Strength after the arthroscopic Latarjet procedure: Are shoulder internal rotation, elbow flexion & supination strength decreased?

Background

The Latarjet procedure is an effective shoulder stabilizing surgery, however, the procedure results in an alteration of anatomy that may result in shoulder and elbow weakness. Thus, the purpose of this study was to assess post-operative shoulder and elbow strength after the Latarjet procedure. We hypothesized that shoulder and elbow strength are not affected after the procedure.

Methods

The study group consisted of patients that had undergone the arthroscopic Latarjet procedure. An isokinetic dynamometer was used to evaluate the strength of bilateral shoulder internal rotation, elbow flexion, forearm supination using peak torque (N/m), as well as grip strength (kilograms). Shoulder range of motion and the potential effects of hand dominance were further analysed.

Results

Nineteen patients with a mean age of 29 years and an average follow up of 47 months were included. Shoulder internal rotation strength, elbow flexion and forearm supination strength and grip strength were not significantly different when compared to the non-operative side (p > 0.13). The range of shoulder external rotation was significantly reduced (p < 0.001) on the Latarjet side.

Conclusion

The results from this study demonstrate no statistically significant differences in the strength of shoulder internal rotation, elbow flexion, forearm supination or grip strength despite the surgical alterations to the subscapularis and conjoint tendon.

Outcomes of Arthroscopic Latarjet as a Revision Surgery After Failed Arthroscopic Bankart Repair

BACKGROUND

The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established.

PURPOSE

To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure.

DESIGN

Cohort study; Level of evidence, 3.

METHODS

This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed.

RESULTS

A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group (P = .14). Patients in the revision group had a lower return to the previous level of sports participation (P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group (P = .000).

CONCLUSION

Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected.

Return to Preinjury-Level Sports After Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability in Professional Athletes

Background

The Latarjet procedure is recommended to treat recurrent anterior shoulder instability with glenoid bone loss. Longer return-to-sport (RTS) times have been reported after the open Latarjet when compared with the arthroscopic Latarjet.

Purpose

To assess the clinical outcomes and RTS in athletes who underwent an arthroscopic Latarjet.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 46 professional athletes with recurrent anterior shoulder instability who underwent an arthroscopic Latarjet between 2010 and 2016. Patients were divided by type of sport: noncollision and nonoverhead (n = 22), collision and martial arts (n = 13), and overhead (n = 11). Sport activity was evaluated with the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Subjective Patient Outcome for Return to Sports score, and RTS time. Clinical results were evaluated by Constant-Murley score, Walch-Duplay score, and range of external and internal rotation. Complication rates, recurrence of shoulder instability, and number of revision procedures were recorded. Correlation tests were used to assess the relationship between measured parameters.

Results

The mean ± SD patient age was 27.1 ± 7.3 years, and the mean follow-up was 50.7 ± 18 months. Overall, 44 patients (95.7%) returned to their previously practiced sports, and 40 (87%) returned to their preinjury levels. The RTS time was 5 ± 1.4 months, with no significant difference among sport types. KJOC and Subjective Patient Outcome for Return to Sports scores were 95.2 ± 5.6 and 9.5 ± 1, respectively. Significant pre- to postoperative improvement was seen on the Constant-Murley score (from 54.3 ± 9.4 to 87.9 ± 8.2; P = .001) and Walch-Duplay score (from 53.7 ± 7.3 to 88.1 ± 10.7; P = .001). Mean postoperative external and internal rotation was 72.8° ± 18.6° and 81.3° ± 11.3°. Procedure-related complications occurred in 10 patients (21.7%); recurrence of shoulder instability was observed in 4 (8.7%); and 4 (8.7%) underwent revision surgery. A worse Walch-Duplay score was significantly associated with longer RTS time (r = -0.39; P = .019) and lower KJOC score (r = 0.29; P = .03).

Conclusion

There was a 95.7% RTS rate after the arthroscopic Latarjet procedure, although the procedure was not free from complications.

