Bristow-Latarjet procedure with specific instrumentation: study of 34 cases

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person-years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill-Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

Decreased motion with normal strength after Latarjet procedure has minimal impact on return to activity

PURPOSE

The Latarjet procedure can affect the range of motion (ROM) and strength of the shoulder, which determine the time to return to the preinjury level of activity. This study prospectively assessed whether the Latarjet procedure leads to a decrease in range of motion and muscle strength, affecting the time to return to the previous level of activity.

METHODS

Fifty-one consecutive patients who underwent the Latarjet procedure for recurrent dislocation of the shoulder were included prospectively. The ROM, strength, Walch-Duplay score, and Rowe score were measured every 3 months for 1 year and then every 6 months for 2 years. Radiological assessments were performed to confirm the graft location, union, and the humeral head position in abduction and external rotation (ER).

RESULTS

Out of 51 patients, 49 completed all follow-ups. The median age was 27 years (17-45 years), and the dominant side was involved in 36 patients. The median number of dislocations was 11 (5-50). Twelve patients were sleep dislocators. There was a significant loss (p < 0.0001) of abduction, forward flexion (FF), ER, and internal rotation (IR) in the affected shoulder compared to the contralateral shoulder. Recovery plateaued at 12 months. There was near complete recovery of muscle strength after the Latarjet procedure, and the difference between the affected and contralateral shoulders was not significant (n.s.). The modified Rowe score was excellent in 44 (90%) patients, and the Walch-Duplay score was excellent in 43 patients (88%) at 24 months. Suboptimal results were associated with non-compliance with rehabilitation in two (4%) patients and neglected unreduced dislocation in one (2%) patient. The coracoid graft position was below the equator in 44 patients (90%). Forty-six patients (94%) could return to the previous level of activity.

CONCLUSION

The Latarjet procedure results in a restricted ROM of the shoulder, but there is no loss of muscle strength.

LEVEL OF EVIDENCE

III.

[The Latarjet procedure in patients with anterior shoulder instability, with outcome depending on coracoid abutment location on radiography]

Anterior shoulder instability following traumatic dislocation in young adults is a common complication. The Latarjet procedure is the most widely used technique for treating this instability. It is based on coracoid abutment repair of the anterior edge of the glenoid. However, joint exposure during this surgical technique is often limited and makes it difficult to position the abutment. The purpose of this study was to evaluate the result of coracoid abutment procedure on functional outcome in the short and medium term. We assessed the positioning of the coracoid abutment on standard postoperative X-rays and the functional outcome according to Duplay score as well as the satisfaction rate in 70 patients. The average age of patients was 25 and a half years, the sex-ratio was nine, and the mean follow-up period was 6.5 years. Radiological examination showed that coracoid abutment was in subequatorial or non-flush position with respect to the anterior glenoid rim (too internal or protruding in intra-articular position) in 20% of cases. This group showed a drop in mean stability score by 7.68 points, in pain by 10.04 points and in Duplay's overall score by 13.3 points as well as a significant increase in the level of glenohumeral arthrosis. This study highlights that coracoid abutment in subequatorial or non-flush position has deleterious effect on the functional outcome of the Latarjet procedure.

11% complications rate after Latarjet procedure at up to 14 years follow-up

PURPOSE

Evaluate complications in correlation with radiological findings after an open Latarjet procedure performed on 140 shoulders with recurrent anterior instability with follow-up from 8 to 174 months.

METHODS

Retrospectively, 140 shoulders, diagnosed with recurrent anterior glenohumeral instability, which were surgically treated with the open Latarjet procedure in our hospital, between January 2004 and November 2017, had been analysed. Mean age of operated patients was 29.5 years. One hundred and twenty-three patients were male (88.5%) and 16 were female (11.5%). Average length of follow-up was 110 months. Radiographs and CT scans of 16 patients with complications had been evaluated and correlations between radiological findings and observed complications had been analysed.

RESULTS

Complications occurred in 16 shoulders (11%). Rates of individual complications were: 1. persistent pain (9%), 2. limited ROM (7%), 3. recurrent instability (6%), 4. neurologic injury (2%), 5. persistent apprehension (2%), 6. reduced strength (2%), 7. hematoma (1%) and 8. intraoperative coracoid graft fracture (0.8%). Mean postoperative ASES score and ROWE score were statistically significantly lower in the group with complications, compared to the group without complications. Good or excellent results were reported by 87.9% patients.

