Open Latarjet Procedures Produce Better Outcomes in Competitive Athletes Compared With Recreational Athletes: A Clinical Comparative Study of 106 Athletes Aged Under 30 Years

Rehabilitation and Return to Sport following Operative and Nonoperative Treatment of Anterior Shoulder Instability

There has been growing interest in the rehabilitation process and timing of returning an athlete to sport following the management options for anterior shoulder instability. The purpose of this article is to review the current rehabilitation and return to sport (RTS) protocols for various nonoperative and operative management strategies following anterior shoulder instability events. When appropriate in the rehabilitation protocol, RTS testing should be criteria based, rather than time based, with a special focus given to psychological readiness in order to promote successful return to athletics and prevention of recurrent instability episodes in the future.

Arthroscopic Management of the Contact Athlete with Anterior Instability

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid.

Isokinetic Strength and Balance Analyses for Predicting Return to Sports After the Latarjet Procedure: A Prospective Cross-sectional Study

BACKGROUND

Isokinetic torque in shoulder internal rotation (IR) and external rotation (ER) can be considered as potential indicators for dynamic stability of the glenohumeral joint.

PURPOSE

To assess the efficacy of 4-month isokinetic testing in predicting the 6-month return-to-sports (RTS) status after Latarjet surgery, explore its correlations with testing parameters, and identify optimal thresholds to ensure a safe RTS.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The study assessed athletes who underwent the Latarjet stabilization procedure between January 2022 and June 2023. The primary outcome was RTS at 6 months after surgery. The primary examined predictors were isokinetic testing metrics at 4 months postoperatively. Secondary outcomes comprised the modified Closed Kinetic Chain Upper Extremity Stability Test (mCKCUEST) and several patient-reported outcome measures, including the Walch-Duplay score, the Western Ontario Shoulder Instability Index (WOSI), and the Shoulder Instability-Return to Sports after Injury scale. To assess the predictors, patients were divided into those who returned to any level of sports compared with those who did not return to sports. The correlation between isokinetic testing results and other outcome scores was also analyzed.

RESULTS

A total of 71 patients (mean age, 27.43 ± 9.09 years) were included in the study. Of these, 23.61% did not return to sports, 38.89% returned at a lower level, and 37.50% returned to the same level. Significant rotational strength disparities were noted. Patients who did not return to sports at 6 months demonstrated inferior strength in concentric ER at 60 deg/s, concentric ER at 240 deg/s, concentric IR at 240 deg/s, and eccentric IR at 30 deg/s (P < .05). Similar trends appeared for all studied patient-reported outcome measures and the mCKCUEST (P < .05). Receiver operating characteristic analysis emphasized the significance of isokinetic testing in concentric ER at 240 deg/s (area under the curve = 0.759; P = .001; cutoff = 0.32 N·m/kg; sensitivity = 100.0%; specificity = 49.1%) and eccentric ER at 30 deg/s (area under the curve = 0.760; P = .001; cutoff = 0.51 N·m/kg; sensitivity = 94.1%; specificity = 49.1%) for RTS prediction. Additionally, ER strength moderately correlated with the Walch-Duplay score across all examined velocities (r = 0.26-0.34; P < .05). The modified WOSI score was weakly linked to ER strength at 240 deg/s and 30 deg/s (r = 0.24-0.25; P < .05) as well as moderately linked to the limb symmetry index in ER at 60 deg/s and 30 deg/s (r = 0.30-0.38; P < .05).

CONCLUSION

Isokinetic testing can act as an independent predictor of successful RTS after Latarjet surgery, with concentric ER at 240 deg/s, concentric IR at 240 deg/s, eccentric ER at 30 deg/s, and eccentric IR at 30 deg/s showing the most accuracy. Strength recovery in ER was associated with better Walch-Duplay and modified WOSI scores.

Postoperative Radiographic Outcomes Following Primary Open Coracoid Transfer (Bristow-Latarjet) Vary in Definition, Classification, and Imaging Modality: A Systematic Review

PURPOSE

To analyze radiographic outcomes by conventional radiography, computed tomography (CT), or both and complication rates of open coracoid transfer at a minimum of 12-months follow-up.

METHODS

A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were clinical studies reporting on open Latarjet as the primary surgical procedure(revision coracoid transfer after failed prior stabilization excluded) with postoperative radiographic outcomes at a minimum mean 1-year follow-up. Patient demographics, type of postoperative imaging modality, and radiographic outcomes and complications including graft union, osteoarthritis, and osteolysis were systematically reviewed. Data were summarized as ranges of reported values for each outcome metric. Each radiographic outcome was graphically represented in a Forest plot with point estimates of the incidence of radiographic outcomes with corresponding 95% confidence intervals and I2.

RESULTS

Thirty-three studies met inclusion criteria, with a total of 1,456 shoulders. The most common postoperative imaging modality was plain radiography only (n = 848 [58.2%]), both CT and radiography (n = 287 [19.7%]), and CT only (n = 321 [22.1%]). Overall, the reported graft union rate ranged from 75% to 100%, of which 79.8% (n = 395) were detected on plain radiography. The most common reported postoperative radiographic complications after the open coracoid transfer were osteoarthritis (range, 0%-100%, pooled mean 28%), graft osteolysis (range, 0%-100%, pooled mean 30%), nonunion (range, 0%-32%, pooled mean 5.1%), malpositioned graft (range, 0%-75%, pooled mean 14.75%), hardware issues (range, 0%-9.1%, pooled mean 5%), and bone block fracture (range, 0%-8%, pooled mean 2.1%). Graft healing was achieved in a majority of cases (range, 75%-100%).