Arthroscopic Latarjet: 2 or 4 Cortical Buttons for Coracoid Fixation? A Case-Control Comparative Study

BACKGROUND

While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons.

PURPOSE

To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months).

RESULTS

The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B (P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B (P≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B (P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009).

CONCLUSION

A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).

Mid-term outcomes of arthroscopic Latarjet procedure in chronic anterior shoulder instability after failed Bankart surgery or with significant glenoid bone loss

INTRODUCTION

Arthroscopic Latarjet surgery is a technique developed to minimize invasive surgical treatment of anterior shoulder instability. However, compared to an open Latarjet operation, it is considered more technically demanding. The aim of our study was to assess its mid-term success rate in the hands of a surgeon with sufficient experience.

PATIENTS AND METHODS

We included 32 patients with recurrent anterior shoulder instability in the analysed cohort who had undergone arthroscopic intervention according to Latarjet as a revision after a previous failed Bankart operation or in the case of the significant bone loss of the glenoid. Patients were followed-up according to a defined protocol for an average of 30.2 months (range 12‒60 months). In this study, we present clinical and radiological results of a long-term follow-up evaluated using Rowe, UCLA, and SST scoring systems, comparing ranges of motion, and thorough analysis of CT examinations performed no earlier than 6 months after surgery. Rowe, UCLA and SST scores were determined pre- and postoperatively; the range of motion was compared to the contralateral side.

RESULTS

The postoperative score was significantly improved in accordance with the clinical finding in the followed-up group (Rowe: preOP 22.1 points ‒ postOP 97.6 points, UCLA: preOP 19.50 points ‒ postOP 33.30 points, SST: preOP 8.2 points ‒ postOP 11.5). However, the postoperative external rotation remains significantly smaller as compared to the contralateral side. The feared neurovascular damage did not occur in our cohort; one patient (3 %) had an infection in the access portal, which was managed conservatively; one patient (3 %) required revision surgery.

CONCLUSION

Our results demonstrated that when in the hands of experienced surgeon, the arthroscopic Latarjet surgery is an effective surgical method with a low incidence of complications and excellent mid-term clinical outcomes (Fig. 17, Ref. 25).

Clinical Relevance of Persistent Off-Track Hill-Sachs Lesion After Arthroscopic Latarjet Procedure

BACKGROUND

The Latarjet procedure is often used to address off-track Hill-Sachs lesions (OFF-HS) in shoulders with anterior instability. There are concerns as to whether the Latarjet procedure is able to convert all OFF-HS into on-track Hill-Sachs lesions (ON-HS) and whether this limitation could explain the cases of recurrent postoperative instability.

HYPOTHESIS

Latarjet surgery converts many preoperative OFF-HS lesions, but not all of them, and there is a difference in the failure rate between shoulders with converted lesions and those with persistent OFF-HS lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with anterior shoulder instability and an OFF-HS lesion treated with an arthroscopic classic Latarjet procedure between January 2010 and September 2017 were retrospectively evaluated. Patients with moderate or severe shoulder arthrosis, rotator cuff tears, or age older than 50 years were excluded. Glenoid track (GT), HS, HS interval (HSI), and the difference between HSI and GT (ΔHSI-GT) were measured preoperatively. A postoperative computed tomography scan and a clinical evaluation, including the Rowe and Western Ontario Shoulder Instability scores, were performed at a minimum 1- and 2-year follow-up, respectively. Postoperatively, 2 groups of patients were obtained: (1) patients with postoperative persistent OFF-HS; (2) patients with postoperative ON-HS. Clinical and imaging data were compared between the 2 groups.

