Salvage Latarjet may provide worse outcomes in terms of recurrent instability and returning to sports compared to primary Latarjet: a systematic review of comparative studies.

BACKGROUND: The Latarjet procedure (LP) is performed as a primary stabilization procedure (primary LP) and a salvage procedure when an earlier shoulder stabilization procedure has failed (salvage LP). However, whether primary LP or salvage LP provides better outcomes for anterior shoulder instability remains unknown. METHODS: Two independent reviewers performed the literature search based on the PRISMA guidelines. A comprehensive search of PubMed, Embase, web of science and Cochrane Library was performed from their inception date to December 4, 2023. Inclusion criteria mainly included the comparison of postoperative outcomes between primary and salvage LP, English language, and full text availability. Two reviewers independently examined the literature, collected data, and evaluated the methodological robustness of the included studies. The Methodological Index for Nonrandomized Studies was used to evaluate the quality of nonrandomized studies. Recurrent instability, complications, reoperations, return to sports, patient-reported outcomes, and range of motion were assessed. Statistical evaluations were conducted using Manager V.5.4.1 (The Cochrane Collaboration, Software Update, Oxford, UK). RESULTS: Twelve studies were included in the systematic review, with 940 shoulders undergoing primary LP and 631 shoulders undergoing salvage LP. Statistically significant differences in favor of primary LP were found in 2 of the 11 and 2 of 4 included studies in terms of recurrent instability and returning to the same sports (RTS) at preinjury level, respectively. In terms of the visual analog scale, subjective shoulder value and the Western Ontario Shoulder Instability Index, 2 of the 4, 1 of the 3 and 1 of the 3 included studies reported statistically significant differences in favor of primary LP. Differences were not noticed regarding complications, reoperations, the time to RTS, the Rowe score, the Athletic Shoulder Outcome Scoring System, and forward flexion. CONCLUSION: Current evidence suggests that compared with primary LP, salvage LP may provide inferior postoperative outcomes in terms of recurrent instability and the rate of RTS at preinjury level. Primary and salvage LP may yield comparable efficacy in terms of complications, reoperations, the rate of RTS, the time to RTS, pain, shoulder function, and range of motion. PROSPERO ID: CRD42023492027.

Shoulder Instability-Return to Sports After Injury (SIRSI) Scale Shows That Lack of Psychological Readiness Predicts Outcomes and Recurrence Following Surgical Stabilization.

PURPOSE: This study aimed to evaluate the predictive ability of psychological readiness to return to sports on clinical outcomes and recurrences in athletes who return to sports following shoulder instability surgery. METHODS: A retrospective analysis was performed of patients who underwent shoulder instability surgery between September 2020 and October 2021 (arthroscopic Bankart repair or Latarjet procedure) with a minimum follow-up of 2 years. Patients were grouped according to the achievement of psychological readiness to return to play using the SIRSI scale (≥ 55 points) measured at 6 months following surgery. Recurrences were measured and functional outcomes were evaluated by the Visual Analogue Scale (VAS), Rowe, and Athletic Shoulder Outcome Scoring System (ASOSS). The minimal clinically important difference (MCID) for the VAS and Rowe scores was calculated using the distribution-based method of ½ standard deviation of the delta (difference between postoperative and preoperative scores). The patient acceptable symptomatic state (PASS) for the VAS scale was set at 2.5 based on previous literature. To evaluate the predictive ability of SIRSI a regression model analysis and a receiver operating characteristic (ROC) curve were used. RESULTS: A total of 108 who achieved psychological readiness (PSR) and 41 who did not (NPSR) met the study criteria. PSR achieved significantly higher percentages of MCID and PASS thresholds for VAS than NPSR (MCID: 68.5% vs 48.7%, p=0.026; PASS: 92.5% vs 58.5%, p<0.001). However, there were no differences in the percentage of patients achieving MCID for the Rowe score between groups (98.1% vs 100%, p=0.999). The only strongest independent predictor of postoperative outcomes was being psychologically ready to return to sports. The SIRSI scale had an excellent predictive ability for recurrences (area under curve 0.745, 95% CI 0.5-0.8). Of those who sustained a recurrence, 20% were not psychologically ready compared to 4.3% who were (p= 0.002). A power analysis was not conducted for this study. CONCLUSION: The SIRSI scale is associated with postoperative clinical outcomes and recurrences in patients who returned to sports following shoulder instability surgery. Patients who were not psychologically ready following shoulder instability surgery had worse clinical outcomes with fewer patients achieving clinically significant outcomes (PASS and MCID) for pain, and a higher risk of recurrence. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

The arthroscopic Latarjet procedure with a posterior guided system and suture-button fixation enables more precise bone block positioning in the axial plane versus anterior screws fixation.

