVANCE

Arthroscopic approaches can offer a good solution for treating previously failed open Latarjet procedures.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Long Term Outcomes of Arthroscopic Shoulder Instability Surgery

BACKGROUND

Anterior shoulder instability has been successfully managed arthroscopically over the past two decades with refined "anatomic" reconstruction procedures involving the use of anchors for the repositioning and re-tensioning of the antero-inferior capsuloligamentous complex, in an effort to recreate its "bumper effect".

METHODS

Research and online content related to arthroscopic treatment of shoulder instability was reviewed and their results compared.

RESULTS

The short- and mid-term results of this technique have been very satisfactory. The greatest number of recent reports suggests that long-term results (>5 years follow-up) remain rather satisfactory, especially in the absence of significant glenoid bone loss (>20-25%). In these studies recurrent instability, in the form of either dislocation or subluxation, ranges from 5.1 to over 20%, clinical scores, more than 5 years after the index procedure, remain good or excellent in >80% of patient population as do patient satisfaction and return to previous level of activities. As regards arthroscopic non-anatomic bony procedures (Latarjet or Bristow procedures) performed in revision cases or in the presence of >20-25% bone loss of the anteroinferior aspect of the glenoid, recent reports suggest that their long-term results are very satisfactory both in terms of re-dislocation rates and patient satisfaction.

CONCLUSION

It appears that even "lege artis" performance of arthroscopic reconstruction decelerates but does not obliterate the degenerative procedure of dislocation arthropathy. The presence and grade of arthritic changes correlate with the number of dislocations sustained prior to the arthroscopic intervention, the number of anchors used and the age at initial dislocation and surgery. However, the clinical significance of radiologically evident dislocation arthropathy is debatable.

Immediate and early complications of the open Latarjet procedure: a retrospective review of a large consecutive case series

BACKGROUND

Immediate and early postoperative complications of the Latarjet procedure are not well documented in the literature. The purpose of this study was to report the procedure-related complications of our large consecutive case series of 3 surgeons at a single high-volume center.

METHODS

We conducted a retrospective chart review of 416 Latarjet procedures performed on 400 patients (16 patients had bilateral procedures) who underwent surgery by the 3 senior authors from October 2002 to July 2015. Immediate and early complications included hardware problems, infection, and neurologic injury. In addition, the patient's age and history of prior instability surgery were noted and evaluated as risk factors for complication.

RESULTS

The overall complication rate was 5.0% (21 complications in 19 procedures). Thirteen neurologic injuries (3.1%) occurred to the axillary (7), musculocutaneous (4), and suprascapular (2) nerves, including 2 patients with multiple nerves affected. All but 2 patients had complete resolution of symptoms at time of last follow-up. Six infections (1.4%) developed, including 3 superficial infections treated with oral antibiotics and 3 deep infections requiring irrigation and débridement with intravenous antibiotics. Two early hardware-related complications (0.05%) were also noted. Increased age was associated with a higher complication rate. History of prior surgery was not associated with increased complications in our series.

CONCLUSIONS

This study highlights the procedural complications of the Latarjet procedure. Neurologic injury was the most common complication in our series, with complete or near-complete recovery in 11 of 13 patients.

Long-Term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure

BACKGROUND

Various operative techniques are used for treating recurrent anterior shoulder instability, and good mid-term results have been reported. The purpose of this study was to compare shoulder stability after treatment with the 2 commonly performed procedures, the arthroscopic Bankart soft-tissue repair and the open coracoid transfer according to Latarjet.

METHODS

A comparative, retrospective case-cohort analysis of 360 patients (364 shoulders) who had primary repair for recurrent anterior shoulder instability between 1998 and 2007 was performed. The minimum duration of follow-up was 6 years. Reoperations, overt recurrent instability (defined as recurrent dislocation or subluxation), apprehension, the subjective shoulder value (SSV), sports participation, and overall satisfaction were recorded.

