Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability

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.

High Rate of Return to Sport in Contact and Collision Athletes After Arthroscopic Latarjet With Cortical Button Fixation

BACKGROUND

Contact and collision athletes face a higher risk of recurrent anterior shoulder instability after surgical stabilization. The Latarjet procedure is often preferred given the high incidence of bony lesions. However, this stabilizing procedure, performed either open or arthroscopically, is met with concerns regarding complications and revision surgery rates.

PURPOSE

To evaluate the return to sport (RTS) and assess complication and instability recurrence rates in contact/collision athletes undergoing the arthroscopic Latarjet procedure using a guided technique with suture buttons for coracoid fixations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis was conducted on contact/collision athletes who underwent the arthroscopic Latarjet procedure for recurrent anterior shoulder instability between January 2011 and March 2018. All patients were operated on arthroscopically using glenoid and coracoid guides and suture button fixation of the transferred coracoid. RTS was defined as the patient being able to participate in his or her activity without any restriction postoperatively. Two independent observers assessed patients using postoperative computed tomography (CT) scans to evaluate coracoid positioning and healing. A multivariate analysis was performed to identify predictive factors associated with persistent apprehension. A group comparison was performed to assess RTS failure risk factors.

RESULTS

In 136 contact/collision athletes (mean age, 25 ± 7 years), 93% were satisfied, and 98% achieved shoulder stability at a mean follow-up of 60 months (range, 24-117 months). No suture button-related complications or neurovascular issues were reported. Overall, 82% (112/136) returned to contact/collision sports. The mean time to RTS was 5.3 ± 1.2 months (range, 3-7.3 months). In a CT study performed 2 weeks after surgery, 87% (118/136) of bone grafts were positioned below the equator and 93% (126/136) were flush to the glenoid surface. At the 6-month postoperative CT examination, complete bone block healing was achieved in 84% (114/136). On clinical examination at the latest follow-up, 36 patients (26%) reported some anterior apprehension on testing. On multivariate analysis, patients with severe humeral bone defects (medium to large Hill-Sachs lesions, Calandra grade 2 or 3) had a higher risk of postoperative persistent apprehension. On group comparison, a visual analog scale score >3 and persistent anterior apprehension were found to be associated with failure of RTS.

CONCLUSION

The arthroscopic Latarjet procedure with suture button fixation allowed 82% of athletes with recurrent anterior shoulder instability to return to contact or collision sports. Patients with severe humeral bone defects have a higher risk of persistent anterior apprehension and decreased RTS. The arthroscopic-guided procedure with suture button fixation is safe; accurate, with a high rate of anatomic graft positioning and healing; and reliable, with a low recurrence rate.

Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability

BACKGROUND

Open Bankart repair and Latarjet stabilization are 2 widely used surgical procedures in the treatment of shoulder instability in contact athletes. This study evaluates the outcomes of bone block arthroscopic procedures, performed with a xenograft, in combination with Bankart repair and selective subscapularis augmentation for contact athletes with recurrent anterior shoulder instability.

METHODS

We retrospectively assessed contact athletes who underwent arthroscopic bone block with xenograft and Bankart repair with selective augmentation of the subscapularis for recurrent anterior shoulder instability between January 2017 and December 2021. Shoulders with posterior instability or multidirectional instability were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score, Western Ontario Shoulder Instability index [WOSI] score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form ASES score) were assessed. A computed tomography scan at 2-year follow-up was performed to assess the status of bone block integration, its displacement and restoration of glenoid surface.

RESULTS

Sixteen patients with a mean age of 24 years were included in the study. None of the patients treated with arthroscopic bone block and subscapularis augmentation presented new dislocation episodes. An increase in preoperative scores was observed at the last follow-up; in particular, the ASES, Rowe, and WOSI scores increased from 69 ± 7, 31 ± 9, and 1235 ± 46, respectively, to 96.1 ± 3.2, 94 ± 6, and 119 ± 51. All athletes returned to sporting activity at or near the same level as presurgery. The glenoid bone surface increase from 83% to 116% at the last follow-up.

CONCLUSION

Bone block treatment with xenograft combined with Bankart repair and arthroscopic subscapularis augmentation procedures has been shown to be effective in treating instability in contact athletes with significant glenoid deficit. All athletes returned to athletic activity at a level similar to the preintervention period.