PURPOSE: Adequate position of the bone block during arthroscopic Latarjet procedure is critical for an optimal functional outcome. However, this procedure is complex with a long learning curve. Our aim was to compare the bone block position between a dedicated glenoid posterior instrumentation and suture button fixation versus an anterior screw fixation, on a postoperative computed tomography (CT) scan. METHOD: Seventy-nine consecutive patients operated on for an anterior shoulder instability were included in this retrospective study. The same surgeon performed arthroscopically the Latarjet procedure either with an anterior drilling and screw fixation (Group A), or with a specific posterior glenoid guide pin, a posterior drilling, and a suture cortical button fixation (Group B). Evaluations were made by two independent observers. The position was evaluated by CT scan in the axial and sagittal planes. Learning curves with operative time, complications and clinical outcomes were assessed at a minimum of 2 years of follow-up. RESULTS: Thirty-five patients were included in Group A and 44 in Group B. In Group A, 27 bone blocks were flush (87.1%) and 38 in Group B (92.7%) (p < 0.01). In Group A, 72% of the bone block height was below the equator and 76%, in Group B (ns). The mean operating time was 123 ± 32.5 min in Group A and 95 ± 34.1 min in Group B (p < 0.0001). At the final follow-up, the mean aggregate Rowe score was respectively 94.6 ± 10.4 and 93.1 ± 9.8 points in Groups A and B. The mean aggregate Walch-Duplay score was respectively 94.2 ± 11.6 and 93.4 ± 10.6 points in Groups A and B. There were 11 complications (31.4%) in Group A and five complications (11.3%) in Group B (ns). CONCLUSION: The arthroscopic Latarjet procedure with a posterior drilling guided system and suture-button fixation allows more precise positioning in the axial plane than with anterior drilling and screw fixation. This posterior-guided procedure could reduce intraoperative and short-term complications. LEVEL OF EVIDENCE: Level IV.

Does previous arthroscopic Bankart repair influence coracoid graft osteolysis in Latarjet procedure? A case-control study with computed tomography scan data.

BACKGROUND: The Latarjet procedure is commonly performed in the treatment of recurrent shoulder instability and is also indicated as a salvage procedure for recurrence after failed arthroscopic Bankart repair. Although this procedure has shown success, there has been an increased awareness of complications in recent studies, especially graft osteolysis. Most relevant research has focused on the pathophysiology, incidence, or location of graft osteolysis or the risk factors for graft osteolysis; however, the data are limited to primary Latarjet procedures. This study aimed to investigate the effect of previous arthroscopic Bankart repair surgery on coracoid bone graft osteolysis in the Latarjet procedure. METHODS: This retrospective case-control study analyzed data from patients who underwent primary Latarjet procedures or revision Latarjet procedures following failed arthroscopic Bankart repair. Clinical outcome measures included range of motion, the Subjective Shoulder Value, and the Rowe score. Volumetric analysis of each transferred coracoid graft was performed using early postoperative and late postoperative computed tomography scan data, and the amount of graft osteolysis was then calculated as the percentage of volume reduction of each graft. RESULTS: A total of 32 patients who met the inclusion criteria were included in this study, with 24 patients in the primary Latarjet group (group I) and 8 patients in the revision Latarjet group (group II). The mean age of the patients was 32.5 ± 7.7 years, and the mean follow-up duration was 52.1 ± 8.9 months. Both study groups showed significant improvement in the Subjective Shoulder Value compared with baseline (P < .05). Comparison of postoperative clinical outcome measures showed no significant difference in any outcome parameter between the 2 study groups (P > .05). No recurrence was observed during the follow-up period. A positive apprehension sign was present in 6 patients (25%) in group I and 4 patients (50%) in group II (P > .05). Analysis of radiologic data revealed that all patients underwent some degree of graft osteolysis, with varying osteolysis ratios between 12% and 98%. The mean osteolysis ratio of the coracoid graft was 67.3% ± 22.6% in group I and 69.4% ± 25.6% in group II, with no significant difference between the 2 groups (P > .05). CONCLUSION: The findings of this study suggest that a considerable amount of coracoid graft osteolysis is observed after both primary Latarjet procedures and revision Latarjet procedures following failed arthroscopic Bankart repair. Previous arthroscopic Bankart repair did not seem to have a significant influence on the amount of graft osteolysis, and both primary and revision Latarjet procedures showed satisfactory clinical outcomes.