CONCLUSION

Postoperative radiographic outcomes after open coracoid transfer vary greatly in definition, classification, and imaging modality of choice. Greater consistency in postoperative radiographic outcomes is essential to evaluate graft healing, osteolysis, and nonunion.

LEVEL OF EVIDENCE

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

Isolated Primary Latarjet Procedures for Anterior Shoulder Instability Results in High Rates of Graft Resorption and Glenohumeral Degenerative Changes With Low Rates of Failure at a Minimum 2-Year Follow-Up: A Systematic Review

PURPOSE

To evaluate the incidence of postoperative complications after an isolated primary Latarjet procedure for anterior shoulder instability at a minimum 2-year follow-up.

METHODS

A systematic review was performed in accordance with 2020 PRISMA guidelines. EMBASE, Scopus, and PubMed databases were queried from database inception through September 2022. The literature search was limited to human clinical studies reporting on postoperative complications and adverse events after a primary Latarjet procedure with a minimum 2-year follow-up. Risk of bias was measured using the Newcastle-Ottawa Scale.

RESULTS

Twenty-two studies, consisting of 1,797 patients (n = 1,816 shoulders), with a mean age of 24 years were identified. The overall postoperative complication rate ranged from 0% to 25.7%, with the most common complication being persistent shoulder pain (range: 0%-25.7%). Radiological changes included graft resorption (range: 7.5%-100%) and glenohumeral degenerative changes (range: 0%-52.5%). Recurrent instability following surgery was documented in 0% to 35% of shoulders, while the incidence of bone block fractures ranged from 0% to 6% of cases. Postoperative nonunion, infection, and hematomas had a reported incidence rate ranging from 0% to 16.7%, 0% to 2.6%, and 0% to 4.4%, respectively. Overall, 0% to 7.5% of surgeries were reported failures, and 0% to 11.1% of shoulders required reoperation, with a revision rate ranging from 0% to 7.7%.

CONCLUSIONS

The incidence of complications following the primary Latarjet procedure for shoulder instability was variable, ranging from 0% to 25.7%. High rates of graft resorption, degenerative changes, and nonunion were present while failure and revision rates remained low at a minimum 2-year follow-up.

LEVEL OF EVIDENCE

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

Criteria-based return to sport testing after open Latarjet reveals residual deficits and can be utilized for sports clearance with excellent outcomes at mean 3.6 year follow-up: A small case series of competitive athletes

OBJECTIVE

The purpose of this study was to assess the use of a criteria-based return to sport (CBRTS) test to evaluate readiness for return to play (RTP) in competitive athletes that underwent open Latarjet.

DESIGN

Retrospective case series.

METHODS

Ten competitive athletes (mean age 19.9 years) treated with open Latarjet for recurrent glenohumeral instability underwent CBRTS testing at a mean of 5.3 months postoperatively. Testing consisted of four components: 1. isometric strength, 2. isokinetic strength, 3. endurance, and 4. function. Patients failing 0 or 1 component of the test were cleared to RTP. Patients failing multiple components underwent additional deficit-based rehabilitation.

RESULTS

Of the 10 patients that tested, 4 passed their overall CBRTS test and were cleared to RTP. The remaining 6 patients failed the overall CBRTS test. Seven patients (70%) failed at least one section of the strength testing, two patients (20%) failed endurance testing, and two patients (20%) failed functional testing. At final follow-up (mean 3.6 years), 1 patient had recurrent instability (10%) and 9 patients returned to play (90%).

CONCLUSIONS

CBRTS testing may be clinically useful for return to play clearance decisions after open Latarjet procedure, as it can reveal deficits that may not be identified with time-based clearance alone.

Arthroscopic Latarjet yields better union and prevention of instability compared to arthroscopic bony Bankart repair in shoulders with recurrent anterior instability: a systematic review

PURPOSE

To determine whether arthroscopic Latarjet procedure or arthroscopic bony Bankart repair provide better outcomes in terms of rates of recurrent instability, non-union and complications, as well as clinical scores and range of motion.

METHODS

An electronic literature search was performed using PubMed, Embase®, and Cochrane databases, applying the following keywords: "Arthroscopic bony Bankart" OR "Arthroscopic osseous Bankart" AND "Arthroscopic Latarjet" OR "Arthroscopic coracoid bone block".

RESULTS

The systematic search returned 1465 records, of which 29 were included (arthroscopic bony Bankart repair, n = 16; arthroscopic Latarjet, n = 13). 37 datasets were included for data extraction, on 1483 shoulders. Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair had significantly higher instability rates (0.14; CI 0.10-0.18; vs 0.04; CI 0.02-0.06), significantly lower union rates (0.63; CI 0.28-0.91 vs 0.98; CI 0.93-1.00), and significantly lower pain on VAS (0.42; CI 0.17-0.67 vs 1.17; CI 0.96-1.38). There were no significant differences in preoperative glenoid bone loss, follow-up, complication rate, ROWE score, ASES score, external rotation, and anterior forward elevation between arthroscopic Latarjet and arthroscopic bony Bankart repair.

CONCLUSION

Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on VAS (0.45 vs 1.17). There were no differences in complication rates, clinical scores, or postoperative ranges of motion.

LEVEL OF EVIDENCE

IV.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

PURPOSE

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure.

METHODS

Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up.

RESULTS

No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P = .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P = .030 and P = .034, respectively).

