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

Efficacy and safety of the Latarjet procedure for the treatment of athletes with glenoid bone defects ≥ 20%: a single-arm meta-analysis

BACKGROUND

The shoulder joint is the most commonly dislocated joint in the human body, and the recurrence rate exceeds 50% after nonsurgical treatment. Although surgical treatment reduces the recurrence rate, there is controversy regarding the optimal surgical approach. Previous studies suggest that the Latarjet procedure yields favourable outcomes for specific populations at risk of recurrence, such as competitive athletes with significant glenoid defects. However, most of the existing related research consists of nonrandomized controlled trials with small sample sizes, and there is a lack of strong evidence regarding the efficacy and safety of the Latarjet procedure.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were systematically searched. Athletes with ≥ 20% glenoid defects were selected for inclusion. The following data were extracted: general patient information, instability rates, return to sports (RTS) rates, imaging features (graft positioning rate and graft healing rate), functional assessments [Rowe score, Athletic Shoulder Outcome Scoring System(ASOSS), visual analogue scale (VAS), forward flexion function, and external rotation function], and complications.

RESULTS

After excluding suspected duplicate cases, a total of 5 studies were included in this meta-analysis. The studies involved a total of 255 patients, including 237 males (93%) and 18 females (7%). The average age at the time of surgery was 25.4 ± 8.5 years. All the studies had a minimum follow-up period of 2 years, with an average follow-up time of 48.7 ± 18.9 months. The pooled rate of return to sport (RTS) was 94.3% (95% CI: 87.3%, 98.8%), and 86.1% (95% CI: 78.2%, 92.5%) of patients returned to their preoperative level of activity. The pooled redislocation rate was 1.1% (95% CI: 0%, 3.8%). Regarding the imaging results, the combined graft retention rate was 92.1% (95% CI: 88.1%, 95.5%), and the graft healing rate was 92.1% (95% CI: 88%, 95.4%). Postoperative functional evaluation revealed that the combined Rowe score, ASOSS score, and VAS score were 93.7 ± 6.5 points, 88.5 ± 4.4 points, and 1.1 ± 10 points, respectively. The forward flexion and external rotation angles were 170.9 ± 6.9 degrees and 65.6 ± 4.5 degrees, respectively. After excluding one study with unclear complications, the combined complication rate was 9.4% (95% CI: 1.0%, 23.6%).

CONCLUSION

For athletes with shoulder instability and a total of ≥ 20% glenoid bone defects, the Latarjet procedure can achieve excellent functional outcomes, with the majority of patients returning to preoperative levels of sports activity. This procedure also leads to a low recurrence rate. Therefore, the Latarjet procedure has been proven to be a safe and effective treatment.

Suspensory fixation for bone transfer procedures in shoulder instability is superior to screws in an angled construct: a biomechanical analysis

Background

The Latarjet procedure is a common bony augmentation procedure for anterior shoulder instability. Historically, screw fixation is used to secure the coracoid graft to the anterior glenoid surface; however, malpositioning of the graft leads to oblique screw insertion that contributes to complications. Suture buttons (SBs) are a more recent fixation technique that have not been studied alongside standard screw fixation in the context of biomechanical models of angulated fixation. This study aims to compare the biomechanical strength of single and double, screw and SB fixation at various levels of angulation.

Methods

Testing was performed using polyurethane models from Sawbones. The graft piece was secured with screw fixation (Arthrex, Naples, FL, USA) or suspensory button (ABS Tightrope, Arthrex, Naples, FL, USA). Single or double constructs of screws and SBs were affixed at 0°, 15°, and 30° angles to the face of the glenoid component. An aluminum testing jig held the samples securely while a materials testing system applied loads. Five constructs were used for each condition and assessed load to failure testing.

Results

For single fixation constructs, suspensory buttons were 60% stronger than screws at 0° (P < .001), and 52% stronger at 15° (P = .004); however, at 30°, both were comparable (P = .180). Interestingly, single suspensory button at 15° was equivalent to a single screw at 0° (P = .310). For double fixation, suspensory buttons (DT) were 32% stronger than screws at 0° (P < .001) and 35% stronger than screws at 15° (P < .001). Both double fixation methods were comparable at 30° (P = .061). Suspensory buttons at 15° and 30° were equivalent to double screws at 0 (P = .280) and 15° (P = .772), respectively.