Stability of novel cow-hitch suture button coracoid bone graft fixation in Latarjet procedures: a biomechanical study.

BACKGROUND: The Latarjet procedure is widely used to address anterior shoulder instability, especially in case of glenoid bone loss. Recently, cortical suture button fixation for coracoid transfer has been used to mitigate complications seen with screw placement. The aim of this biomechanical study was to evaluate the stability of a novel and cost-effective cow-hitch suture button technique, designed to be performed through a standard open deltopectoral approach, and compare this to a well-established double suture button technique. MATERIALS AND METHODS: We randomly assigned 12 fresh frozen cadaveric shoulders to undergo the Latarjet procedure with either 4 suture button (S&N EndoButton) fixations (SB group; n = 6, age 72 ± 9.8 years) or cow-hitch suture button technique using a 1.7-mm FiberTape looped sequentially in 2 suture buttons (Arthrex Pectoralis Button) placed from anterior on the posterior glenoid (CH-SB group; n = 6, age 73 ± 9.3 years). After fixation, all shoulders underwent biomechanical testing with direct loading on the graft via a material testing system. Cyclic loading was performed for 100 cycles (10-100 N) to determine axial displacement with time; each graft was then monotonically loaded to failure. RESULTS: The maximum cyclic displacement was 4.3 ± 1.6 mm for the cow-hitch suture button technique and 5.0 ± 1.7 mm for the standard double suture button technique (P = .46). Ultimate load to failure and stiffness were, respectively, 190 ± 82 N and 221 ± 124 N/mm for the CH-SB technique and 172 ± 48 N and 173 ± 34 N/mm for the standard double SB technique (P = .66 and .43). The most common failure mode was suture cut-through at the anteroinferior aspect of the glenoid for both fixation groups. CONCLUSIONS: The cow-hitch suture button technique resulted in a similar elongation, stiffness, and failure load compared to an established double suture button technique. Therefore, this cost-effective fixation may be an alternative, eligible for open approaches, to the established double suture button techniques.

Latarjet procedure: biomechanical evaluation of 2-screw coracoid fixation.

BACKGROUND: Coracoid nonunion is a relevant complication following the Latarjet procedure and is influenced by multiple factors, including the method of graft fixation. The purpose of this study was to evaluate and characterize the biomechanical properties of various two-screw fixation constructs used for coracoid graft fixation in the Latarjet procedure. METHODS: Forty model scapulae (Sawbones Inc., Vashon, WA, USA) were used for this study. A 15% anterior inferior glenoid bone defect was created. The coracoid was osteotomized at the juncture of the vertical and horizontal aspects, transferred to the anterior-inferior edge of the glenoid, and fixed with either two 3.5 mm fully threaded cannulated cortical screws, two 3.5 mm fully threaded solid cortical screws, two 3.5 mm partially threaded cannulated screws, or two 4.5 mm partially threaded malleolar screws (MS). Biomechanical testing was performed with an Instron material testing machine (Instron Corp., Norwood, MA, USA) by applying loads to the lateral aspect of the transferred coracoid graft. The constructs were preconditioned with nondestructive cyclical loading (0N-20N) to determine construct stiffness. After 100 cycles of dynamic loading, the construct was loaded to failure to determine ultimate failure load, yield displacement, and mode of failure. RESULTS: All failures were associated with plastic deformation of the screws and coracoid graft fracture. There was a significantly lower initial stiffness for partially threaded cannulated screws compared to MS (186 ± 49.3 N/mm vs. 280 ± 65.5 N/mm, P = .01) but no significant differences among the other constructs. There was no difference in ultimate failure load (P = .18) or yield displacement (P = .05) among constructs. CONCLUSION: Two screw coracoid fixation of the coracoid in a simulated classic Latarjet procedure with 3.5 mm fully threaded cortical and cannulated screws is comparable to 4.5 mm MS in strength, stiffness, and displacement at failure. On the other hand, partially threaded 3.5 mm cannulated screws provide inferior fixation stiffness and could potentially affect clinical outcomes.