Primary bone graft stability after Latarjet surgery: biomechanical evaluation of a fixation technique with metal-free all-suture cerclage vs. cortical screws

BACKGROUND

To reduce hardware-related complications in coracoid graft fixation to the anterior aspect of the glenoid, a metal-free Latarjet technique was recently introduced. The aim of this study was to compare the primary stability of a classic Latarjet procedure with 2 metal screws to a novel metal-free, all-suture cerclage method. It is hypothesized that fixation of the coracoid graft with 2 malleolar screws will provide higher primary stability compared with an all-suture cerclage technique.

METHODS

This biomechanical in vitro study was conducted on 12 fresh-frozen cadaveric shoulders (6 matched pairs) with a mean donor age of 80 years (range, 67-89 years). Coracoid graft fixation was performed using a recently introduced all-suture cerclage technique (group A) or a classic Latarjet technique with two 4.5-mm malleolar screws (group B). The conjoint tendon was loaded with a static force of 10 N to simulate the sling effect. Graft loading with a probe head consisted of 6 ascending load levels (10-50 N, 10-100 N, 10-150 N, 10-200 N, 10-250 N, and 10-300 N) with 100 cycles each at 1 Hz. Relative motion of the bone graft to the glenoid was measured using an optic 3-dimensional system.

RESULTS

While loading the conjoint tendon with 10 N, no difference in mean displacement of the bone-graft was found between both groups (P = .144). During cyclic loading, a significant difference in relative displacement for both groups was already detected in load level 1 (group A: 2398.8 μm vs. group B: 125.7 μm; P = .024), and this trend continued with the following load levels (P < .05).

DISCUSSION AND CONCLUSION

The study demonstrated that the innovative metal-free, all-suture cerclage fixation technique results in higher micromotion than the classic coracoid graft fixation with 2 malleolar screws. According to the present biomechanical investigation, shoulders treated with a metal-free all-suture cerclage technique might need adapted rehabilitation protocols to protect the construct and allow for graft healing.

The open Latarjet-Patte procedure for the treatment of anterior shoulder instability in professional handball players at a mean follow-up of 6.6 years

BACKGROUND

The popularity of team handball is increasing, with >10 million children playing this overhead throwing and collision sport with highest demands on the shoulder joint. Because of the risk of recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball players.

METHODS

We retrospectively included 20 shoulders (18 players [17 male patients]; mean age, 22.9 years [range, 17-35 years]; minimum follow-up period, 2 years; mean follow-up period, 6.6 years) operated on by 3 expert surgeons (2011-2020) with the Walch LP technique. We documented preoperative hyperlaxity (25%, n = 5), affected throwing arm (55%, n = 11), position (backcourt, winger, and goalkeeper, 22% each; full back and pivot, 17% each), >2 dislocations prior (20%, n = 4), >10 dislocations prior (5%, n = 1), previous failed Bankart or humeral avulsion of glenohumeral ligament (HAGL) repair (10%, n = 2), and large Hill-Sachs lesions (HSLs) (20%, n = 4). Clinical and radiographic outcomes, visual analog scale score, Subjective Shoulder Value, Walch-Duplay score, Rowe score, and return-to-sport (RTS) rate were recorded.

RESULTS

The RTS rate was 85% (17 of 20 shoulders); rate of RTS at the same level, 80% (16 of 20); and rate of RTS with no throwing pain, 73% (8 of 11). The time to training with a ball was 3.2 months, and the time to competition was 4.9 months. The mean Rowe score, Walch-Duplay score, and Subjective Shoulder Value were 90 points, 88 points, and 89%, respectively. Shoulder symptoms led players to give up handball in 2 cases (10%), whereas 1 player (5%) stopped playing handball for other reasons. We recorded 1 recurrent dislocation (5%) (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in 1 goalkeeper (5%). Residual pain was seen in 4 shoulders (20%); this was relieved by screw removal in 1. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%, 1 of whom had a large HSL) and 1 goalkeeper (5%; large HSL with >10 dislocations prior), all 3 of whom were aged > 30 years. Bone block positioning was correct (no lateral overhang) in all shoulders. At final follow-up, 1 shoulder (5%) showed mild arthritic changes (>10 dislocations, large HSL).