CONCLUSION

Open Latarjet procedure is an effective and safe method for the treatment of recurrent shoulder instability, resulting in good to excellent outcomes in 87.9% of our cases. However, it is related to a higher postoperative complication rate compared to some other treatment options. Overall, very good results with high level of patient satisfaction have been demonstrated.

Return to Sport After Coracoid Bone Block Transfer for Shoulder Instability: A Systematic Review

BACKGROUND

Shoulder dislocations can be devastating for an athlete. Coracoid bone block transfer is often used for the treatment of recurrent shoulder instability.

QUESTIONS/PURPOSES

The primary purpose of this study was to determine the rate and mean time of return to sport in athletes after a coracoid bone block transfer at the pre-operative level of competition, a lower level, or a different level. We also sought to determine how return to sport rates after a coracoid bone block procedure compared with rates after several comparator interventions. Finally, we looked to determine the post-operative clinical outcomes and complications reported after a coracoid bone block procedure.

METHODS

We systematically searched three databases (PubMed, Embase, and MEDLINE) for studies reporting return to sport after a coracoid bone block procedure.

RESULTS

A total of 52 studies (with levels of evidence ranging from II to IV) evaluating 2953 shoulders in 2888 patients were included in this systematic review. The mean rate of return to sport at any level was 88.4% (2291 of 2592 patients). However, the rate of return to the pre-operative level was 70.3% (1387 of 1974 patients). The mean time to return to sport was 5.38 months (range 21 days to 36 months). The rate of return to sport was higher after the Latarjet procedure, as compared with Bankart repair (87.0% and 75.8%, respectively). All studies showed improvements in clinical outcome measures after coracoid bone block intervention. The cumulative complication rate was found to be 6.46% (158 of 2446 patients).

CONCLUSION

Coracoid bone block transfer allows for a high rate of return to sport, although the rate of return to sport at athletes' pre-operative level is lower. The rate of return to sport after Latarjet procedure is higher in comparison with Bankart repair. Additionally, coracoid bone block transfer is associated with improvements in a number of clinical outcome measures. Common post-operative complications include non-union between bone block and glenoid, hematoma, and infection.

Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review

BACKGROUND

Traumatic anterior shoulder instability is a common clinical problem among athletic populations. The Latarjet procedure is a widely used treatment option to address shoulder instability in high-demand athletes at high risk of recurrence. However, rates and timing of full return to sports have not been systematically analyzed.

PURPOSE

To systematically review the evidence in the literature to ascertain the rate and timing of return to play and the availability of specific criteria for safe return to play after the Latarjet procedure.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature search was conducted based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using the EMBASE, MEDLINE, and Cochrane Library databases. Eligible for inclusion were clinical studies reporting on return to play after the Latarjet procedure. Statistical analysis was performed by use of SPSS.

RESULTS

Our review found 36 studies including 2134 cases meeting our inclusion criteria. The majority of patients were male (86.9%), with a mean age of 25.4 years (range, 15-59 years) and a mean follow-up of 83.5 months. The overall rate of return to play was 88.8%, with 72.6% returning to the same level of play. Among collision athletes, the overall rate of return to play was 88.2%, with 69.5% returning to the same level of play. In overhead athletes, the overall rate of return to play was 90.3%, with 80.6% returning to the same level of play. The mean time to return to play was 5.8 months (range, 3.2-8 months). Specific return to play criteria were reported in the majority of the studies (69.4%); time to return to sport was the most commonly reported item (66.7%).

CONCLUSION

The overall rate of return to play was reportedly high after the Latarjet procedure. However, almost a fifth of athletes returning to sports were not able to return at the same level. Further development of validated criteria for safe return to sports could potentially improve clinical outcomes and reduce recurrence rates.

Analysis of failures after the Bristow-Latarjet procedure for recurrent shoulder instability

PURPOSE

Despite good clinical results and low recurrence rates, post-operative complications of coracoid process transfer procedures are not well understood. This study aims to evaluate the underlying failure mechanism in cases requiring major open revision surgery after prior Bristow or Latarjet stabilization.