Kinematic stabilization after the Latarjet procedure: beyond the triple blocking effect.

BACKGROUND: The rationale for the Latarjet procedure was described as the "triple blocking" effect. Satisfactory surgical outcomes have been reported after surgery. However, it has been reported that the "triple blocking" effect increases joint stability, but it does not fully restore it. Moreover, the procedure is nonanatomic and concerns remain regarding the effects. The study of scapulohumeral rhythm, which is a clinical parameter used for the functional evaluation of shoulder kinematics, can offer new perspectives on the rationale for the procedure. This study aimed to compare the shoulder kinematics of patients after the Latarjet procedure to the shoulders of a healthy population using magnetic and inertial measurement units with a motion analysis system. METHODS: A retrospective study with prospective data collection was conducted on 28 patients who underwent the open Latarjet procedure for recurrent shoulder instability. At a minimum 12-month follow-up, each patient was evaluated by assessing the range of motion, the Rowe score, and the Constant-Murley score. Patients were examined using the ShowMotion 3D kinematic tracking system (NCS Lab, Modena, Italy), which uses wireless wearable noninvasive magnetic and inertial measurement units sensors to assess the three-dimensional kinematics of the shoulder. For each plane of elevation (ie, flexion and abduction), the scapulohumeral rhythm was described by three scapulothoracic rotations (ie, protraction-retraction, mediolateral rotation and posterior-anterior tilting) as a function of humeral anteflexion or humeral abduction. RESULTS: The mean time from first shoulder dislocation to surgery was 6.6 ± 3 years (range, 1-12 years). No intraoperative complications occurred, and computed tomography (CT) performed 3 months after surgery showed graft union in all patients. After a mean follow-up time of 32.4 ± 20 months (range, 12-96), the mean Constant-Murley score and Rowe scores were 94.5 ± 4.8 (range, 84-100) and 96.7 ± 3.5 (range, 90-100), respectively. All patients showed no signs of glenohumeral arthritis on X-ray examination. Scapular posterior tilt and scapular internal rotation were significantly greater in the patient group than in the healthy population for the flexion-extension and abduction-adduction movements along the whole shoulder range of motion (all P < .05); no differences were found in upward/downward scapular rotation. CONCLUSION: A greater scapular posterior tilt and scapular internal rotation were observed after the Latarjet procedure. The modified position of the scapula was maintained during the entire range of motion, suggesting a shoulder-stabilizing kinematic effect in addition to the bony, sling and bumper effects.

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.

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

PURPOSE: This study aimed to compare the clinical results of revision Bankart repair versus the Latarjet procedure for failed Bankart repair. METHODS: A literature search was performed in databases, such as Pubmed, Embase, and Scopus Library. The studies were appraised using the Methodological Index for Non-randomized Studies tool. Studies for failed Bankart repair with revision Bankart repair or Latarjet procedure were included. The pain VAS, ROWE score, rate of return to sports and preinjury level of sports, recurrent instability, range of motion, and complications were compared. Additionally, the pain VAS, ROWE score, forward flexion, and external rotation at side were subjected to a meta-analysis. RESULTS: Twenty-four articles were included in the systematic review. The functional outcomes in terms of the ROWE score, recurrent instability, return to sports, and the preinjury level of sports was better in the Latarjet procedure group than those in the revision Bankart repair group (ROWE score, 91 vs. 86.7; recurrent instability rate, 3.5% vs. 14.4%; return to sports rate, 100% vs. 87.9%; return to preinjury level of sports rate, 89.9% vs. 74.9%; all P < 0.001). However, the results of postoperative pain and the postoperative limitation of external rotation at side were worse in the Latarjet procedure group than those in the revision Bankart repair group (pain VAS, 1.4 vs. 0.8; postoperative external rotation at side, 38° vs. 60°; all P < 0.001). In addition, the majority of the complications occurred in the Latarjet procedure group. In the meta-analysis, the postoperative ROWE score was significantly higher in the Latarjet procedure group than that in the revision Bankart group (revision Bankart repair: 95% CI 88.9-80.9, I2 = 65.70; Latarjet procedure: 95% CI 95.8-88.1, I2 = 93.37; P = 0.014). However, the pain VAS, forward flexion, and external rotation at side did not reach the significant level in the meta-analysis. CONCLUSION: Compared with revision Bankart repair, the Latarjet procedure for failed Bankart repair showed better ROWE scores, stability, and return to sports or preinjury level of sports; however, the postoperative pain and the limitation of external rotation at side were worse with more complications. IRB NO: KUMC 2022-01-024. LEVEL OF EVIDENCE: Level IV.