CONCLUSION

The open LP procedure is consistent in providing shoulder stability combined with return-to-throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, large HSLs, or age > 30 years may have an increased risk of persistent symptoms.

High Rates of Return to Play and Low Recurrence Rate After Arthroscopic Latarjet Procedure for Anterior Shoulder Instability in Rugby Players

Purpose

To analyze the rate of return to play, changes in athletic level, and recurrence rate and to report subjective outcomes in a series of rugby players with anterior shoulder instability who underwent an arthroscopic Latarjet procedure.

Methods

A multicenter retrospective study done in 2 centers on rugby players who were operated on between January 2011 and December 2020 was performed. Rugby players who underwent arthroscopic Latarjet procedure for anterior shoulder stabilization with a minimum follow-up period of 2 years were included. Rugby players were grouped according to their competitive level in their country (recreational, regional, national, and international). Data collected included return to sport after surgery, time to return to rugby, athletic level before and after surgery, patient satisfaction, and subjective scores. Recurrence and apprehension rates were also evaluated.

Results

A total of 73 subjects were included. Mean age at time of surgery was 23 ± 5 years. Mean duration of follow-up was 5 ± 2.6 years. Eighty-four percent of rugby players returned to rugby within a mean period of 6.6 months. Initial athletic level was a significant factor (P = .012) for not returning to sport, with 67% of patients who initially played at a recreational level not returning to rugby and 33% of patients who initially played at a regional league level not returning. All national and international players returned to play. Of the 12 non-returning rugby players, only 30% did not return because of their shoulder. Mean Subjective Shoulder Value was 90 ± 9%. Recurrence rate was 7%.

Conclusions

Arthroscopic Latarjet procedure proved its efficacy in managing recurrent anterior shoulder instability in rugby players. Return to play was achieved in almost all cases, with low recurrence rates. Despite high global return to the same level of sport, the higher the level of competition, the harder it is for rugby players to resume sport at the same level.

Level of Evidence

Level IV, therapeutic case series.

Return to play following operative management of anterior shoulder instability in overhead athletes-A systematic review

Background

The purpose of this study was to systematically review the rate and timing of return to play in overhead athletes following operative management of anterior shoulder instability.

Methods

A systematic literature search based on PRISMA guidelines, utilizing the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to play among overhead athletes following arthroscopic Bankart repair, open Latarjet procedure or Remplissage procedure.

Results

There are 23 studies included with 961 patients. Among those undergoing arthroscopic Bankart repair, the rate of return to play was 86.2%, with 70.6% returning to the same level of play and the mean time to return to play was 7.1 months. Among those undergoing an open Latarjet procedure, the rate of return to play was 80.9%, with 77.7% returning to the same level of play and the mean time to return to play was 5.1 months. Among those undergoing a Remplissage procedure, the rate of return to play was 70.6%, with 70.0% returning to the same level of play or mean time to return to play.

Discussion

Overall, there were high rates of return to play following operative management of anterior shoulder instability in overhead athletes.

Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review

PURPOSE

To systematically review the current evidence in the literature to compare return to play following arthroscopic Bankart repair versus open Latarjet procedure for the treatment of anterior shoulder instability.

METHODS

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies reporting return to play following arthroscopic Bankart repair versus open Latarjet procedure were included. Return to play was compared, with all statistical analysis performed using Review Manager, Version 5.3.

RESULTS

Nine studies with 1,242 patients (mean age: 15-30 years) were included. The rate of return to play was 61% to 94.1% among those undergoing arthroscopic Bankart repair and 72% to 96.8% in those undergoing an open Latarjet procedure. Two studies (Bessiere et al. and Zimmerman et al.) found a significant difference in favor of the Latarjet procedure (P < .05 for both, I2 = 37%). The rate of return to play at preinjury level was 9% to 83.8% among those undergoing arthroscopic Bankart repair and 19.4% to 80.6% in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 0%). The mean time of return to play was 5.4 to 7.3 months among those undergoing arthroscopic Bankart repair and 5.5 to 6.2 months in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 39%).

CONCLUSIONS

Overall, the majority of studies showed no significant difference in rates of return to play or timing following arthroscopic Bankart repair or open Latarjet procedure. Furthermore, no study has found a significant difference in rate of return to play at pre-injury level, or rate of return to play among collision athletes.

