Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members

Reliability in 2-Dimensional On-track/Off-track Measurements: Analysis of Key Values for Glenohumeral Bone Loss

Background

The relationship between glenoid bone loss and Hill-Sachs lesions (HSLs), which is known as the glenoid track, has been well described in the literature. Off-track lesions have been found to be associated with recurrent shoulder instability.

Purpose

To assess the intraobserver and interobserver reliability in glenoid track measurement using 2-dimensional (2D) computed tomography (CT).

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Electronic medical records between 2009 and 2019 were reviewed for patients with known shoulder instability and bone loss. Using 2D CT, fellowship-trained orthopaedic surgeons and orthopaedic residents measured glenoid loss and humeral head bone loss to calculate the glenoid track and to assess for on-track and off-track lesions.

Results

A total of 38 patients met the inclusion criteria. For fellowship-trained surgeons, there was moderate intraobserver reliability when assessing the glenoid diameter (intraclass correlation coefficient [ICC], 0.704) and HSI (ICC, 0.720). There was good reliability when evaluating glenoid defects (ICC, 0.761) and glenoid track (ICC, 0.825). Intraobserver assessment of on-track and off-track lesions according to kappa criteria was moderate (κ = 0.531; P < .001). The interobserver reliability among fellowship-trained surgeons for the glenoid track was good (ICC, 0.762); the reliability measurement for the glenoid defect (ICC, 0.672), glenoid diameter (ICC, 0.627), and HSI (ICC, 0.520) were moderate; and the on-track and off-track assessments were moderate (κ = 0.405; P < .001). For the residents, there was moderate intraobserver reliability when assessing the glenoid diameter (ICC, 0.633), glenoid defect (ICC, 0.709), HSI (ICC, 0.536), and glenoid track (ICC, 0.708). Interobserver reliability within the residents was moderate for the glenoid diameter (ICC, 0.542), glenoid defect (ICC, 0.574), and glenoid track (ICC, 0.629) and poor for the HSI (ICC, 0.292). Determination of on- and off-track lesions among residents was fair (κ = 0.234; P < .001).

Conclusion

Among fellowship-trained surgeons, both the interobserver and intraobserver reliability of measuring the glenoid track on 2D CT were good; however, agreement on whether lesions were on-track or off-track was only moderate. The reliability among residents was moderate; however, their agreement on whether lesions were on-track or off-track was poor.

Blind-Tie Remplissage: Technique and Sequence

Patients with recurrent anterior shoulder instability and an associated Hill-Sachs lesion are commonly encountered by orthopaedic surgeons. Effective management of the Hill-Sachs lesion can be performed using an arthroscopic remplissage technique to fill the bony defect with the infraspinatus and posterior capsule. Various surgical techniques, anchor configurations, and tying mechanisms can be used to accomplish the remplissage procedure. The goal of this Technical Note is to describe our technique and sequence for accomplishing an arthroscopic "blind-tie" remplissage procedure. In this remplissage technique, the suture anchor sutures placed into the Hill-Sachs defect are tied in a blind fashion over the infraspinatus fascia without direct visualization from within the subacromial space.

Editorial Commentary: Patients Reliably Return to Work After Shoulder Latarjet Procedure

When we need a bone block, a well-performed open or arthroscopic Latarjet procedure is a powerful tool. The Latarjet remains the current gold standard for surgical treatment of large anterior glenoid defects, and it is projected that performance of Latarjet will continue to increase in the United States while Bankart repair declines. What patients want to know is, "When can I expect to return to work or sport after Latarjet?" Return to work is dictated by occupation. Recent research shows that time to return to work can range from 2 to 8 months, and 89% to 100% of patients eventually return to work after Latarjet. Return to sport is influenced by the sport and position played.

Most Athletes Who Fail to Return to Sport After Latarjet Procedure Cite Psychological Factors: A Systematic Review

PURPOSE

To identify the return-to-sport (RTS) rate in athletes undergoing a Latarjet procedure while outlining the specific reasons for failure to RTS.

METHODS

An electronic literature search was conducted (PubMed/MEDLINE, Scopus, Web of Science). Studies in peer-reviewed journals with Latarjet procedures performed on athletes that reported rates and reasons for failure to RTS were included. Excluded studies were those that reported solely on nonathletes, non-Latarjet surgery, and missing rates of and reasons for failure to RTS. Study heterogeneity was assessed using the I2 statistic, and quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria.

RESULTS

After review of 3,617 articles, a total of 18 studies with 1,066 patients met the inclusion criteria. The level of evidence for included studies ranged from II to IV. Rates of not returning to sports (NRTS) ranged from 3.4% to 35.3%. More studies cited shoulder-unrelated reasons than shoulder-related reasons for why athletes failed to RTS. Ten (55.5%) studies, making up 656 (61.5%) patients, reported that shoulder-unrelated reasons were accountable for more than 50% of NRTS. Only 3 (16.7%) studies reported 100% NRTS because of shoulder-related reasons, which include fear of reinjury and psychological factors. Study heterogeneity was found to be moderate (I2 = 73.4%; 95% confidence interval 57.5-83.3; P < .001) and study quality was found to be satisfactory (mean Methodological Index for Non-Randomized Studies score 12.1 for noncomparative and 20.5 for comparative studies).