Low rates of serious complications after open Latarjet procedure at short-term follow-up.

PURPOSE: To report on intraoperative and short-term postoperative adverse events after open Latarjet procedure in patients with recurrent anterior shoulder instability. These complications were classified into different grades of severity based on the treatment required and the learning curve of the procedure. METHODS: Ninety-six patients (102 shoulders) underwent open Latarjet procedure for recurrent post-traumatic anterior glenohumeral instability between 2012 and 2020. The minimum duration of patients' follow-up was 6 months. Adverse events were classified into 3 classes based on the severity and subsequent treatment. The complications in the first 50% of all cases were compared with the latter 50% to evaluate the role of learning curve on the complication rates. RESULTS: The mean follow-up was 7.2 ± 2.8 months. The patients' mean age was 26.7 ± 8.9 years and consisted of 83 (86.4%) male and 13 (13.6%) female patients. The total adverse events rate was 18.6%. Adverse events requiring no additional treatment (class 1) occurred in 6 cases (5.8%) including fibrous union (3.9%) and asymptomatic resorption of the graft (1.9%). Adverse events requiring additional or extended nonoperative management (class 2) occurred in 8 cases (7.8%), including coracoid fracture (2.9%), musculocutaneous nerve palsy (1.9%), axillary nerve palsy (0.9%), suprascapular nerve palsy (0.9%), and stiffness (0.9%). All the nerve palsies recovered without long-term sequelae. Adverse events requiring secondary operative procedures (class 3) occurred in 5 cases (4.9%), including symptomatic hardware (1.9%), medial healing of the graft (0.9%), screw loosening (0.9%), and deep infection (0.9%). The rate of adverse events in revision cases was higher than primary cases in 11.7% and 6.8%, respectively (P = .119). The complication rate was significantly higher in the first half of the surgeons' practice (14.7%) than in the second half (3.9%) (P ≤ .05). CONCLUSIONS: The overall complication rate reported in this open Latarjet series is 18.6%; however, the rate of class 3 adverse events that required additional surgery or long-term medical treatment was only 4.9%. Revision cases had a higher rate of complications than primary cases, and the learning curve has had a significant impact on the rate of adverse events.

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

Background: Anterior dislocation is the most common type of shoulder dislocation, and even after appropriate treatment, recurrence after a primary traumatic anterior dislocation is highly frequent. Surgical options for treating recurrent anterior dislocations mainly include Bankart arthroscopic and Latarjet open surgery. We aimed to evaluate the outcomes and complication rates of the open Latarjet procedure in a series of patients with recurrent anterior shoulder dislocation. Methods: A total of 55 patients with recurrent anterior shoulder dislocation who underwent an open Latarjet procedure were included in this retrospective cohort study. Shoulder range of motion and postoperative complications, including neurapraxia, re-dislocation, hematoma, infection, dehiscence, implant failure, and pain, were evaluated. Results: The mean age of the patients was 27.7 ± 6.5 years . The mean time interval after the first dislocation was 3.4 ± 2.7 years . The mean preoperative and postoperative forward flexion (P = 0.200), abduction (P = 0.200), external rotation (P = 0.066), and internal rotation (P = 0.310) were not significantly different. Postoperative complications included 1 case of postoperative musculocutaneous nerve neurapraxia, 1 case of re- dislocation, 1 case of wound dehiscence, and 2 cases of screw breakage. Postoperative pain was also recorded in 11 (20%) patients that were either in the form of occasional night pain (n = 6) or activity-dependent pain (n = 5). Conclusion: Open Latarjet procedure is an efficient procedure for the treatment of recurrent anterior shoulder dislocation. However, its rate of complications remains relatively high, and surgeons must consider this drawback in their decision-making and address patients' expectations.