CONCLUSIONS

Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

A comprehensive comparison and evaluation of surgical techniques for anterior shoulder instability: a Bayesian network meta-analysis

BACKGROUND

Anterior shoulder instability is a common clinical problem; however, conflicting evidence exists regarding optimal treatment algorithms. We perform a comparative analysis of stabilization techniques used for recurrent anterior shoulder instability to identify the one associated with the lowest rate of recurrent instability. We additionally explore how glenoid bone loss and osseus lesions affect recurrence rates.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched for clinical studies comparing surgical techniques for anterior shoulder instability. Two team members independently assessed all potential studies for eligibility and extracted data. Each included study underwent a risk of bias assessment using the Cochrane risk of bias summary tool. The primary outcome of interest was the rate of recurrent instability, which underwent a Bayesian network meta-analysis. Additional analyses were performed relating to the degree of glenoid bone loss and the presence of osseous lesions.

RESULTS

Of 2699 studies screened, 52 studies with 4209 patients were included. Patients who underwent open Latarjet demonstrated the overall lowest rate of recurrent instability [log odds ratio (LOR) 1.93], whereas patients who underwent arthroscopic Bankart repair demonstrated the highest (LOR 2.87). When glenoid bone loss was 10% to 20%, open Latarjet had significantly lower recurrent instability (P = .0016) compared to arthroscopic Bankart repair. When glenoid bone loss increased from 0%-10% to 10%-20%, arthroscopic Bankart repair had a significantly increased rate of recurrence (P = .021). In the presence of an engaging Hill-Sachs lesion, both open Latarjet (P = .01) and arthroscopic Bankart with remplissage (P = .029) had significantly reduced recurrence rates compared to arthroscopic Bankart repair. Finally, regardless of procedure, the presence of a Hill-Sachs or bony Bankart lesion was associated with an increased risk of recurrent instability (r = 0.44, P = .0003, and r = 0.40, P = .006, respectively).

CONCLUSION

The open Latarjet has the overall lowest recurrent instability and significantly lower compared to arthroscopic Bankart repair in the setting of increasing glenoid bone loss. Bone loss between 0% and 10% results in similar outcomes across all procedures.

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.

Outcomes After Open Latarjet in Patients With or Without SLAP Lesions

Background

Up to 20% of shoulders with anterior instability are associated with superior labrum anterior-posterior (SLAP) lesions, and they remain untreated after an open Latarjet procedure. SLAP lesions can be responsible for pain and feelings of instability in high-demand patients.

Purpose/Hypothesis

The aim of this study was to compare the early functional outcomes and return to sport rates in athletes after the Latarjet procedure with versus without associated SLAP lesions. It was hypothesized that untreated SLAP lesions would not influence clinical results.

Study Design

Cohort study; Level of evidence, 3.

Methods

Inclusion criteria were athletes with anterior shoulder instability treated with Latarjet procedure, a minimum follow-up of 1 year, and an available preoperative computed tomography arthrogram. We recorded patient characteristics; type of sport; bone loss; Rowe, Single Assessment Numeric Evaluation (SANE), and 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; 5-point pain and satisfaction scores; reported apprehension; and return to sport. Patients with and without a preoperative type 5 SLAP lesion on imaging were compared.

Results

Fifty patients were included (mean age, 22 ± 5 years [range, 16-36 years]; mean follow-up, 27 ± 9 months [range, 12-42 months]). Thirty-four patients practiced contact sports, including 20 rugby players. Twelve patients (24%) had a preoperative SLAP lesion. Groups with (+) and without (-) a SLAP lesion were comparable in terms of age, sex, number of instability episodes, type of sport, and glenoid and humeral bone loss. The SLAP+ group had significantly worse outcomes with a lower Rowe score (79 ± 23 vs 91 ± 15; P = .018) and painless rate (50% vs 77%; P = .04). There were no significant differences between the groups in SANE score (SLAP+ vs SLAP-: 80% vs 87%), QuickDASH score (8% vs 8%), return to sport (83% vs 91%), apprehension (79% vs 50%), and reported satisfaction. There was 1 episode of postoperative subluxation in each group.

Conclusion

Patients who underwent an open Latarjet procedure with an associated SLAP tear more frequently reported postoperative pain than those without a SLAP lesion. Patients with untreated SLAP tears had significantly lower Rowe scores, although SANE score and return to sport were not significantly different between the groups.

Open Latarjet Versus Arthroscopic Bankart Repair for the Treatment of Traumatic Anterior Shoulder Instability in High-Demand Patients With Minimal Glenoid Bone Loss

BACKGROUND

This study compared the clinical outcomes and return to sports/work between open Latarjet and arthroscopic Bankart repair in high-demand patients with traumatic anterior shoulder instability with minimal glenoid bone loss.

METHODS

We prospectively recruited 30 patients and randomised them to either open Latarjet or arthroscopic Bankart. The mean duration of follow-up in our study was 13.27 months±2.70. All patients were males with a mean age at surgery of 28.6 years (range, 18-41 years).

RESULTS

The overall mean for the Rowe score in the 30 patients increased from 33.5±14 points preoperatively to 79.6±18 points. However, there was no statistically significant difference in the postoperative ROM (range of motion) and Rowe score among the Bankart and Latarjet groups. The main finding in our study was the time to return to sports/work which was significantly lower in the Latarjet group (5.2 months) compared to the Bankart group (seven months).

CONCLUSIONS

Open Latarjet is considered a more invasive and non-anatomical procedure, however, it is less costly with a shorter time to return to sports/work compared to the Bankart procedure, which is very crucial for high-demand patients, especially the competitive athletes targeting an early return to sports at the same pre-injury level with minimal incidence of recurrence, making the surgeon's choice very challenging.