RESULTS

An open Latarjet procedure was performed in 93 shoulders, and an arthroscopic Bankart repair was done in 271 shoulders. Instability or apprehension persisted or recurred after 11% (10) of the 93 Latarjet procedures and after 41.7% (113) of the 271 arthroscopic Bankart procedures. Overt instability recurred after 3% of the Latarjet procedures and after 28.4% (77) of the Bankart procedures. In the Latarjet group, 3.2% of the patients were not satisfied with their result compared with 13.2% in the Bankart group (p = 0.007). Kaplan-Meier analysis of survivorship, with apprehension (p < 0.001), redislocation (p = 0.01), and operative revision (p < 0.001) as the end points, documented the substantial superiority of the Latarjet procedure and the decreasing effectiveness of the arthroscopic Bankart repair over time. Twenty percent of the first recurrences after arthroscopic Bankart occurred no earlier than 91 months postoperatively, as opposed to the rare recurrences after osseous reconstruction, which occurred in the early postoperative period, with only rare late failures.

CONCLUSIONS

In this retrospective cohort study, the arthroscopic Bankart procedure was inferior to the open Latarjet procedure for repair of recurrent anterior shoulder dislocation. The difference between the 2 procedures with respect to the quality of outcomes significantly increased with follow-up time.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of an engaging Hill-Sachs lesion: arthroscopic remplissage with Bankart repair versus Latarjet procedure

PURPOSE

This study compared the clinical outcomes of arthroscopic remplissage with Bankart repair and Latarjet operation in patients with a large engaging Hill-Sachs lesion.

METHODS

Thirty-seven shoulders subjected to arthroscopic remplissage with a Bankart repair (group A) and 35 shoulders subjected to a Latarjet operation (group B), for a large engaging Hill-Sachs lesion without significant glenoid bone loss, were retrospectively evaluated. Each group was followed up for a mean more than 2-year period.

RESULTS

At the last follow-up, postoperative pain, shoulder mobility, muscle strength, Rowe score, and UCLA score revealed no significant difference between the two groups. The postoperative mean deficit in external rotation at the side (ERs) was 8° ± 23° in group A (P = 0.044). In group B, the mean deficits in ERs, external rotation at 90° of abduction, and internal rotation to the posterior were 10° ± 20°, 7° ± 16°, and 1.9° ± 4°, respectively (P = 0.004, 0.022, and 0.009, respectively). The recurrence rate was 5.4 % (two shoulders) in group A and 5.7 % (two shoulders) in group B (n.s.). The overall complication rate was significantly higher in group B (14.3 %) than in group A (0 %) (P = 0.017).

CONCLUSIONS

For recurrent anterior shoulder instability with a large engaging Hill-Sachs lesion, both arthroscopic remplissage with Bankart repair and the Latarjet procedure were safe and reliable techniques with a low recurrence rate. However, the Latarjet group had a significantly higher postoperative complication rate than the remplissage group.

LEVEL OF EVIDENCE

Case-control study, Level III.

Coracoid bone block fixation with cortical buttons: An alternative to screw fixation?

BACKGROUND

The purpose of this study was to evaluate suture button fixation in a bone block (Bristow and Latarjet) procedure. We hypothesize that (1) cortical button fixation will allow predictable and reproducible bone union and (2) minimize the complications reported with screw fixation.

MATERIALS AND METHODS

Seventy patients (mean age, 27 years) underwent an arthroscopic bone block procedure with a guided surgical approach and suture button fixation for recurrent anterior shoulder instability. There were two groups of patients: 35 Bristow procedures (group A) and 35 Latarjet procedures (group B). Bone graft union and positioning accuracy were assessed by postoperative computed tomography imaging at 2 weeks and 6 months, respectively.

RESULTS

The coracoid graft was positioned below the equator in 93% and strictly tangential to the glenoid surface in 94% of the cases. Bone healing was observed in 83% of the cases (58/70) with 74% bone union in group A and 91% in group B. Neurologic and hardware complications, classically reported with screw fixation, were not observed with this novel fixation method.

CONCLUSIONS

(1) Suture button fixation can be an alternative to screw fixation, obtaining bone block union, (2) in the lying position (Latarjet) bone healing was better than in the standing position (Bristow), and (3) complications classically reported with screw fixation were not observed.

LEVEL OF EVIDENCE

Level IV.