Low grade of osteoarthritis development after Latarjet procedure with a minimum 5 years of follow-up: a systematic review and pooled analysis.

PURPOSE: The purpose of this systematic review and pooled analysis was to evaluate incidence and risk factors for glenohumeral osteoarthritis (OA) in patients who underwent Latarjet procedure with a minimum of 5-year follow-up. METHODS: The PRISMA guidelines were followed to perform this systematic review. PubMed and EMBASE were searched up to February 29, 2020 for English, human in vivo studies that evaluated glenohumeral OA in patients undergoing Latarjet procedure at least 5 years after surgery. A pooled analysis on the included databases sent by authors was performed to evaluate the risk factors influencing the development or progression of dislocation arthropathy after the Latarjet procedure. RESULTS: Four studies, including a total of 280 patients (213 males and 67 females), were analysed. In our study population, the median age at surgery was 25.0 years (range 20.8-32.6 years). and 92.1% were athletes. In 90% of the cases, the number of dislocations before surgery were fewer than 5. The recurrence of instability after Latarjet procedure was observed only in seven patients (2.5%). The position of the bone graft resulted flush to the anterior glenoid rim in 238 cases (85.3%), medial in 8 (2.9%) and overhanging in 33 (11.8%). Radiological signs of development or progression of shoulder OA were observed in 25.8% of the patients, of which 88.6% presented a grade 1 of OA according to Samilson and Prieto classification. The overhanging position of the bone graft resulted statistically significant for onset or worsening of OA. The age at surgery, the number of dislocations before surgery and the Hill-Sachs lesion were not significantly associated with joint degeneration. Instead, hyperlaxity showed a prevention role in the development of OA after open Latarjet procedure. CONCLUSION: The Latarjet procedure is a valid and safe surgical treatment in recurrent anterior shoulder instability with a low risk of developing moderate or severe OA also at long-term follow-up. The overhanging position of the bone graft represents the principal risk factor of joint degeneration, whereas the hyperlaxity seems to be protective. Finally, age, gender, time between first dislocation and surgery, and number of dislocations do not seem to affect the onset of OA after Latarjet procedure. Therefore, an accurate execution of the Latarjet procedure can be considered a valid treatment even in young and athletes thanks to the low recurrence rates and the low development of major long-term complications. LEVEL OF EVIDENCE: IV.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019.

BACKGROUND: Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR). METHODS: We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR). RESULTS: Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men. CONCLUSION: ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Biomechanical comparison between various screw fixation angles for Latarjet procedure: a cadaveric biomechanical study.

BACKGROUND: The Latarjet procedure is a reliable treatment for the management of anterior glenohumeral instability with glenoid bone loss. However, the biomechanical properties of different fixation angles between screw and glenoid surface (α angle) have rarely been studied. The aim of the study was to investigate and compare the fixation stability, failure load, and failure mechanism between different α angles for Latarjet procedures, which were performed on cadaver specimens. METHODS: Twenty-four shoulder specimens (8 in each of 3 groups) were dissected free of all soft tissue, and a 25% glenoid defect was created. The coracoid process was osteomized and fixed with 2 screws at 3 different α angles: 0° (group A), 15° (group B), and 30° (group C). Specimens were mounted to a testing apparatus, and cyclic loading (100 cycles at 1 Hz) was applied with a staircase protocol (50, 100, 150, and 200 N). Gross graft displacement and interface displacement were measured. The ultimate failure loads and failure mechanisms were recorded. RESULTS: There was no significant difference in gross displacement under any cyclic load between 3 groups. However, a significant larger interface displacement was noted in group C than in group A in 150-N cyclic loading (P = .017). Under failure strength testing, all 24 specimens failed because of screw cutout from the glenoid, and the ultimate failure load was similar among the three groups. CONCLUSION: Compared with the 0° α angle, the displacement after cyclic loading did not significantly increase when the α angle was increased to 15° but significantly increased at 30° for Latarjet procedures, which were performed on cadaver specimens. The results suggest that surgeons should apply the screws as parallel as possible to the glenoid surface when performing the Latarjet procedure. Although mild deviation may not reduce fixation stability, α angles greater than 30° should be avoided.