Quality of life following an open Latarjet-Bristow procedure in a general population with recurrent anterior shoulder instability

Background

Despite the extensive literature on anterior glenohumeral instability, to date, there are no studies that report on the quality of life following a Latarjet-Bristow procedure with recurrent anterior shoulder instability. The purpose of this study was to evaluate the quality of life in patients who had a Latarjet-Bristow procedure.

Methods

A single-center retrospective review with a prospective recall of patients who underwent a Latarjet-Bristow technique for recurrent anterior glenohumeral instability between January 2017 and March 2020. Outcomes measures included health-related quality of life using the Short Form-36 (SF-36) questionnaire and patient-related outcome measures using the Western Ontario Shoulder Instability Index and Rowe scores.

Results

A total of 66 patients were identified to participate in the study; 40 (60.6%) responded and were included in the analysis. There were nine females and 31 males, with a median age of 32 years (27.5‒41 years). Three cases had bilateral anterior shoulder instability with a single joint being operated and three patients were epileptic. Physical and mental components summary of the SF-36 showed a better health-related quality of life in the general population. There was a significant strong correlation between SF-36 and Western Ontario Shoulder Instability Index. However, SF-36 and Rowe score showed a fair correlation.

Conclusion

The Latarjet-Bristow procedure improves the quality of life in a general population similarly to an athletic population. The number of episodes of dislocation before surgery and the delayed surgical intervention did not increase the recurrent anterior shoulder instability rates postoperatively.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial

BACKGROUND

There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction.

METHODS

This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded.

DISCUSSION

This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction.

TRIAL REGISTRATION

The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.

Complications Related to Latarjet Shoulder Stabilization: A Systematic Review

BACKGROUND

In cases of recurrent anterior shoulder instability with a glenoid defect, Latarjet procedures are widely used for stabilization. Although complications with this procedure have been reported, few studies have comprehensively analyzed issues related to the Latarjet procedure.

PURPOSE

To identify the overall complication rate of the Latarjet procedure used for anterior shoulder instability and to compare the rate of complications between arthroscopic and open approaches.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed by using the PubMed, EMBASE, Scopus, and Cochrane Library databases. Data on complications were extracted and classified as intraoperative, postoperative, or instability-related for further analysis. Quality assessments were performed with criteria from the Methodological Index for Nonrandomized Studies (MINORS). A quantitative synthesis of data was conducted to compare the complication rates between arthroscopic and open approaches.

RESULTS

A total of 35 articles were included in this analysis. The MINORS score was 11.89. A total 2560 Latarjet procedures (2532 patients) were included. The overall complication rate was 16.1% (n = 412). The intraoperative complication rate was 3.4% (n = 87) and included a 1.9% (n = 48) incidence of nerve injuries and a 1.0% (n = 25) incidence of iatrogenic fractures. Screw problems, vascular injuries, and conversion arthroscopic to open surgery each occurred at a rate of <1%. The postoperative complication rate was 6.5% (n = 166), and the most common complication was nonunion (1.3%; n = 33). The instability-related complication rate was 6.2% (n = 159) and included a 1.5% (n = 38) rate of redislocation, a 2.9% (n = 75) rate of positive apprehension test, and a 1.0% (n = 26) rate of instability. Overall, 2.6% (n = 66) of patients required an unplanned secondary operation after the initial surgery. The arthroscopic approach was associated with a higher rate of intraoperative complications compared with the open approach (5.0% vs 2.9%; P =.020) and a lower rate of instability-related complications (3.1% vs 7.2%; P < .001).

CONCLUSION

The Latarjet procedure for anterior shoulder instability results in an overall complication rate of 16.1% and a reoperation rate of 2.6%. However, serious complications at short-term follow-up appear rare. When the arthroscopic approach was used, the rate of intraoperative complications was higher, although instability-related complications were lower when compared with the open approach.

Surgeon variation in glenoid bone reconstruction procedures for shoulder instability

BACKGROUND

Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice.

METHODS

A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice.

RESULTS

All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss.

CONCLUSIONS

Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

[Short-term effectiveness of modified arthroscopic Latarjet procedure with double EndoButtons for recurrent anterior shoulder dislocation]

Objective

To evaluate the short-term effectiveness of modified arthroscopic Latarjet procedure with double EndoButtons for recurrent anterior shoulder dislocation.

Methods

Between January 2019 and November 2020, 36 patients with recurrent anterior shoulder dislocation were treated by modified arthroscopic Latarjet procedure with double EndoButtons. There were 26 males and 10 females, with an average age of 27.8 years (range, 18-36 years). The number of shoulder dislocations ranged from 3 to 12 times, with an average of 6.5 times. The disease duration ranged from 5 to 36 months, with an average of 16.2 months. Preoperative shoulder fear test was positive, and the Beighton score of joint relaxation was 0-4, with an average of 1.3. Imaging examination showed that the defect width of the ipsilateral glenoid bone was 16%-28%, with an average of 21.5%. Postoperative complications, recurrent dislocation, subluxation, and instability of shoulder joint were recorded. Shoulder range of motion was examined, including forward flexion, external rotation at side, external rotation at 90° abduction, and internal rotation. Shoulder joint function was evaluated by Walch-Duplay score, American Association for Shoulder and Elbow Surgery Score (ASES), and ROWE score. X-ray film and CT images were taken to observe the shaping of coracoid process graft.