METHODS

Between January 2006 and January 2017, 26 patients underwent major open revision after primary Bristow or Latarjet procedure. Clinical notes and radiographic images were retrospectively reviewed for all cases to determine underlying pathology. Choice of treatment and clinical and radiographic outcome were similarly reported for all cases.

RESULTS

The underlying failure mechanism was associated with non-union in 42.3%, resorption in 23.1%, graft malpositioning in 15.4%, and trauma or graft fracture in 19.2% of cases. Although none of the patients reported any dislocations, mean subjective shoulder score was 60.2% and WOSI scores averaged 709.3 points at final follow-up. Radiographic signs of deteriorating degenerative arthritis were seen in 34.6%.

CONCLUSION

Graft non-union resulting in recurrent instability was the main indication for open revision surgery after Bristow or Latarjet procedure, followed by resorption, malpositioning, and graft fracture in this retrospective case series. Revision surgery consisted of a structural iliac crest bone graft in the majority of cases. Clinical and radiographic outcomes are predictably variable in this population of multioperated patients.

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.

Are collision athletes at a higher risk of re-dislocation after an open Bristow-Latarjet procedure? A systematic review and meta-analysis

BACKGROUND

The primary aim of the present study was to review, summarize and compare the redislocation risk for collision athletes and noncollision athletes after an open Bristow-Latarjet procedure. Our secondary aim was to summarize return to sport, satisfaction, pain and complications.

METHODS

We conducted a systematic review in PubMed and EMBASE of articles until 1 July 2016. We included all studies describing Bristow-Latarjet like procedures as a result of glenohumeral instability, mentioning redislocation rates in collision athletes with >2 years of follow-up. We pooled the data using random-effects meta-analysis for redislocation risk-differences (RD) between collision and noncollision athletes, and assessed heterogeneity with I² and Tau² tests.

RESULTS

From 475 titles and abstracts, 11 studies were included and eight studies were meta-analyzed. The pooled RD to develop a postoperative redislocation between collision athletes and noncollision athletes was -0.00 (95% confidence interval: -0.03 to 0.03, p = 0.370). Return to sports rates were high (67-100%), and patients reported high satisfaction scores (93-100% satisfied) and low pain scores (mean visual analogue scale score of 1.6); however, postoperative complication rates varied from 0.8% to 19.2%.

CONCLUSIONS

Collision athletes are not more at risk for redislocation rates after an open Bristow-Latarjet procedure compared to noncollision athletes. Overall postoperative outcomes were good, although numerous complications occurred.

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.

Coracoid bone block transfer procedure: Correlation between subscapularis volume below the bone graft and shoulder stability

INTRODUCTION

Coracoid bone graft transfer has become the gold standard in patients with recurrent anterior shoulder instability associated with bony defect. Several studies have shown that the main stabilizing component of this procedure is the sling effect by the conjoint tendon and the lower portion of subscapularis (SS). The purpose of this study was to determine whether a larger SS volume below the bone block was correlated to greater postoperative shoulder stability.

MATERIALS AND METHODS

This prospective study included a cohort of patients who underwent open coracoid bone graft transfer for post-traumatic recurrent anterior shoulder instability. Forty patients were reviewed at 2 years with a clinical and CT scan evaluation. A correlation analysis assessed the relation between the SS volume index (ratio of SS volume below the bone block to volume over the bone block) and Rowe and Walch-Duplay instability scores.

RESULTS

There exists a positive and significant correlation between SS volume index and postoperative Rowe score, r=0.37 (P=0.03). The same trend was observed for Walch-Duplay score without statistical significance. A larger inferior SS volume did not result in a limitation of external rotation, greater fatty infiltration, or malposition of the coracoid graft.

CONCLUSION

A larger SS volume below the bone block is related to greater postoperative shoulder stability. We recommend performing the split in the middle of the SS or higher instead of the junction of the superior two-thirds and inferior one-third as usually reported.

LEVEL OF EVIDENCE

III, prospective study.

What is a Bristow-Latarjet procedure? A review of the described operative techniques and outcomes

OBJECTIVES

A variety of operative techniques have been described as under the term 'Bristow-Latarjet' procedure. This review aims to define the original procedure, and compare the variation in techniques described in the literature, assessing any effect on clinical outcomes.