Conclusion

These measurements indicate that the suspensory button has a significantly higher load to failure capacity over the screw fixation technique, perpendicularly and with up to 15° of angulation. These analyses also indicate that the suspensory button fixation offers superior strength even when positioned more obliquely than the screw fixation. Therefore, suspensory button fixation may confer more strength while offering greater margin for error when positioning the graft.

All Arthroscopic Salvage Technique for Intraoperative Vertical Split Coracoid Graft Fracture in Latarjet Procedure-Technical Note

Intraoperative vertical coracoid graft fractures during the Latarjet procedure are well-described complications, which typically have a poor prognosis or may necessitate further iliac crest bone grafting for stabilization. The vertical split coracoid fractures are reasoned to be caused by excessive tightening of the screws, poor bone quality, especially in females and the smaller dimension of the coracoid graft. In this technical note, we propose an arthroscopic salvage technique for salvaging the fractured coracoid graft and to avoid the need for additional bone graft, thereby reducing morbidity to the patient. We use two double-loaded, all-suture anchors (Stryker, India) on either side of the split coracoid graft, and double-pulley configuration of suture tightening is done, providing compression and stability to the fractured graft.

SLAP lesion type IX: case series and a review of literature

PURPOSE

A type IX SLAP (superior labrum anterior to posterior) lesion involves 360° of the glenohumeral labrum. Only rare reports have been published analyzing the risk factors of this lesion and the success of its arthroscopic management. The aim of our study is to evaluate predisposing factors that lead to SLAP IX and to assess the clinical outcome after arthroscopic treatment. Our treatment algorithm is also presented.

METHODS

We report on a series of six patients treated in our institution between January 2014 and January 2019 who underwent shoulder arthroscopy and were intraoperatively found to have a SLAP lesion type IX. Arthroscopic labral repair and biceps tenodesis were indicated in all patients. American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Rowe Score and Constant Murley Shoulder Score (CS) were used for clinical evaluation. Patients were evaluated preoperatively and at 12 weeks, 1 year and 2 years postoperatively.

RESULTS

We analyzed six patients of which 83% were males (5/6 patients). The average age at the time of surgery was 37.16 (range 30-42 years). The dominant arm was affected in 50% of patients (3/6 patients). A significant postoperative improvement was seen in all six patients. 83% (5/6) of patients returned to their pre-injury activity level. Average values of all three measured scores show a significant increase comparing preoperative to postoperative period (P-value < 0.05). All patients were able to return to work.

CONCLUSIONS

The final diagnosis was established intraoperatively as 83% (5/6) of radiology reports differed from subsequent arthroscopic findings. The mechanism of injury in all our cases was high energy trauma with traction, arm in abduction or anteflexion. We observed great success with arthroscopic treatment as high percentage of our patients returned back to work and sports.

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.

Short-term Complications of Open Latarjet Procedure for Recurrent Anterior Shoulder Dislocation

Background

Anterior dislocation is the most common type of shoulder dislocation, and even after appropriate treatment, recurrence after a primary traumatic anterior dislocation is highly frequent. Surgical options for treating recurrent anterior dislocations mainly include Bankart arthroscopic and Latarjet open surgery. We aimed to evaluate the outcomes and complication rates of the open Latarjet procedure in a series of patients with recurrent anterior shoulder dislocation.

Methods

A total of 55 patients with recurrent anterior shoulder dislocation who underwent an open Latarjet procedure were included in this retrospective cohort study. Shoulder range of motion and postoperative complications, including neurapraxia, re-dislocation, hematoma, infection, dehiscence, implant failure, and pain, were evaluated.

Results

The mean age of the patients was 27.7 ± 6.5 years . The mean time interval after the first dislocation was 3.4 ± 2.7 years . The mean preoperative and postoperative forward flexion (P = 0.200), abduction (P = 0.200), external rotation (P = 0.066), and internal rotation (P = 0.310) were not significantly different. Postoperative complications included 1 case of postoperative musculocutaneous nerve neurapraxia, 1 case of re- dislocation, 1 case of wound dehiscence, and 2 cases of screw breakage. Postoperative pain was also recorded in 11 (20%) patients that were either in the form of occasional night pain (n = 6) or activity-dependent pain (n = 5).

Conclusion

Open Latarjet procedure is an efficient procedure for the treatment of recurrent anterior shoulder dislocation. However, its rate of complications remains relatively high, and surgeons must consider this drawback in their decision-making and address patients' expectations.