Results

All incisions healed by first intention, and no vascular or nerve injury occurred. All patients were followed up 12-28 months, with an average of 19.9 months. During follow-up, no shoulder dislocation recurred, and shoulder fear test was negative. At last follow-up, there was no significant difference in shoulder forward flexion, external rotation at side, external rotation at 90° abduction, and internal rotation when compared with preoperative values (P>0.05). The Walch-Duplay score, ASES score, and ROWE score of shoulder function significantly improved (P<0.05). Postoperative imaging examination showed that coracoid process graft was at the same level with the glenoid in 33 cases (91.7%), medial in 1 case (2.8%), and lateral in 2 cases (5.6%); the center of coracoid process graft was mainly located between 3 to 5 o'clock in 33 cases (91.7%), higher than 3 o'clock in 1 case (2.8%), and lower than 5 o'clock in 2 cases (5.6%). There was no obvious glenohumeral joint degeneration during follow-up, and the coracoid process graft gradually formed concentric circles with the humeral head.

Conclusion

The modified arthroscopic Latarjet procedure with double EndoButtons can effectively treat recurrent anterior shoulder dislocation, and the short-term effectiveness is satisfactory, and the position of coracoid process graft is accurate.

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.

High Rate of Return to Work by 3 Months Following Latarjet for Anterior Shoulder Instability

PURPOSE

To evaluate the rate and duration of return to work in patients undergoing Latarjet for failed soft-tissue stabilization or glenoid bone loss.

METHODS

Consecutive patients undergoing Latarjet from 2005 to 2015 at our institution were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a standardized and validated work questionnaire, Western Ontario Shoulder Instability Index Survey, and a satisfaction survey.

RESULTS

Of 89 eligible patients who had Latarjet, 67 patients (75.3%) responded to the questionnaire, of whom 51 patients (76.1%) were employed within 3 years before surgery (mean age: 29.9 ± 11.8 years; mean follow-up: 54.6 ± 11.9 months) and had an average glenoid bone loss of 14.5 ± 6.1%. Fifty patients (98.0%) returned to work by 2.7 ± 3.0 months postoperatively; 45 patients (88.2%) patients returned to the same level of occupational intensity. Those who held sedentary, light, moderate, or heavy intensity occupations returned to their previous occupation at a rate of 100.0%, 93.3%, 90.0%, and 66.7% (P = .2) at a duration of 1.2 ± 1.6 months, 1.8 ± 1.9 months, 3.1 ± 3.5 months, and 6.5 ± 4.1 months (P = .001), respectively. The average postoperative Western Ontario Shoulder Instability Index score was 70.9 ± 34.2. Fifty patients (98.0%) noted at least "a little improvement" in their quality of life following surgery, with 35 patients (68.6%) noting great improvement. Furthermore, 49 patients (96.1%) reported being satisfied with their procedure, with 25 patients (49.0%) reporting being very satisfied. Four patients (7.8%) returned to the operating room, with 1 patient (2.0%) requiring arthroscopic shoulder stabilization.

CONCLUSIONS

Approximately 98% of patients who underwent Latarjet returned to work by 2.7 ± 3.0 months postoperatively. Patients with greater-intensity occupations had a longer duration of absence before returning to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations.

LEVEL OF EVIDENCE

IV, case series.

Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability

BACKGROUND

Latarjet coracoid transfer reconstruction is the gold standard for the treatment of recurrent shoulder instability with anterior-inferior glenoid bone loss, and return to sport is often a primary outcome of interest in this patient population. The purpose of this study was to determine the rate of return to sport in patients undergoing the Latarjet procedure and variables that are associated with a higher likelihood of a successful return to sport.

METHODS

A prospectively maintained institutional registry was retrospectively queried between August 2012 and August 2016 for all patients who underwent the Latarjet procedure. Patients were contacted electronically and via telephone to administer a previously validated and standardized return-to-sport survey. Patients self-reported return to sport, varying sports participation, recurrence of instability, and time to return to sport. Multivariate analysis was performed to determine variables associated with each outcome.

RESULTS

Of 83 patients, 66 (75.3%) were available for final follow-up, of whom 60 participated in sports prior to surgery and were eligible for inclusion. The average follow-up period was 53.8 ± 11.8 months. The average age at surgery was 26.7 ± 11.3 years, and the average body mass index was 26.2 ± 4.0 kg/m². There were 54 patients (90%) who were able to return to sport at an average of 8.6 ± 4.1 months following surgery. In total, 36 patients (60%) were able to return to sport at the same level or a better level of intensity, 19 of 28 patients (67.9%) were able to return to throwing sports without difficulty, and 31 of 60 patients (51.7%) reported that their shoulder was a hindrance to some activity. An increased likelihood of returning to sport was associated with increased body mass index (P = .016), male sex (P = .028), and decreased humeral bone loss volume (P = .034). An increased likelihood of returning to sport at the same level or a better level of intensity was associated with reduced humeral bone loss volume (P = .026). Recurrent instability was associated with humeral bone loss (P = .038).

CONCLUSION

Although a large majority of patients were able to return to sport following the Latarjet procedure, some patients experienced limitation with throwing and return to sport at the preinjury level. Greater humeral bone loss was associated with inferior outcomes. These findings should be discussed with patients in the preoperative setting to manage expectations appropriately.

Clinical Outcomes of the Traditional Latarjet Versus the Congruent Arc Modification for the Treatment of Recurrent Anterior Shoulder Instability: A Meta-analysis

Background:

Few studies have compared clinical outcomes between the traditional Latarjet procedure for anterior shoulder instability and the congruent arc modification to the Latarjet procedure.

Purpose:

To systematically evaluate the literature for the incidence of recurrent instability, clinical outcomes, radiographic findings, and complications for the traditional Latarjet procedure and the congruent arc modification and to compare results of each search.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included studies published between January 1990 and October 2020 that described clinical outcomes of the traditional Latarjet and the congruent arc modification with a follow-up range of 2 to 10 years. The difference in surgical technique was analyzed using a chi-square test for categorical variables, while continuous variables were evaluated using a Student t test.