How does anterior glenoid bone loss affect shoulder stability? A cadaveric analysis of glenoid concavity and bony shoulder stability ratio.

BACKGROUND: Concavity compression is an important glenohumeral stabilizing factor, and recent studies have suggested that peripheral glenoid bone loss creates the most relevant change in stability. This study analyzed changes in the bony shoulder stability ratio (BSSR) with sequential anterior glenoid bone loss (0%-40% width) and with reconstructive bone graft procedures. The aim was to quantify the critical bone defect size that would significantly alter the BSSR and determine restoration of the BSSR with the Latarjet procedure. METHODS: Anterior glenoid defects were created with sequential osteotomies (10%-40%), and defects were reconstructed using 2 Latarjet modifications (classic Latarjet procedure and congruent-arc Latarjet [CAL] procedure). We obtained 108 computed tomography scans of (1) intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). The glenoid concavity depth and concavity radius were measured, and the BSSR was determined using a validated mathematical formula. Statistical analysis was performed to determine significant differences between the intact state and each of the deficient and reconstructed glenoids. RESULTS: The glenoid concavity radius increased by approximately 30% (14 mm) and the glenoid concavity depth decreased by 50% (1.5 mm) from the 0% to 40% defect. The maximal sequential change in depth (1.2 mm, 44%; P < .001) and radius (6 mm, 12%; P < .001) occurred at the 10% glenoid defect. The overall BSSR decreased by approximately 40% (0.15) from the intact glenoid to the 40% defect. This change in the BSSR was most profound (0.11, 30%; P < .001) at the 10% glenoid defect and was only marginal thereafter between the 20% and 40% defects (0.24, 0.22, and 0.21). The Latarjet procedure adequately restored glenoid concavity; however, the CAL procedure significantly overcorrected all 3 parameters at 10% defect. CONCLUSION: The glenoid concavity depth and BSSR undergo progressive deformation with sequential bone loss, and 90% of this change occurs with a 10% glenoid defect. Articular concavity and the BSSR are adequately restored with the Latarjet procedure, and the CAL procedure significantly overcorrects concavity in mild (0%-10%) defects.

A biomechanical comparison of steel screws versus PLLA and magnesium screws for the Latarjet procedure.

INTRODUCTION: The fixation of the coracoid process onto the glenoid is an important step of the Latarjet procedure, and implant-associated complications are a relevant and severe problem. This study compares the fixation strength and failure mode of two biodegradable materials with stainless-steel screws. METHODS: 24 Fresh-frozen cadaveric scapulae were divided into three groups of equal size and received a coracoid transfer. Cadavers were matched according to their bone mineral density (BMD). In group 1, small-fragment screws made of stainless steel were used. In the second group, magnesium screws were used, and in the third group, screws consisted of polylactic acid (PLLA). A continuously increasing sinusoidal cyclic compression force was applied until failure occurred, which was defined as graft displacement relative to its initial position of more than 5 mm. RESULTS: At 5-mm displacement, the axial force values showed a mean of 374 ± 92 N (range 219-479 N) in group 1 (steel). The force values in group 2 (magnesium) had a mean of 299 ± 57 N (range 190-357 N). In group 3 (PLLA), failure occurred at 231 ± 83 N (range 109-355 N). The difference between group 1 (steel) and group 2 (magnesium) was not statistically significant (P = 0.212), while the difference between group 1 (steel) and group 3 (PLLA) was significant (P = 0.005). CONCLUSION: Stainless-Steel screws showed the highest stability. However, all three screw types showed axial force values of more than 200 N. Stainless steel screws and PLLA screws showed screw cut-out as the most common failure mode, while magnesium screws showed screw breakage in the majority of cases. EVIDENCE: Controlled laboratory study.

Intra-articular biomechanical environment following modified Bristow and Latarjet procedures in shoulders with large glenoid defects: relationship with postoperative complications.