Latarjet procedure for failed Bankart repair provides better stability and return to sports, but worse postoperative pain and external rotation limitations with more complications, compared to revision Bankart repair: a systematic review and meta-analysis

PURPOSE

This study aimed to compare the clinical results of revision Bankart repair versus the Latarjet procedure for failed Bankart repair.

METHODS

A literature search was performed in databases, such as Pubmed, Embase, and Scopus Library. The studies were appraised using the Methodological Index for Non-randomized Studies tool. Studies for failed Bankart repair with revision Bankart repair or Latarjet procedure were included. The pain VAS, ROWE score, rate of return to sports and preinjury level of sports, recurrent instability, range of motion, and complications were compared. Additionally, the pain VAS, ROWE score, forward flexion, and external rotation at side were subjected to a meta-analysis.

RESULTS

Twenty-four articles were included in the systematic review. The functional outcomes in terms of the ROWE score, recurrent instability, return to sports, and the preinjury level of sports was better in the Latarjet procedure group than those in the revision Bankart repair group (ROWE score, 91 vs. 86.7; recurrent instability rate, 3.5% vs. 14.4%; return to sports rate, 100% vs. 87.9%; return to preinjury level of sports rate, 89.9% vs. 74.9%; all P < 0.001). However, the results of postoperative pain and the postoperative limitation of external rotation at side were worse in the Latarjet procedure group than those in the revision Bankart repair group (pain VAS, 1.4 vs. 0.8; postoperative external rotation at side, 38° vs. 60°; all P < 0.001). In addition, the majority of the complications occurred in the Latarjet procedure group. In the meta-analysis, the postoperative ROWE score was significantly higher in the Latarjet procedure group than that in the revision Bankart group (revision Bankart repair: 95% CI 88.9-80.9, I² = 65.70; Latarjet procedure: 95% CI 95.8-88.1, I² = 93.37; P = 0.014). However, the pain VAS, forward flexion, and external rotation at side did not reach the significant level in the meta-analysis.

CONCLUSION

Compared with revision Bankart repair, the Latarjet procedure for failed Bankart repair showed better ROWE scores, stability, and return to sports or preinjury level of sports; however, the postoperative pain and the limitation of external rotation at side were worse with more complications.

IRB NO

KUMC 2022-01-024.

LEVEL OF EVIDENCE

Level IV.

High resorption rates following glenoid augmentation procedures do not seem to lead to higher recurrence rates or worse clinical outcomes: a systematic review and meta-analysis

PURPOSE

Bone augmentation techniques show a relatively high complication rate, which might be due to graft non-union and resorption. It is unclear which augmentation techniques demonstrate the highest amount of non-union and resorption and whether this leads to worse clinical or functional outcomes. Therefore, the aim of this review was (i) to compare non-union and resorption rates between surgical approaches, procedures, graft types, donor sites and fixation methods regarding clinical and functional outcomes and (ii) determine whether high non-union or resorption rates lead to less favorable clinical or functional outcomes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements were followed. PubMed, EMBASE (Ovid) and Cochrane Library were searched on December 15th 2021 for studies examining bone graft non-union or resorption using radiograph or CT following glenoid augmentation to treat anterior shoulder dislocation.

RESULTS

The search resulted in 103 inclusions, comprising 5,128 glenoid augmentations. When comparing pooled proportions of bony union, graft fracture rate, hardware failure rate, recurrence rate, return to sports and Rowe score, most results were similar between approaches, procedures, graft types, donor sites and fixation methods. High resorption rates were seen for allograft augmentation (74.3; 95% CI: 39.8-92.7) compared to autograft augmentation (15.5; 95% CI 10.1-23.2), but this was not associated with higher recurrence rates or worse clinical outcomes. Meta-analyses (8 studies; 494 patients) demonstrated no difference in incomplete and complete non-union rates between arthroscopic and open procedures; however, both analyses showed substantial heterogeneity. Higher partial resorption rates were observed on CT (48.0; 95% CI 43.3-52.7) compared to radiograph (14.1; 95% CI 10.9-18.1). Three studies comprising 267 shoulders demonstrated a higher rate of non-union and recurrence in smokers, whereas one study comprising 38 shoulders did not.

CONCLUSION

Non-union and resorption rates were similar among procedures, grafts and fixation methods. Higher resorption rates were observed in allografts, but this was not associated with higher recurrence rates or worse clinical outcomes. Pooling data demonstrated substantial heterogeneity and definitions varied among studies, warranting more standardized measuring.