RESULTS

A total of 51 patients (n = 51 shoulders), with a mean age of 29.8 ± 8.4 years (range, 15-50 years), met the inclusion criteria. Six shoulders (11.8%) still showed OFF-HS lesions despite Latarjet surgery. There were no postoperative dislocations, but 3 patients reported subluxations. The subluxation rate was significantly higher in the postoperative persistent OFF-HS group (2 [33%] vs 1 [2.2%]; P = .033). There was a wider preoperative HSI (29.8 ± 2.4 mm vs 22.9 ± 3.5 mm; P < .001) and a larger preoperative ΔHSI-GT (12.2 ± 3.8 mm vs 4.82 ± 3.2 mm; P < .001) in the persistent OFF-HS group. A receiver operating characteristic curve was performed based on preoperative ΔHSI-GT values. A preoperative ΔHSI-GT value ≥7.45 mm predicted a persistent OFF-HS after Latarjet surgery (sensitivity, 100%; specificity, 87%; positive predictive value, 50%; and negative predictive value, 100%).

CONCLUSION

Latarjet surgery converted many preoperative OFF-HS lesions into ON-HS lesions, but not all of them. Six patients (11.8%) retained an OFF-HS and had a statistically significantly higher failure rate after Latarjet surgery compared with those with postoperative ON-HS lesions. Because there were few postoperative OFF-HS lesions and few recurrences, findings are statistically fragile and should be confirmed with larger series.

The arthroscopic Latarjet: a multisurgeon learning curve analysis

BACKGROUND

The open Latarjet procedure is a standard surgical treatment option for anterior shoulder instability in patients with a high risk of failure following soft tissue stabilization. The arthroscopic technique has potential advantages of minimal invasiveness, reduced postoperative stiffness, and faster rehabilitation but is regarded as technically challenging with concern over surgical risk during the learning curve. The aim of this study was to undertake a multisurgeon, large-volume learning curve analysis of the arthroscopic Latarjet procedure using continuous learning curve analysis.

METHODS

Individual patient data from 12 surgeons across 5 countries were retrospectively reviewed. A total of 573 patients undergoing the arthroscopic Latarjet procedure were included. Outcome measures of learning were collected, including operative time, computed tomography (CT) bone-block positioning, complications, and patient-reported outcome measures (PROMs). A segmented linear regression modeling technique was used for learning curve analysis.

RESULTS

High-volume surgeons converged to an operative time steady state after 30-50 cases. Surgeons completing fewer procedures demonstrated a constant reduction in operative time without reaching a plateau. Low-volume surgeons completing fewer than 14 operations did not demonstrate a reduction in operative time. Accuracy of bone-block positioning on postoperative CT demonstrated constant improvement without reaching a plateau after 53 cases. There was no change in PROMs or complications with increased operative volume.

CONCLUSION

Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning. Only surgeons expecting to undertake the arthroscopic Latarjet in high volume should consider adopting this procedure.

Arthroscopic Latarjet for Recurrent Shoulder Instability

Background and Objectives: The all-arthroscopic Latarjet (aL) procedure was introduced to manage recurrent shoulder instability. Our study aimed to report the outcomes of aL procedures with the Rowe, University of California-Los Angeles (UCLA), simple shoulder test (SST) scores, and range of motion (ROM) in external rotation at a minimum follow-up of 2 years. Material and Methods: A total of 44 patients presenting recurrent shoulder instability were managed with aL procedure. Clinical outcomes were assessed at a mean follow-up of 29.6 ± 6.9 months. The postoperative active ROM was measured and compared with the contralateral shoulder. The Rowe, UCLA, and SST scores were administered preoperatively and postoperatively. Results: No patients experienced infections or neuro-vascular injuries. Seven (15%) patients required revision surgery. After surgery, the external rotation was statistically lower compared to the contralateral shoulder, but it improved; clinical outcomes also improved in a statistically significant fashion. Conclusions: The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist.

Radiographic Analysis of Glenoid Size and Shape After Arthroscopic Coracoid Autograft Versus Distal Tibial Allograft in the Treatment of Anterior Shoulder Instability

BACKGROUND

The Latarjet procedure for autograft transposition of the coracoid to the anterior rim of the glenoid remains the most common procedure for reconstruction of the glenoid after shoulder instability. The anatomic glenoid reconstruction using distal tibial allograft has gained popularity and is suggested to better match the normal glenoid size and shape. However, concerns about decreased healing and increased resorption arise when an allograft bone is used.