CONCLUSIONS

According to this systematic review, the rate of NRTS after Latarjet ranged from 3.4% to 35.3% across 18 studies, with the majority of studies citing nonshoulder-related reasons such as fear or reinjury or psychological factors as the major deterrent for returning to sports.

LEVEL OF EVIDENCE

Level IV, systematic review of case series.

Over 89% of Patients Return to Work After Undergoing Arthroscopic or Open Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review

PURPOSE

To better define the rate of return to work in patients undergoing Latarjet surgery for anterior shoulder instability.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane Center Register of Controlled Trials, and Scopus were queried in October 2023 with the following keywords: ((latarjet) OR (anterior shoulder instability)) AND ((work) or (compensation)). Articles were included if they reported return to work in patients (including military members) undergoing Latarjet surgery for traumatic anterior shoulder instability with bone loss and were written in English. This study was registered in Prospero (ID blinded).

RESULTS

Six studies reporting on 419 shoulders were included in the review. Five studies reported on patients in the general population, and 1 reported on military members. Mean age ± standard deviation of patients ranged from 23.1 ± 5.8 to 32.0 ± 12.3 years. Moreover, there were 286 primary Latarjet procedures, 131 revision Latarjet procedures, and 2 unspecified as primary or revision surgery. Mean glenoid bone loss ranged from 14.5% to 22.9%. Return-to-work rates ranged from 89.1% to 100%, with 2 studies reporting all patients were able to return to work. Among military members, 89.1% were able to return to duty. Mean time to return to work ranged from 8.69 to 34.8 weeks after surgery. Four studies also reported return to sport, which ranged from 60.9% to 100%. Mean time for returning to sport varied between 10.0 and 35.2 weeks after the Latarjet procedure.

CONCLUSIONS

Patients with anterior shoulder instability who undergo an arthroscopic or open Latarjet procedure can expect high rates of return to work and sport. All studies reported return-to-work rates over 89%, with 89.1% of military members able to return to duty.

LEVEL OF EVIDENCE

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

The Perfect Circle Technique Shows Poor Inter-rater Reliability in Measuring Anterior Glenoid Bone Loss on Magnetic Resonance Imaging

Purpose

To evaluate the reliability of the perfect circle methodology for measurement of glenoid bone loss in patients with anterior glenohumeral instability.

Methods

We performed a chart review of retrospectively collected patients who underwent isolated arthroscopic anterior labral repair between January 1 and June 30, 2021, using our institution's electronic medical records. The inclusion criteria included isolated anterior shoulder instability with anterior labral repair and corroborated tears on magnetic resonance imaging. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder magnetic resonance imaging scans twice, with a minimum of 2 weeks between measurements. Measurements followed the "perfect circle" technique and included projected anterior-to-posterior glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Intrarater reliability and inter-rater reliability were then determined by calculating intraclass correlation coefficients (ICCs).

Results

Ten consecutive patients meeting the selection criteria were chosen for inclusion in this analysis. Average estimated bone loss for the cohort was 2.45 mm, and the mean estimated glenoid diameter of the involved shoulder was 28.82 mm. The average percentage of bone loss measured 8.54%. The ICC for interobserver reliability was 0.55 for the perfect circle diameter and 0.17 for the anterior bone loss measurement (poorly to moderately reliable). The ICC for intraobserver reliability was 0.69 for the perfect circle diameter and 0.71 for anterior bone loss (moderately reliable).

Conclusions

The perfect circle technique for estimating anterior glenoid bone loss on magnetic resonance imaging was found to have moderate intrarater reliability; however, reliability between observers was found to be moderate to poor.

Level of Evidence

Level IV, diagnostic case series.

Return to military duty following anterior cruciate ligament reconstruction is associated with preoperative Body Mass Index and postoperative physiotherapy

PURPOSE

To determine the rate and time of return to duty following anterior cruciate ligament reconstruction (ACLR) in military members, and to determine whether their outcomes are influenced by patient characteristics or surgical parameters.

METHODS

We prospectively assessed 280 military members that underwent ACLR. 27 were excluded due to multi-ligamentous injuries or revision surgery, two did not provide informed consent and 62 were lost to follow-up. Patient demographics, pre-injury physical workload, complications and whether/when patients resumed duty and sports were noted, as well as clinical outcomes at a minimum follow-up of one year, including Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), Lysholm, and Tegner scale.

RESULTS

The final cohort of 189 military members (82% men) had mean age of 25.5 ± 3.4 (range,19-38) at ACLR. At 3.3 ± 1.6 years (range, 1.0-6.3), the Tegner score was 6.1 ± 2.0, Lysholm was 87.0 ± 13.7, IKDC was 80.1 ± 15.7, and KOOS was 81.1 ± 14.8. Only 144 patients (76%) resumed duty, at 9.5 ± 5.3 months (range,1-28), and 141 patients (75%) resumed sport, at 10.2 ± 6.2 months (range,1-35). Multivariable analysis revealed that return to duty was less likely in patients with higher BMI (OR,0.89;p = 0.025), but more likely in patients that followed military physiotherapy (OR,2.76;p = 0.017) and with higher pre-injury physical workload (OR,3.93;p = 0.010).