Results:

In total, 26 studies met the inclusion criteria: 20 studies describing the traditional Latarjet procedure in 1412 shoulders, and 6 studies describing the congruent arc modification in 289 shoulders. No difference between procedures was found regarding patient age at surgery, follow-up time, Rowe or postoperative visual analog scores, early or late complications, return-to-sport timing, or incidence of improper graft placement or graft fracture. A significantly greater proportion of male patients underwent glenoid augmentation using the congruent arc modification versus traditional Latarjet (P < .001). When comparing outcomes, the traditional Latarjet procedure demonstrated a lower incidence of fibrous union or nonunion (P = .047) and broken, loose, or improperly placed screws (P < .001), and the congruent arc modification demonstrated improved outcomes with regard to overall return to sport (P < .001), return to sport at the same level (P < .001), incidence of subluxation (P = .003) or positive apprehension (P = .002), and revision surgery for recurrent instability (P = .027).

Conclusion:

Outcomes after the congruent arc modification proved at least equivalent to the traditional Latarjet procedure in terms of recurrent instability and return to sport, although early and late complications were equivalent. The congruent arc procedure may be an acceptable alternative to traditional Latarjet for the treatment of anterior shoulder instability with glenoid bone loss; however, long-term outcomes of this procedure are needed.

Return to Professional Australian Rules Football After Surgery for Traumatic Anterior Shoulder Instability

BACKGROUND

The treatment of traumatic anterior shoulder instability in professional Australian Football League (AFL) players is challenging, with an emphasis on early return to play and avoidance of instability recurrence.

PURPOSE

To investigate return-to-sport (RTS) outcomes and complications after 2 different procedures for traumatic anterior shoulder instability in professional AFL players.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively reviewed our surgical database for professional AFL players who underwent capsulolabral stabilization or open Latarjet procedure by a single surgeon between 2006 and 2017. Outcomes included RTS, on-field performance, and complications. Between-group analyses for RTS and complications were estimated using Kaplan-Meier survival analyses. Within-group analyses for on-field performance data were performed using paired t tests with significance set at .05.

RESULTS

A total of 58 capsulolabral stabilization procedures in 54 players and 32 Latarjet procedures in 29 players were included in the analysis; 93.1% of capsulolabral patients and 96.9% of Latarjet patients returned to professional AFL. The median RTS time was 6.8 months for the capsulolabral group and 7.3 months for the Latarjet group. There was no significant difference in RTS rates between the 2 groups (P = .270). Of those undergoing surgery early in the season, 75% of the capsulolabral and 71% of Latarjet group were able to RTS within the same season, at a mean time of 16.9 weeks and 18.8 weeks, respectively. There was a significant difference in instability recurrence, with 19% for the capsulolabral group and no recurrence in the Latarjet group (P = .017). There was no significant reduction in player on-field performance in either group (P < .05).

CONCLUSION

In this study, the median RTS in AFL players was approximately 7 months after capsulolabral and Latarjet surgery with no compromise to on-field performance. Instability-related complications occurred only in the capsulolabral group, and the incidence increased with time.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures

Background:

Standardized criteria are lacking to guide patient return to sport (RTS) after rotator cuff surgery (RCS) or shoulder stabilization surgery (SSS).

Purpose:

To describe RTS criteria used after RCS and SSS in athletic populations.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

This scoping review was based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. A total of 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced search) and the gray literature were searched for English-language studies that reported at least 1 RTS criterion in athletes after shoulder surgery. Studies were assigned to the RCS or SSS subgroup based on the primary procedure performed. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation.

Results:

Included were 52 studies and 2706 athletes (2206 male, 500 female, with a mean age of 28.8 ± 1.8 years). The RCS group consisted of 14 studies and the SSS group consisted of 38 studies. Time from surgery was the most common RTS criterion reported overall (37/52 studies; 71%) as well as within the RCS (93%) and SSS (63%) subgroups. Muscle strength (25/52 studies; 48%) and range of motion (23/52; 44%) were used by almost half of the included articles. RTS criteria reported less often were absence of pain, successful completion of sport-specific or position-specific test, proprioception, radiographic evaluation, patient-surgeon agreement, minimum time required to participate in pain-free throwing, and satisfactory scapulothoracic mechanics. All studies used 1 to 3 of the above RTS criteria; however, the definition of each criterion differed among the included articles.

Conclusion:

Time from surgery was the most commonly reported RTS criterion after RCS or SSS in athletes, whereas muscle strength and range of motion were used by almost half of the articles. There was high heterogeneity in the definition of each RTS criterion used among the included studies, which also used different combinations of 1 to 3 RTS criteria. These results suggest the need to better define quantitative and qualitative RTS criteria in athletes undergoing rotator cuff and shoulder stabilization procedures in order to safely return athletes to sport.

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.

Clinical and radiographic outcomes after Latarjet using suture-button fixation

Background

Latarjet has become a common treatment option for patients with shoulder instability in the setting of bone loss. The coracoid is commonly secured with screws

Methods

All patients who underwent Latarjet with suture-button fixation with minimum 1-year follow-up were eligible for inclusion. Preoperative demographic and clinical outcome data including American Shoulder and Elbow Surgeons (ASES), Single Assessment Numerical Evaluation (SANE), and Visual Analog Scale (VAS) were recorded and compared with postoperative scores. Radiographs were reviewed for signs of nonunion. Complications were recorded.