Anterior shoulder instability with engaging Hill-Sachs defects: a comparison of arthroscopic Bankart repair with and without posterior capsulodesis

PURPOSE

The purpose of this study was to compare the clinical results of isolated arthroscopic Bankart repair and those of arthroscopic Bankart repair with posterior capsulodesis for anterior shoulder instability with engaging Hill-Sachs lesions.

METHODS

Thirty-five shoulders that underwent isolated arthroscopic Bankart repair (Bankart group) and 37 shoulders that underwent arthroscopic Bankart repair with posterior capsulodesis (remplissage group) for anterior shoulder instability with engaging Hill-Sachs lesions were evaluated retrospectively. The mean age at the time of the surgery was 26.1 ± 7.0 years in the Bankart group and 24.8 ± 9.0 years in the remplissage group.

RESULTS

At the final follow-up, the Rowe and UCLA scores significantly improved in both the Bankart and remplissage groups (P < 0.001, in both groups). The post-operative mean deficit in external rotation at the side was 3° ± 10° in the Bankart group and 8° ± 23° in the remplissage group (P = n.s. and P = 0.044, respectively). There was no decrease in muscle strength in either group. The recurrence rate was 25.7 % in the Bankart group and 5.4 % in the remplissage group (P = 0.022).

CONCLUSIONS

Arthroscopic Bankart repair with posterior capsulodesis demonstrated good clinical outcomes with a low recurrence rate in the treatment for anterior shoulder instability with an engaging Hill-Sachs lesion. Although a limitation in external rotation was observed, there was no significant limitation of any other motion and no decrease in muscle strength after the remplissage procedure. Posterior capsulodesis alone for remplissage should be considered as a surgical technique that can replace the conventional method.

LEVEL OF EVIDENCE

Case-control study, Level III.

Accuracy of Latarjet graft and screw position after using novel drill guide

PURPOSE

For the success of Latarjet procedure a correct graft positioning is mandatory. Furthermore, the correct screw placement is important to avoid cartilage damage and soft tissue irritation. Due to a cadaveric experimental study, the accuracy of graft and screw positioning utilizing a novel drill guide for a minimal-invasive Latarjet procedure was analyzed.

METHODS

Five human fresh-frozen shoulder specimens have been treated in accordance with the Congruent-Arc Latarjet technique using the glenoid bone loss set (Arthrex, Naples, FL, USA) with 3.75 mm cannulated screws throughout a 5 cm skin incision without detachment of the scapularis tendon. All procedures were performed by one single, experienced shoulder surgeon. The accuracy of graft and screw positioning was assessed due to a CT scan.

RESULTS

A noticeable learning curve was noted during the study period as the first surgery took 45 min and the last 33 min. All grafts were correctly positioned with regard to the articular line of the glenoid surface. Impingement with the maximum head circumference was not encountered. The screw positions did not affect the suprascapular nerve. A damage of the graft was not noticed.

CONCLUSIONS

The authors can recommend the usage of the new drill guide tested in this study. It seems to be beneficial in the Latarjet procedure and may ease correct graft positioning and prevent screw misplacement. Compared to fully arthroscopically performed Latarjet procedures it provides much steeper learning curve and seems technically easier and quicker to handle.

Current concepts in the management of recurrent anterior gleno-humeral joint instability with bone loss

The management of recurrent anterior gleno-humeral joint instability is challenging in the presence of bone loss. It is often seen in young athletic patients and dislocations related to epileptic seizures and may involve glenoid bone deficiency, humeral bone deficiency or combined bipolar lesions. It is critical to accurately identify and assess the amount and position of bone loss in order to select the most appropriate treatment and reduce the risk of recurrent instability after surgery. The current literature suggests that coracoid and iliac crest bone block transfers are reliable for treating glenoid defects. The treatment of humeral defects is more controversial, however, although good early results have been reported after arthroscopic Remplissage for small defects. Larger humeral defects may require complex reconstruction or partial resurfacing. There is currently very limited evidence to support treatment strategies when dealing with bipolar lesions. The aim of this review is to summarise the current evidence regarding the best imaging modalities and treatment strategies in managing this complex problem relating particularly to contact athletes and dislocations related to epileptic seizures.