CONCLUSION

At a follow-up of 3.3 ± 1.6 years, 76% returned to duty at 9.5 ± 5.3 months, and 75% returned to their main sport at 10.2 ± 6.2 months. Patients with higher BMI are significantly less likely to resume military duty and sports; those that followed military physiotherapy were most likely to resume duty, while those that had greater pre-injury physical workload were more likely to both resume duty and sport.

A High Rate of Return to Running Is Seen After Both Arthroscopic and Open Shoulder Surgery

PURPOSE

To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery.

METHODS

We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively.

RESULTS

A total of 126 patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively (P = .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability.

CONCLUSIONS

Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Screw-Related Complications May Occur at a Greater Rate After Arthroscopic Versus Open Latarjet Procedure: A Systematic Review

Purpose

To determine the rate of complications attributable to the use of screw fixation during the Latarjet procedure and to delineate screw-related complications for open and arthroscopic Latarjet surgery.

Methods

A systematic review of the literature was performed by querying MEDLINE and EMBASE computerized databases for relevant articles that reported clinical outcomes associated with the Latarjet procedure. Clinical studies of open and/or arthroscopic Latarjet surgery that employed screw fixation of the coracoid were included in our analysis.

Results

From 692 articles identified initially, 32 studies met eligibility criteria. The study cohort comprised 2,758 shoulders, with a mean age of patients ranged from 17 to 62 years, and the mean duration of follow-up ranged from 0.3 to 25.6 years. Twenty-two studies reported outcomes of an open Latarjet technique whereas 10 studies reported on an arthroscopic Latarjet technique. Across all studies, the overall complication rate ranged from 1.4% to 36%. The rate of screw-related complications ranged from 0% to16%, and the rate of screw removal ranged from 0% to 18%. Among the subset of studies that reported specific indications for screw removal, the most common indications were pain and screw loosening. Reported rates of screw-removal among arthroscopic Latarjet procedures range from 0% to 18% and among open procedures range from 0% to 7.3%.

Conclusions

(1) Up to one-third of the overall surgical complications associated with the Latarjet procedure may be related to the use of screw fixation, (2) arthroscopic Latarjet procedure did not decrease the rate of screw related complications. The reported rate of screw-removal may be higher after the arthroscopic Latarjet procedures (up to 18%) than after open procedures (up to 7,3%), and is mainly indicated for persistent shoulder pain and/or screw loosening.

Level of Evidence

Level IV, systematic review of Level III-IV studies.

Simultaneous Arthroscopic Glenohumeral Stabilization and Glenoid Microfracture in Young, Active-Duty Military Patients: Outcomes at 5-Year Follow-up

Background

Glenohumeral instability represents a common cause of shoulder pain and disability among active-duty members of the military and is associated with the development of glenoid osteochondral defects.

Purpose

To report clinical outcomes and survivorship after combined microfracture of isolated chondral lesions of the glenoid and labral repair among young, active-duty military patients and to compare outcomes with those of patients who underwent isolated shoulder stabilization.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 31 active-duty military patients aged <40 years who underwent simultaneous microfracture of chondral lesions of the glenoid and labral repair for shoulder instability between January 2011 and January 2017 (microfracture group) and 209 patients without chondral defects who underwent shoulder stabilization during the same time period (instability group). Preoperative and 5-year postoperative outcomes (range of motion [ROM], visual analog scale [VAS] for pain, Single Assessment Numeric Evaluation [SANE] score, American Shoulder and Elbow Surgeons [ASES] shoulder score, and Rowe instability score) were compared within and between groups, and separate subgroup analyses were performed to determine whether variant of instability and dominant-shoulder involvement were associated with worse outcomes.

Results

The mean follow-up was significantly longer for the microfracture group versus the instability group (95.58 ± 23.12 vs 83.38 ± 25.93 months; P = .014). Age and sex distributions were similar between groups. In both groups, there was significant pre- to postoperative improvement on all outcomes scores (P = .0001 for all). When compared with the instability cohort, microfracture patients had significantly worse postoperative VAS pain (2.65 ± 1.78 vs 1.55 ± 1.92; P = .003), SANE (79.13 ± 14.43 vs 91.23 ± 13.20; P < .0001), and ASES (79.90 ± 13.87 vs 89.03 ± 14.28; P = .001) scores, as well as decreased ROM in forward flexion (151.29° ± 11.76° vs 155.48° ± 10.3°; P = .039) and external rotation (63.65° ± 8.34° vs 65.17° ± 0.64°; P = .010). At latest follow-up, 58% of microfracture patients had returned to active-duty military service compared with 93.78% of isolated instability patients (P < .0001).

Conclusion

Combined microfracture and arthroscopic labral repair produced modest, albeit statistically significant, improvements in patient-reported outcome measures and may be a reasonable treatment option for patients with chondral lesions who are not candidates for arthroplasty. However, microfracture patients had significantly worse outcomes than patients who underwent stabilization without concomitant chondral defects.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.