Results

Overall 21 patients (76% male, average age: 30.4 ± 11.3 years) underwent Latarjet with suture-button fixation. Significant improvements at 1 year were seen in ASES (P < 0.001), SANE (P < 0.001), and VAS (P = 0.011) scores compared with preoperative scores. Of the 21 patients who had reached 1-year follow-up, 17 (81%) reached 2-year follow-up. For the 17 patients who reached 2-year follow-up, there were significant improvements in ASES (P = 0.001), SANE (P = 0.001), and VAS (P = 0.005) scores from preoperative values. When isolating the 17 patients with 2-year follow-up, there were no significant differences between their 1-year and 2-year ASES (P = 0.73), SANE (P = 0.17), and VAS (P = 0.37) scores. Overall, 3 patients (14%) sustained a complication (one redislocation, one with coracoid migration and a fibrous union, and one superior labral tear requiring biceps tenodesis and superior labral repair).

Conclusion

Suture-button fixation of the coracoid during the Latarjet provides encouraging clinical and radiographic outcomes at 1 and 2 years.

Outcomes of the Latarjet Procedure Versus Free Bone Block Procedures for Anterior Shoulder Instability: A Systematic Review and Meta-analysis

BACKGROUND

Free bone block (FBB) procedures for anterior shoulder instability have been proposed as an alternative to or bail-out for the Latarjet procedure. However, studies comparing the outcomes of these treatment modalities are limited.

PURPOSE

To systematically review and perform a meta-analysis comparing the clinical outcomes of patients undergoing anterior shoulder stabilization with a Latarjet or FBB procedure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed, Embase, and the Cochrane Library databases were systematically searched from inception to 2019 for human-participants studies published in the English language. The search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement including studies reporting clinical outcomes of patients undergoing Latarjet or FBB procedures for anterior shoulder instability with minimum 2-year follow-up. Case reports and technique articles were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine the proportions of recurrent instability, other complications, progression of osteoarthritis, return to sports, and patient-reported outcome (PRO) improvement.

RESULTS

A total of 2007 studies were screened; of these, 70 studies met the inclusion criteria and were included in the meta-analysis. These studies reported outcomes on a total of 4540 shoulders, of which 3917 were treated with a Latarjet procedure and 623 were treated with an FBB stabilization procedure. Weighted mean follow-up was 75.8 months (range, 24-420 months) for the Latarjet group and 92.3 months (range, 24-444 months) for the FBB group. No significant differences were found between the Latarjet and the FBB groups in the overall random pooled summary estimate of the rate of recurrent instability (5% vs 3%, respectively; P = .09), other complications (4% vs 5%, respectively; P = .892), progression of osteoarthritis (12% vs 4%, respectively; P = .077), and return to sports (73% vs 88%; respectively, P = .066). American Shoulder and Elbow Surgeons scores improved after both Latarjet and FBB, with a significantly greater increase after FBB procedures (10.44 for Latarjet vs 32.86 for FBB; P = .006). Other recorded PRO scores improved in all studies, with no significant difference between groups.

CONCLUSION

Current evidence supports the safety and efficacy of both the Latarjet and FBB procedures for anterior shoulder stabilization in the presence of glenoid bone loss. We found no significant differences between the procedures in rates of recurrent instability, other complications, osteoarthritis progression, and return to sports. Significant improvement in PROs was demonstrated for both groups. Significant heterogeneity existed between studies on outcomes of the Latarjet and FBB procedures, warranting future high-quality, comparative studies.

Latarjet procedure enables 73% to return to play within 8 months depending on preoperative SIRSI and Rowe scores

PURPOSE

Systematic reviews report return to play (RTP) within 5.8 months (range, 3-8) following the Latarjet procedure, but the factors that influence RTP remain unknown. The present study aimed to report the rate and time of return to play (RTP) during the first 8 months following the Latarjet procedure, and to determine the influence of sport type or patient characteristics.

METHODS

The authors retrospectively collected the records of patients that underwent Latarjet procedures for anterior shoulder instability between 2015 and 2017. Patients were excluded if they had any concomitant rotator cuff tendon lesions, or previous ipsilateral shoulder surgery. The authors retrieved patient demographics, time from injury to surgery, type of sport practiced (overhead/non-overhead, contact/non-contact), as well as pre- and postoperative Western Ontario Shoulder Instability index (WOSI), Shoulder Instability-Return to Sport After Injury index (SIRSI), and Rowe score.

RESULTS

A total of 217 patients (217 shoulders) were eligible for inclusion, comprising 184 males and 33 females, aged 26.8 ± 7.3 years at index surgery. The main sport practiced prior to surgery involved overhead (n = 173, 80%) and/or contact (n = 152, 70%) activities. By 8 month follow-up, 158 patients (73%) resumed their main sport, at a mean of 5.1 ± 1.5 months. Multivariable analysis revealed that RTP was more likely in patients with higher preoperative Rowe score (OR, 1.02; p = 0.024) and SIRSI score (OR, 1.02; p = 0.008).

CONCLUSIONS

By 8 months following the Latarjet procedure, 73% of patients had resumed their main sport. The likelihood of RTP was significantly associated with preoperative Rowe and SIRSI scores, but not with sport type.

LEVEL OF EVIDENCE

IV.

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.

Outcome Measures After Shoulder Stabilization in the Athletic Population: A Systematic Review of Clinical and Patient-Reported Metrics

Background:

Athletic endeavor can require the “athletic shoulder” to tolerate significant load through supraphysiological range and often under considerable repetition. Outcome measures are valuable when determining an athlete’s safe return to sport. Few data are available to guide a clinician’s choice from the variety of measures available.