PURPOSE

To use radiological findings to evaluate the arthroscopic reconstruction of the glenoid with respect to the size, shape, healing, and resorption of coracoid autograft versus distal tibial allograft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review was performed of 48 consecutive patients who had an arthroscopic bony reconstruction of the glenoid (12 coracoid autograft, 36 distal tibial allograft), diagnosed anterior shoulder instability, and computed tomography (CT)-confirmed glenoid bone loss more than 20%. Coracoid autograft was performed only when tibial allograft was not accessible from a bone bank. Two fellowship-trained musculoskeletal radiologists reviewed pre- and postoperative CT scans at a minimum follow-up of 6 months for the following: graft position, glenoid concavity, cross-sectional area, width, version, total area, osseous union, and graft resorption. Clinical outcome was noted in terms of instability, subluxation, and dislocation at a minimum follow-up of 2 years. Simple logistic regression, 2-tailed independent-sample t tests, paired t tests, and Fisher exact tests were performed.

RESULTS

Graft union was seen in 9 of the 12 patients (75%) who had coracoid autograft and 34 of the 36 patients (94%) who had tibial allograft (odds ratio, 5.66; 95% CI, 0.81-39.20; P = .08). The odds ratio comparing allograft to coracoid for overall resorption was 7.00 (95% CI, 1.65-29.66; P = .008). Graft resorption ≥50% was seen in 3 (8%) of the patients who had tibial allograft and none of the patients who had coracoid autograft. Graft resorption less than 50% was seen in the majority of patients in both groups: 27 (73%) patients with tibial allograft and 5 (42%) patients with coracoid autograft. No statistically significant difference was found between the 2 procedures regarding anteroposterior diameter of graft ( P = .81) or graft cross-sectional area ( P = .93). However, a significant difference was observed in step formation between the 2 procedures ( P < .001). Two patients experienced subluxations in the coracoid group (16%) as well as 2 patients in the tibial allograft group (6%) with a P value of .25.

CONCLUSION

Arthroscopic anatomic glenoid reconstruction via distal tibial allograft showed similar bony union but higher resorption compared with coracoid autograft. Even so, no statistically significant difference was found between the 2 procedures regarding final graft surface area, the size of grafts, and the anteroposterior dimensions of the reconstructed glenoids. These short-term results suggest that distal tibial allografts can be used as an alternative to coracoid autograft in the recreation of glenoid bony morphologic features.

A guided surgical approach and novel fixation method for arthroscopic Latarjet

BACKGROUND

Most of the complications of the Latarjet procedure are related to the bone block positioning and use of screws. The purpose of this study was to evaluate if an arthroscopic Latarjet guiding system improves accuracy of bone block positioning and if suture button fixation could be an alternative to screw fixation in allowing bone block healing and avoiding complications.

MATERIALS AND METHODS

Seventy-six patients (mean age, 27 years) underwent an arthroscopic Latarjet procedure with a guided surgical approach and suture button fixation. Bone graft union and positioning accuracy were assessed by postoperative computed tomography imaging. Clinical examinations were performed at each visit.

RESULTS

At a mean of 14 months (range, 6-24 months) postoperatively, 75 of 76 patients had a stable shoulder. No neurologic complications were observed; no patients have required further surgery. The coracoid graft was positioned strictly tangential to the glenoid surface in 96% of the cases and below the equator in 93%. The coracoid graft healed in 69 patients (91%).

CONCLUSIONS

A guided surgical approach optimizes graft positioning accuracy. Suture button fixation can be an alternative to screw fixation, obtaining an excellent rate of bone union. Neurologic and hardware complications, classically reported with screw fixation, have not been observed with this guided technique and novel fixation method.