MATERIALS AND METHODS

A systematic review of 24 studies was performed to compare specific steps of the technique (coracoid osteotomy site, subscapularis approach, orientation and position of coracoid graft fixation and fixation method, additional labral and capsular repair) and detect any effect this variability had on outcomes.

RESULTS

Overall recurrence rate was 5.36% (2.94% to 43%). Half of the studies performed the procedure for recurrent shoulder instability, with only five studies documenting glenoid bone loss as an indication: 12 studies used the procedure as the primary surgical intervention for recurrent instability. No change in outcome was noted when examining variation in the coracoid osteotomy site, the fixation site on the scapular neck, the fixation method or whether a capsular repair was also performed. Performing a horizontal split in subscapularis may preserve external rotation compared with performing a tenotomy.

CONCLUSIONS

This is the first review to examine various operative techniques of the Bristow-Latarjet procedure, and their effect on outcome. We found that other than the approach through subscapularis, outcome was independent of the surgical technique, and depended more on patient selection. We would commend future publications on this procedure to provide a detailed description of the surgical technique, and as a minimum present rates of recurrence as an outcome measure. Cite this article: Bone Joint J 2016;98-B:1208-14.

Coracoid graft positioning in the Latarjet procedure

PURPOSE

The success of shoulder stabilization with the Latarjet procedure depends on the correct positioning of the coracoid graft at the glenoid. The aim of this study was to assess intra-observer reproducibility and inter-observer reproducibility of a new standardized CT scan analysis for coracoid graft positioning in the axial plane after the Latarjet procedure and to assess the positioning in the study group.

METHODS

A consecutive series of 27 patients (22 men, 5 woman, 26.1 ± 6.4 years-13 right, 14 left shoulders) were followed up with CT scans between 2010 and 2012. The analysis of the CT scans (2.4 ± 0.7 months postoperatively) was performed with Osirix™ software. The assessment included two criteria in the axial plane: relation of the graft to the articular surface of the glenoid and impingement of the graft with the maximal humeral head circumference. Grafts were judged to be lateral, congruent, flush or medial. The strength of intra-observer agreement and inter-observer agreement was measured by the Kappa coefficient.

RESULTS

The Kappa coefficient for intra-observer agreement was "substantial" (K = 0.64 ± 0.14, z = 4.6) to "almost perfect" (K = 0.81 ± 0.14, z = 5.7). The Kappa coefficient for inter-observer variability was "substantial" (K = 0.59 ± 0.14, z = 4.3) to "almost perfect" (K = 0.89 ± 0.14, z = 6.0). In our study, in the axial plane, 3 (11 %) transplants were lateral; 6 (22 %) transplants were congruent; 16 (60 %) flush and 2 (7 %) medial.

CONCLUSION

This standardized CT scan analysis after Latarjet procedure has shown to accurately describe graft positioning in the axial plane with both good intra-observer reproducibility and inter-observer reproducibility.

LEVEL OF EVIDENCE

Case series, treatment study, Level IV.

Minimally invasive modified latarjet procedure in patients with traumatic anterior shoulder instability

Background:

Despite recent advances in arthroscopic soft tissue repair and reconstruction for shoulder instability, Latarjet procedure is continuously a method of choice for many cases of unstable shoulders.

Objectives:

To evaluate the clinical results of minimally invasive modified Latarjet technique in recurrent, traumatic anterior shoulder instability associated with obvious Hill-Sachs and Bankart lesions.

Patients and Methods:

Between 2007 and 2013, 36 consequent patients with traumatic anterior shoulder instability who underwent modified Latarjet operation were enrolled in this prospective study. The MRI studies revealed labrum detachment and Hill-Sachs lesion in all shoulders. For all patients, demographic and injury data were obtained and Constant Shoulder score, Rowe score, and UCLA scores were completed by related surgeon. Stability of the shoulder was assessed with the Jobe’s relocation test preoperatively. The patients were followed up at two weeks, one month, three months, and six months from the date of the surgery and evaluated for probable complications. Above mentioned assessments were completed again at the time of the final follow-up.