BACKGROUND: Although coracoid transfers including the modified Bristow and Latarjet procedures are widely used to treat anterior shoulder instability, the influence of the choice of procedure on the biomechanical outcomes is not well characterized. We aimed to clarify the intra-articular stress distribution following these 2 procedures using 3-dimensional finite-element analysis and to investigate the role of stress distribution in the pathophysiology of postoperative complications. METHODS: Overall, 6 male patients aged 17-47 years with unilateral anterior shoulder instability were recruited. Computed tomographic digital imaging and communications in medicine (CT-DICOM) data of the contralateral (healthy) shoulder of each patient was obtained and used for developing the 3-dimensional normal glenohumeral joint model. A 25% bony defect was created in the anterior glenoid rim where the coracoid process was transferred in the standing and lying-down positions to create the Bristow and Latarjet models, respectively. The arm position was set as 0° or 90° abduction. The Young moduli of the humerus and scapula were calculated using CT data, and set as 35.0 MPa and 113.8 GPa for the articular cartilage and inserted screw, respectively. A compressive load (50 N) was applied to the greater tuberosity toward the center of the glenoid, and a tensile load (20 N) was applied to the tip of the coracoid in the direction of conjoint tendon. Elastic analysis was used to determine the equivalent stress distribution. RESULTS: A significant reduction in mean equivalent stress was observed within the glenoid cartilage for both models (P = .031); however, a new stress concentration appeared within the grafted coracoid-facing region of the humeral-head cartilage in both models. The proximal half of the coracoid graft exhibited lower equivalent stress than the distal half in 5 of the 6 Latarjet models, whereas the proximal half showed higher equivalent stress than the distal half in all 6 Bristow models. High stress concentration was identified at the midpoint of the inserted screw in Bristow models. DISCUSSION AND CONCLUSIONS: Intra-articular stress distribution may explain the different rates of postoperative complications associated with the modified Bristow and Latarjet procedures. New stress concentration within the humeral-head cartilage might contribute to the development of glenohumeral osteoarthritis following both procedures. Stress shielding in the proximal part of the coracoid graft might contribute to osteolysis following the Latarjet procedure. Surgeons should be aware of the risk of breakage of the inserted screw following the modified Bristow procedure.

Early postoperative complications after Latarjet procedure: a single-institution experience over 10 years.

BACKGROUND: The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications. METHODS: This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence. RESULTS: During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P < .001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1 brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases. CONCLUSION: The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.

Results and complications of head-preserving techniques in chronic neglected shoulder dislocation: a systematic review.

BACKGROUND: Humeral head-preserving procedures may be needed for chronic neglected shoulder dislocation because the presenting age of the patient is often reported to be less than 45 years. The aim of this systematic review was to evaluate the results of the various head-preserving procedures for chronic anterior dislocation (CAD) and chronic posterior dislocation (CPD). This review also aimed to evaluate the results of conservative neglect for CAD. METHODS: PubMed, Embase, and Cochrane library databases were queried for studies that reported on results of head-preserving procedures for CAD or CPD and for studies that reported on the results of conservative neglect for CAD. Case reports, review articles, acute dislocations, and fracture-dislocations were excluded. The results of the different techniques were pooled for further evaluation. RESULTS: Seventeen studies were selected for qualitative analysis. These were further subdivided into 9 studies for the CAD group and 11 studies for the CPD group. In the CAD intervention group, 53 shoulders in 7 studies were managed by 5 different head-preserving techniques. The choice of procedure to stabilize the shoulder after open reduction varied between coracoid transfer, capsulolabral repair, remplissage, and Putti-Platt procedure and acromiohumeral K-wire fixation. High resubluxation rates and early arthrosis were reported after open reduction techniques for CAD. In the CAD conservative group, 8 shoulders in 2 studies were managed by conservative methods. In the CPD group, the 2 most common techniques, McLaughlin or modified McLaughlin and bone grafting, were used to treat 74 shoulders in 7 studies and showed good functional outcomes. CONCLUSION: The choice of open reduction and stabilization technique for CAD was highly variable between the different studies and led to a wide variation in the reported outcomes with a high number of complications such as resubluxation and early arthrosis. The conservative treatment of CAD led to poor functional results. The choice of treatment for CPD was mostly between 2 techniques-McLaughlin and modified McLaughlin reconstruction or the bone graft reconstruction-and they consistently led to good functional outcomes with less complications.

Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients.

INTRODUCTION: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure. METHODS: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. CONCLUSIONS: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.