LEVEL OF EVIDENCE

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

Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of return to sports after coracoid transfer

PURPOSE

This study aims to determine the rate of different levels of return to sports (RTS) in athletes undergoing the modified arthroscopic Bristow procedure and the factors associated with the level of RTS.

METHODS

The study was performed retrospectively on patients with traumatic anterior shoulder instability who underwent the modified arthroscopic Bristow procedure with a minimum follow-up of 2 years. The RTS rate, the level of return and the timing of return were assessed. Additionally, factors such as preoperative basic information, clinical outcomes, graft position, graft healing and graft absorption were analysed to investigate their correlation with the level of RTS. Multivariate regression models were used to evaluate the factors affecting the level of RTS.

RESULTS

In total, this study included 182 shoulders of 177 athletes undergoing the modified arthroscopic Bristow procedure. Of these patients, 142 (78.0%) shoulders of 137 athletes were enrolled, with a mean of 3.3-year follow-up. At the final follow-up, 134 (94.4%) shoulders were able to RTS, 123 (86.6%) shoulders were able to RTS to the pre-injury level, 52 (36.6%) shoulders could be completely "forgotten" without any psychological barrier during exercise. The multivariate logistic regression analysis identified the variable associated with RTS at the pre-injury level as previously failed arthroscopic Bankart repair (p < 0.001). As for the "forgetting" operated shoulder, the duration from first dislocation to surgery was a significant independent predictor (p = 0.034).

CONCLUSION

Although a large majority of athletes were able to RTS at the pre-injury level after the modified arthroscopic Bristow procedure, about two-thirds of the athletes felt difference in shoulders on both sides and could not completely "forget" the operated shoulder during exercise. Previously failed Bankart repair and the duration from first dislocation to surgery were the risk factors associated with the level of RTS after the modified arthroscopic Bristow procedure.

LEVEL OF EVIDENCE

IV.

[Chronic posttraumatic shoulder instability]

Chronic posttraumatic shoulder instability is characterized by trauma-associated, recurrent dislocations. Surgical treatment is indicated in most cases but it remains controversial how risk factors should be weighted to decide between arthroscopic Bankart repair (ABR), Latarjet or alternative procedures. Known risk factors for recurrence are patient age, hyperlaxity, sports profile and bone loss. Surgical techniques are discussed in detail. The ABR leads to high patient satisfaction and return to sports; however, in association with risk factors, recurrent dislocations are seen even several years later. Latarjet or bone block procedures lead to high patient satisfaction, sustainable stability as a revision procedure, but can also be primarily indicated for chronic instability depending on risk factors. Early complications are more frequent but of a minor nature in most cases. All techniques are known for a serious learning curve. If performed well, they do not seem to increase the risk of arthritis, which is most affected by the number of lifetime dislocations and higher energy trauma.

Managing Bone Loss in Shoulder Instability-Techniques and Outcomes: a Scoping Review

PURPOSE OF REVIEW

The aim of this scoping review is to provide an overview of the literature published over the past 5 years related to the management of bone loss in anterior shoulder instability.

RECENT FINDINGS

During recent years, there has been a focus on patients at high risk for failure following soft tissue anterior stabilization (Bankart repair). A growing body of evidence suggests that anterior capsulolabral repair is insufficient in the setting of subcritical glenoid bone loss with an off-track Hill Sachs lesion. In such cases, the addition of a remplissage procedure to a Bankart repair or a bone-block augmentation to the glenoid (Latarjet, for example) is often advocated to decrease the risk of recurrent instability. Recent studies have also evaluated the role of alternative bone-block procedures in comparison to the Latarjet, outcomes with arthroscopic and open techniques as well as various fixation methods and radiological outcomes (bone graft resorption, glenohumeral osteoarthritis). Advances in our understanding of subcritical glenoid bone loss and the glenoid track concept have significantly impacted clinical decision making and treatment selection. The development of arthroscopic techniques has allowed for minimally invasive and safe arthroscopic bone-block procedures as an alternative to open procedures. Further research related to free bone-block procedures will inform long-term outcomes between these procedures and the gold standard Latarjet. Additionally, high-quality evidence is lacking to identify the ideal treatment for patients with glenoid subcritical glenoid bone defect. Variability in outcome reporting suggests the need to standardize outcome measures for future instability trials.