Results:

The average age of the enrolled patients was 24.6 (ranging from 18 to 33 years) and 35 patients out of the total of 36 patients were males. Motor-vehicle accidents were the major cause of the injuries (52%) with the average interval between the injury and operation of 3.1 ± 1.2 years (Ranging from 1 to 5 years). The average number of incidents of dislocations between the injury date and the surgery was 7.2 ± 2.1 (Ranging from 4 to 20). The average follow-up period was 37 months (Ranging from 12 to 65 months). All patients had Jobe’s relocation test (Apprehension sign) pre-operatively and negative Jobe’s relocation test post-operation. Significant improvements in functional scores were demonstrated postoperatively compared to preoperational assessment in all cases. Final follow up radiographs showed union of all the grafts and patients reported no incidents of re-dislocation during the follow-up period. One incidence of a superficial infection 2 weeks post operation was the only complication in this study. The infection was resolved with antibiotic treatment.

Conclusions:

The Latarjet procedure demonstrated good or excellent short-term outcomes in management of patients with traumatic, recurrent anterior shoulder dislocation with a low level of post-operative complication risks.

Optimization of bone-block positioning in the Bristow-Latarjet procedure: a biomechanical study

BACKGROUND

In the Bristow-Latarjet procedure, optimal positioning of the coracoid bone-block on the anterior aspect of the glenoid (standing or lying on the glenoid rim) remains debated. A biomechanical study assessed the effect of the position of the bone-block with its attached conjoint tendon on anterior and inferior stabilization of the humeral head.

MATERIALS AND METHODS

The Bristow-Latarjet procedure was performed on 8 fresh cadaveric shoulders. The bone-block size was systematically at 2.5×1×1 cm. Anterior translation of the humeral head was stress induced under 30-N traction, in maximum external rotation at 0° and at 90° abduction: respectively, adduction and external rotation (ADER), and abduction and external rotation (ABER). Under radiological control, displacement of the center of the humeral head was compared with the glenoid surface at the 3, 4 and 5 o'clock (medial, antero-inferior and inferior) positions for the 2 bone-block positionings.

RESULTS

The lying position at 4 o'clock substantially decreased anterior and inferior displacement of the humeral head respectively in ADER and ABER; and in ABER it also tended to decrease anterior translation, but not significantly. The standing bone-block position did not affect translation.

CONCLUSIONS

Positioning the bone-block so that it lies on the anterior aspect of the glenoid in the middle of the antero-inferior quarter of the rim at 4 o'clock can decrease anterior displacement of the humeral head and inferior glenohumeral translation, especially in ADER for anterior displacement and in ABER for inferior displacement.

STUDY DESIGN

Laboratory study.

Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature

PURPOSE

The aim of this study was to evaluate clinical outcome, rate of recurrence, complications, and rate of postoperative osteoarthritis in patients with anterior shoulder instability managed with Latarjet, Bristow, or Eden-Hybinette procedures.

METHODS

A systematic review of the literature on management of anterior dislocation of the shoulder with glenoid bony procedures was performed. A comprehensive search of PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "dislocation," "treatment," "Latarjet," "Bristow," "bone loss," "Eden-Hybinette," "iliac," "bone," "block," "clinical," "outcome," and "Bankart." The following data were extracted: demographics, bone defects and other lesions, type of surgery, outcome measurement, range of motion (ROM), recurrence of instability, complications, and osteoarthritis. A quantitative synthesis of all comparative studies was performed to compare bone block procedures and Bankart repair in terms of postoperative recurrence of instability and osteoarthritis.

RESULTS

Forty-six studies were included and 3,211 shoulders were evaluated. The mean value of the Coleman Methodology Score (CMS) was 65 points. Preoperatively, the injuries detected most were glenoid bone loss and Bankart lesions. The Eden-Hybinette procedure had the highest rate of postoperative osteoarthritis and recurrence. Pooled results from comparative studies showed that the bone block procedures were associated with a lower rate of recurrence when compared with Bankart repair (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.28 to 0.74; P = .002), whereas there was no significant difference between the 2 groups in terms of postoperative osteoarthritis (P = .79).