Purpose:

To describe the use of quantifiable objective outcome measures and patient-reported outcome tools after glenohumeral joint stabilization, specifically in an athletic population. The secondary aim of our study was to assess whether the method of measurement used was clearly described and standardized to aid clinical interpretation.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of MEDLINE, Scopus, SPORTDiscus, and Web of Science databases was performed in December 2018 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the application of selection criteria, a full review of identified papers, and screening of reference lists, a total of 62 studies were included in the review. All studies were independently appraised for quality, predefined data fields were populated and cross-checked for accuracy, and results were then summarized from these data fields.

Results:

Of the 62 included studies, 94% used a quantifiable objective clinical outcome. A majority (85%) of the studies measured range of motion, 21% recorded muscle strength, 5% measured electromyographic activity, 5% examined shoulder kinematics, and 3% assessed joint proprioception after surgery. However, only 18% of the studies clearly described a standardized method of measuring the outcome. Nearly all (95%) of the studies used at least 1 patient-reported outcome measure. The Rowe score was most commonly used (35%).

Conclusion:

We must standardize and clearly describe the use of quantifiable objective outcome measures to aid clinical interpretation. A concerted effort should also be made to standardize the use of patient-reported outcome tools after shoulder stabilization in the athletic population.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures

BACKGROUND

Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain.

PURPOSE/HYPOTHESIS

The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders.

RESULTS

Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment.

CONCLUSION

The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

Immediate self-rehabilitation after open Latarjet procedures enables recovery of preoperative shoulder mobility at 3 months

PURPOSE

To evaluate short-term clinical outcomes of shoulders treated for anterior instability by open Latarjet procedures (OLP) followed by immediate self-rehabilitation. The hypothesis was that patients would recover preoperative function at 3 months with no adverse events related to self-rehabilitation.

METHODS

The authors retrieved clinical and radiographic records of 307 consecutive shoulders treated by the same surgeon for anterior instability by OLP with immediate self-rehabilitation. Four shoulders did not meet eligibility criteria and 38 were lost to follow-up, leaving a study cohort of 265 shoulders. Patients performed self-rehabilitation exercises at home from the first postoperative day. Follow-ups at 1 and 3 months evaluated recurrence of instability, postoperative complications, pain, active forward elevation (AFE), passive forward elevation (PFE), external rotation (ER) and internal rotation (IR).

RESULTS

The difference between mobility before surgery and at 3 months was 0° for AFE, 0° for PFE, 10° for ER, and 0 spine segments for IR. Thirteen shoulders (5%) which had not followed the self-rehabilitation protocol during the first month had significantly more pain and less improvements in mobility (p < 0.05). Multivariable analyses revealed that patients who adhered to self-rehabilitation in the first month had greater improvements of AFE, PFE, and IR (p < 0.05).

CONCLUSIONS

Immediate self-rehabilitation after open Latarjet procedures enabled recovery of preoperative shoulder mobility at 3 months. Patients who did not adhere to immediate self-rehabilitation had more pain and less improvement in mobility. Furthermore, immediate self-rehabilitation was found to be independently associated with better recovery and did not cause any adverse events.

LEVEL OF EVIDENCE

Level IV.

Biomechanical Comparison of the Long Head of the Biceps Tendon Versus Conjoint Tendon Transfer in a Bone Loss Shoulder Instability Model

Background:

Augmentation of Bankart repair with long head of the biceps tendon transfer has been previously described, although there is a paucity of literature describing its biomechanical effects.

Purpose/Hypothesis:

The purpose of this study was to assess the effect of augmenting Bankart repair with either the conjoint tendon or the long head of the biceps tendon, both with and without subcritical (13%) glenoid bone loss. We hypothesized that, in a cadaveric model, augmenting Bankart repair with the long head of the biceps tendon would restore a greater degree of stability compared with augmenting Bankart repair with the conjoint tendon.

Study Design:

Controlled laboratory study.

Methods:

A total of 12 cadaveric shoulders were tested on a 6-degrees-of-freedom robotic musculoskeletal simulator to measure the peak resistance force due to an anterior displacement of 1 cm. The rotator cuff muscles were loaded during testing to simulate physiological conditions. The following test conditions were used for each specimen: (1) intact shoulder, (2) Bankart lesion with 13% anterior bone loss, (3) 13% bone loss with Bankart repair (anchors placed at the 3-, 4-, and 5-o’clock positions), (4) 13% bone loss with both Bankart repair and transfer of the long head of the biceps tendon, and (5) 13% bone loss with Bankart repair and transfer of the conjoint tendon.

Results:

Labral repair with the addition of long head of the biceps tendon transfer had the greatest peak resistance force to anterior displacement among all groups (54.1 ± 5.5 N) and was significantly stronger than both standard Bankart repair by 16.3% (46.5 ± 7.6 N; P = .039) and the conjoint transfer procedure by 16.6% (46.4 ± 7.7 N; P = .008).

Conclusion:

Given the susceptibility of recurrent instability in shoulders with subcritical bone loss after isolated labral repair, it is important to consider augmenting Bankart repair in high-risk patients to avoid potential recurrence and the need for reoperations. Transferring the long head of the biceps tendon to the anterior glenoid represents one possible augmentation.

Clinical Relevance:

We present biomechanical data for a relatively novel technique for augmenting capsulolabral repair strength in an anterior instability model with subcritical bone loss. These data represent biomechanical justification for the utilization of this relatively novel technique.

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.

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

Background:

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

Purpose:

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

Study Design:

Cohort study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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