LEVEL OF EVIDENCE

IV.

Glenoid bone augmentation: a contemporary and comprehensive systematic review of open procedures

Introduction

There is a trend towards arthroscopically treating shoulder instability with glenoid deficiency. Despite this, there remains the option for treatment through an open technique. Multiple bone augmentation options are available for recurrent anterior shoulder instability.

Objective

To provide a systematic review of recent studies for recurrent anterior shoulder instability necessitating glenoid bone augmentation specifically through open procedures using coracoid bone or free bone blocks [iliac crest bone autograft/allograft or distal tibia allograft (DTA)].

Methods

PubMed, Cochrane, EMBASE, and Google Scholar were searched for studies reporting open glenoid bone augmentation procedures with iliac crest, tibia, or coracoid bones within 10 years. Extracted data included study/patient characteristics, techniques, prior surgeries, prior dislocations, radiographic findings, range of motion (ROM), recurrent instability, patient-reported outcomes, and complications.

Results

92 met inclusion criteria (5693 total patients). Six were studies of iliac crest bone, four of DTA, and 84 using the coracoid bone. 29 studies measured postoperative arthritis showing no development or mild arthritis. 26 studies reported postoperative graft position. 62 studies reported ROM noting decline in internal/external rotation. 87 studies measured postoperative instability with low rates. Rowe Scores with noted improvement across 31/59 (52.5%) studies were seen. Common post operative complications included infection, hematoma, graft fracture, nerve injury, pain, and screw-related irritation.

Conclusion

Despite a trend towards arthroscopic management of recurrent anterior shoulder instability with glenoid deficiency, open procedures continue to provide satisfactory outcomes. Additionally, studies have demonstrated safe and efficacious use of free bone block graft options in the primary and revision setting.

Free bone grafting improves clinical outcomes in anterior shoulder instability with bone defect: a systematic review and meta-analysis of studies with a minimum of 1-year follow-up

BACKGROUND

Evidence on the efficacy and safety of the free bone grafting in treating anterior shoulder instability is limited. The purpose of this study was to systematically evaluate the clinical and imaging results of free bone grafting in treating anterior shoulder instability with glenoid bone defect and to explore the incidence of complications in clinically relevant subgroups.

METHODS

This systematic review was conducted per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched up to January 29, 2021, for studies that had reported on free bone grafting in treating anterior shoulder instability with glenoid bone defect with a minimum of 1-year follow-up. Two researchers independently screened studies and extracted data. A random-effects model was used to pool data on clinical function scores, imaging results, and incidence of complications (recurrent instability and non-instability-related complications). Meta-regression analysis was used to evaluate the incidence of complications in different subgroups and investigate the sources of heterogeneity.

RESULTS

A total of 29 studies were included in the meta-analysis, comprising 840 patients (845 shoulders) with average ages ranging from 21 to 34.6 years. Compared with preoperatively, free bone grafting increased the postoperative Rowe score, American Shoulder and Elbow Surgeons score, Constant score, Subjective Shoulder Value, and Oxford Shoulder Instability Score by 53.16, 31.80, 20.81, 38.63, and 4.07 points, respectively, and reduced the visual analog scale pain score by 3 points on average. During the postoperative follow-up period, the rates of return to sport and return to preoperative levels were 84.2% and 73.1%, respectively. The imaging results showed that the free bone healing rate was 98.9% and the incidence of osteoarthritis was 10.9%. The incidence rates of recurrent instability and non-instability-related complications were 3.4% and 5.6%, respectively. Meta-regression analysis showed no evidence of effect modification by the year, follow-up time, proportion of male patients, autograft or allograft, and arthroscopy or open surgery on the incidence of complications. Subgroup analysis showed that the incidence rates of recurrent instability for open surgery, arthroscopy, allograft, autograft, Latarjet revision, and non-bone block revision were 4.1%, 2.3%, 1.5%, 4.4%, 10.3%, and 3.5%, respectively.

CONCLUSION

The application of free bone grafting in treating anterior shoulder instability with glenoid bone defect can effectively improve shoulder joint function and is associated with a high return-to-sport rate and a low overall recurrence rate, but there were some differences in the complications of recurrent instability and non-instability-related complications among the subgroups. Given that these results need to be confirmed via head-to-head comparisons, we recommend that future clinical and biomechanical studies focus on comparing and investigating the advantages and disadvantages of different surgical approaches, thus providing a basis for orthopedic surgeons to make reliable choices.