CONCLUSIONS

The open Bristow-Latarjet procedure continues to be a valid surgical option to treat patients with anterior shoulder instability. Bone block procedures were associated with a lower rate of recurrence when compared with the Bankart repair. The Eden-Hybinette procedure has clinical outcomes very similar to the Bristow-Latarjet technique but has a higher rate of postoperative osteoarthritis and recurrence. An arthroscopic Bristow-Latarjet procedure seems to be better in terms of prevention of recurrence and rehabilitation, but randomized studies are needed to reach definitive conclusions.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss

BACKGROUND

Coracoid bone graft osteolysis and fibrous union are the principal causes of failure in patients treated with the Latarjet procedure. This study aims to investigate the hypothesis that coracoid bone graft osteolysis is more pronounced in cases without glenoid bone loss, which may be due to a diminished mechanotransduction effect at the bone healing site.

METHODS

We prospectively followed up 34 patients, treated with a mini-plate Latarjet procedure, divided into 2 groups (group A patients had glenoid bone loss >15% and group B patients had no glenoid bone loss). A computed tomography scan evaluation with 3-dimensional reconstruction was then performed on all patients to evaluate coracoid bone graft osteolysis according to our coracoid bone graft osteolysis classification.

RESULTS

The computed tomography scan analysis showed a different distribution of osteolysis between group A and group B. The statistical analysis showed a significant difference (P < .01, Bonferroni test) between groups A and B for the following sections: proximal/lateral/superficial, proximal/medial/deep, distal/lateral/superficial, and distal/lateral/deep. On average, the coracoid grafts in group A patients showed less osteolysis than the coracoid grafts in group B patients (39.6% vs 65.1%).

DISCUSSION

The coracoid bone graft underwent much less osteolysis in patients with significant glenoid bone loss (>15%) than in those without it. Because factors of blood supply, compression, and surgical technique were the same for both groups, we believe that the mechanotransduction effect from the humeral head on the graft influences its remodeling.

CONCLUSION

The results of this study suggest that the bone graft part of the Latarjet procedure plays a role in patients with significant coracoid bone loss but much less so when there is no bone loss.

Coracoid bone graft osteolysis after Latarjet procedure: A comparison study between two screws standard technique vs mini-plate fixation

AIMS

One of the reason for Latarjet procedure failure may be coracoid graft osteolysis. In this study, we aimed to understand if a better compression between the coracoid process and the glenoid, using a mini-plate fixation during the Latarjet procedure, could reduce the amount of coracoid graft osteolysis.

MATERIALS AND METHODS

A computed tomography scan analysis of 26 prospectively followed-up patients was conducted after modified Latarjet procedure using mini-plate fixation technique to determine both the location and the amount of coracoid graft osteolysis in them. We then compared our current results with results from that of our previous study without using mini-plate fixation to determine if there is any statistical significant difference in terms of corcacoid bone graft osteolysis between the two surgical techniques.

RESULTS

The most relevant osteolysis was represented by the superficial part of the proximal coracoid, whereas the deep part of the proximal coracoid graft is least involved in osteolysis and has best bone healing. The current study showed a significant difference only for the deep part of the distal coracoid with our previous study (P < 0.01).

DISCUSSION

To our knowledge, there are no studies in literature that show the causes of coracoid bone graft osteolysis after Latarjet procedure.

CONCLUSION

Our study suggests that there is a significant difference only for the deep part of the distal coracoid in terms of osteolysis. At clinical examination, this difference did not correspond with any clinical findings.

LEVEL OF EVIDENCE

Level 4.

CLINICAL RELEVANCE

Prospective case series, Treatment study.

Risk factors for dislocation arthropathy after Latarjet procedure: a long-term study

PURPOSE

The purpose of this study was to analyse the long-term incidence of dislocation arthropathy after a modified Latarjet procedure for glenohumeral instability.

METHODS

Long-term follow-up information was obtained from a consecutive series of patients who had undergone a modified Latarjet procedure by one surgeon between 1986 and 1999. Multivariable regression analysis was performed to examine the relation between the development of a dislocation arthropathy and patients and surgery-related factors.

RESULTS

There were 117 patients (117 shoulders) for evaluation, (35 women and 82 men) with a mean age 28.4 ± 8.5 (range, 16-55). The mean follow-up was 16.2 years (range, ten to 22.2 years). Signs of dislocation arthropathy were found in 36 % of patients, graded as Samilson 1 in 30 %, Samilson 2 in 3 %, and 3 % Samilson 3 in 3 % of patients. Risk factors for dislocation arthropathy included surgery in patients older than 40 years of age (64.3 vs. 34.4 %; adjusted RR 2.2, 95 % CI 1.7-2.9) and lateral positioning of the transferred coracoid process in relation to the glenoid rim (82.4 vs. 30.4 %; adjusted RR 2.3, 95 % CI 1.7-3.2). Patients with hyperlaxity developed less dislocation arthropathy (15 vs. 42.5 %; adjusted RR 0.4, 95 % CI 0.1-0.95).

CONCLUSION

The development of dislocation arthropathy after the Latarjet procedure remains a source of concern in the long term. It correlates with surgery after the age of 40 and lateral coracoid transfer in relation to the glenoid rim. On the other hand, hyperlaxity seems to have a protective effect on the development of dislocation arthropathy.

Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review

BACKGROUND

Various methods of bony stabilization, including modifications of Bristow and Latarjet procedures, are considered gold-standard treatment for recurrent anterior shoulder instability but are associated with unique complications and risk of reoperation. The purpose of this study was to identify the prevalence of these complications. We hypothesized that the Bristow-Latarjet procedure would be a successful technique for treatment of shoulder instability but associated with a risk of recurrent postoperative instability, reoperation, and other complications.

METHODS

A systematic review of multiple medical databases included studies reporting outcomes with complication and reoperation rates following original or modified versions of the Bristow or Latarjet shoulder stabilization surgeries.

RESULTS

Forty-five studies were analyzed (1,904 shoulders) (all Level IV evidence). Most subjects were male (82%). The dominant shoulder was the operative shoulder in 64% of cases. Mean subject age was 25.8 years. Mean clinical follow-up was 6.8 years. Ninety percent of surgeries were done open; 9.3% were all-arthroscopic. Total complication rate was 30%. Recurrent anterior dislocation and subluxation rates were 2.9% and 5.8%, respectively. When reported, most dislocations occurred within the first year postoperatively (73%). Nearly 7% of patients required an unplanned reoperation following surgery.

CONCLUSION

Osseous stabilization shoulder surgery using original or modified Bristow and Latarjet procedures has a 30% complication rate. Rates of recurrent dislocation and reoperation were 2.9% and 7%, respectively. Mild loss of external rotation is common. Reoperation rates were lower following all-arthroscopic techniques. There was a greater loss of postoperative external rotation with all-arthroscopic surgery.

Chronic anterior glenohumeral instability in soccer players: results for a series of 28 shoulders treated with the Latarjet procedure

BACKGROUND

Glenohumeral instability is a common problem in young and active patients. Both open and arthroscopic procedures have proven to be effective options. In cases with large bone defects on the glenoid side or on the humeral head or in contact sports, arthroscopy leads to a high risk of recurrence. We report the results of the modified Latarjet procedure in a population of 26 soccer players affected by chronic anterior instability. To our knowledge there are no previous reports on the results of this procedure when used in a homogeneous group of sportsmen.

MATERIALS AND METHODS

Twenty-six patients (28 shoulders) were retrospectively reviewed. We analyzed the roles of the players, the levels at which they played, and the average amount of hours that they trained before their injury and after surgery. Moreover, the type of bone loss detected on a preoperative imaging study and its relevance to the patient's sporting comeback was recorded.

RESULTS

Eight-five months after surgery the mean Duplay score was 89.3; most of the players came back to the play at the same sporting level. Ninety-three percent of the patients were happy or very happy with their functional results. One patient underwent a redislocation.

CONCLUSIONS

Our series is the first in the literature to refer to a homogeneous group of soccer players. According to our results, and other series, the Latarjet procedure seems to be the gold standard in the treatment of chronic anterior instability in patients with large bone defects and in sportsmen playing contact sports.

Complications associated with open coracoid transfer procedures for shoulder instability

BACKGROUND

Interest has been maintained in the use of coracoid transfer procedures for recurrent shoulder instability despite the significant potential for serious complications. A comprehensive systematic review of the literature was performed to quantify and characterize the complication rate associated with these procedures to better inform practicing surgeons and their patients.

MATERIALS AND METHODS

Medline, Excerpta Medica Database (EMBASE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for therapeutic studies published between 1985 and 2011. Data regarding complications was extracted from selected articles in a standardized manner. Complication rates were determined and expressed as percentages with 95% confidence intervals.

RESULTS

Included were 30 studies describing the results of 1658 coracoid transfer procedures. Repeat surgery was documented in 4.9% ± 1.0% of cases. Recurrent instability occurred in 6.0% ± 1.2%. Hardware complications occurred in 6.5% ± 1.3%. Collectively, the rate of graft nonunion, fibrous union, or postoperative graft migration was 10.1% ± 1.6%; graft osteolysis occurred in 1.6% ± 0.7%. There was a 1.2% ± 0.8% rate of nerve palsy. Surgical site infection occurred in 1.5% ± 0.7%. Intraoperative fractures occurred in 1.1 ± 0.6%.

CONCLUSION

Coracoid transfers for shoulder instability can improve shoulder stability with acceptable recurrence rates. They are challenging procedures associated with a broad range and significant incidence of complications. A detailed appreciation of anatomy and meticulous attention to technical detail, particularly graft placement, is key to reducing complications. These procedures may be best indicated in the setting of glenoid or humeral bony deficiency, although efficacy over open capsular procedures remains equivocal.

A prospective, comparative, radiological, and clinical study of the influence of the "remplissage" procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair

BACKGROUND

Certain failures of arthroscopic Bankart repairs seem to be related to the presence of a Hill-Sachs defect. It has been suggested that Hill-Sachs lesions can be treated by "remplissage" (filling in) of the defect. The effect of this procedure on the mobility of the shoulder is not known.

PURPOSE

To determine if filling in the Hill-Sachs defect with rotator cuff tendon would modify the range of motion of the operated shoulder.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective study of 2 patient populations (arthroscopic Bankart repair alone vs Bankart and remplissage) was undertaken after selecting patients using the Instability Severity Index Score (ISIS). Patients with a Hill-Sachs lesion seen on anteroposterior radiographs had a remplissage procedure if this procedure allowed them to obtain an ISIS lower than 4. The main clinical outcome was the range of motion (external rotation at the side [ER1], external rotation in abduction [ER2], internal rotation [IR], and forward elevation), assessed by the difference between each shoulder at 1 and 2 years' follow-up. Complications, recurrence, and the Walch-Duplay scores were noted at the same time. Minimum follow-up was 2 years.

RESULTS

No significant statistical difference was noted in the range of motion between each group: ER1, difference of 4° (P = .22); ER2, difference of 3° (P = .49); anterior elevation, difference of 5° (P = .35); and internal rotation, 2 vertebrae (P = .22). The rate of recurrence was identical in both groups (6.25%). For patients without redislocation, the Walch-Duplay score was excellent (14/17) or good (3/17) in the first group and excellent (12/15) or good (3/15) in the second group. Posterosuperior pain during forceful movements or when tired was noted in one third of patients having undergone remplissage.

CONCLUSION

The remplissage technique did not alter the range of motion of the shoulder compared with Bankart procedure alone; however, one third of patients did experience posterosuperior pain.

Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients

BACKGROUND

The Latarjet procedure has been advocated as an option for the treatment of anteroinferior shoulder instability in certain patients. However, progression of the transferred coracoid bone graft to osteolysis has been reported in the literature. We propose that the coracoid bone graft osteolysis could be one of the causes of failure of the Latarjet procedure.

MATERIALS AND METHODS

A computed tomography scan analysis was done of 26 patients prospectively followed-up after the Latarjet procedure to determine the location and the amount of the coracoid graft osteolysis.

RESULTS

The most relevant osteolysis was represented by the superficial part of the proximal coracoid, whereas the distal region of the coracoid bone graft, especially in the deep portion, was the least involved in osteolysis and had the best bone healing.

DISCUSSION

To our knowledge, this is the first study to quantify and localize coracoid osteolysis after Latarjet procedure for anteroinferior shoulder instability using CT scan analysis.

CONCLUSION

Our study suggests that the bone-block effect from the Latarjet procedure may not be the principal effect in its treatment of anteroinferior shoulder instability in patients without significant bony defects.