Abstract
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Nothing true or beautiful or good makes complete sense in any immediate context of history. —Reinhold Niebuhr; The Irony of American History (1952)
In the surgical management of anterior shoulder instability, the Latarjet procedure has experienced a surge in popularity. One driving force behind this heightened interest is the recognition that patients with a critical amount of bone loss are prone to poorer outcomes following an arthroscopic Bankart repair of the damaged tissues. While several other options are available to reconstruct a compromised glenoid, the Latarjet remains a popular choice, with an established track record and the possibility of adding a “sling effect” to the benefit of bony restoration. Current practice and clinical research are now directed at further defining and possibly expanding the indications for the Latarjet.
Two avenues of research have led to calls for lowering the threshold for performing a bony procedure like the Latarjet. Critical bone loss has been a common indication for the Latarjet, and the amount of glenoid deficiency that is considered “critical” seems to be shrinking.20,21,27 The Instability Severity Index Score, which takes into account bone loss, as well as ligamentous laxity, patient age, and activity demands, has also been useful for identifying patients at increased risk of failure of a purely soft tissue repair. As with measurements of critical bone deficiency, clinical research has been pushing the inflection point of the Instability Severity Index Score, originally set at 6, lower and lower.3,17,23
In this month’s The American Journal of Sports Medicine, 2 multicentric French studies use a comparative cohort design to explore the success of the Latarjet procedure in different patient populations. In the first, Hardy and colleagues 8 compare the outcomes of patients who underwent the Latarjet following their primary shoulder dislocation with others who experienced a mean of almost 9 dislocations prior to surgery. The authors noted that operations like the Bankart procedure, which aim to repair the damaged anatomy directly, tend to have worse results after the native tissue has been damaged by multiple episodes of instability. 14 Because the Latarjet uses the coracoid process and attached conjoint tendon to create a nonanatomic stabilizing construct, the authors hypothesized that it would be equally successful in both groups of patients.
As the surgery was carried out at 5 clinical centers, 3 different variations of the Latarjet were included in this study: a “mini-open” technique with screw fixation, an arthroscopic technique with screw fixation, and an arthroscopic technique with suture button fixation. After a mean 3.4 years of follow-up, the authors were able to report the results in 83 patients who underwent the Latarjet following a single dislocation and 225 who had surgery after multiple episodes.
The multiple-dislocation group had several characteristics that might have left them prone to worse outcomes. Compared with the single-dislocation group, they had a significantly greater prevalence of both humeral head and glenoid defects and a somewhat higher Instability Severity Index Score. Notwithstanding this potential bias, the outcomes of the 2 groups did not differ significantly. The single-dislocation group had a mean Walch-Duplay score of 67.3 and recurrence rate of 4.8%, compared with 71.8 and 3.6%, respectively, in the multiple-dislocation group. The authors concluded that, when the Latarjet is employed as the initial surgical treatment, it is as effective after multiple episodes of instability as it is after just one such episode.
In this month’s second Latarjet article, Werthel and many of the same authors 24 compared the outcomes of 216 patients who underwent the procedure as their initial surgical treatment for chronic shoulder instability with a group of 20 who had the Latarjet performed to salvage a failed Bankart stabilization. In all cases in this study, whether performed arthroscopically or through a mini-open approach, the transplanted coracoid was fixed in place with 2 cannulated cancellous screws. The mean follow-up in both groups was greater than 3 years, and their demographic details and sports participation histories were also similar. On the other hand, the patients who had undergone a prior Bankart operation were less likely to have a Hill-Sachs lesion, and their Instability Severity Index Score was about 1 point lower.
At the time of follow-up, 5% of the revision group had experienced recurrences, although none of them had had further stabilization surgery. Of the patients who had the Latarjet as their primary procedure, 2.3% experienced recurrences, and 6.5% had undergone revision. Given the numbers available for analysis, these rates were not significantly different. However, the group that had a failed prior Bankart procedure fared significantly worse by several other outcome measures. Their postoperative pain visual analog scale (VAS) score averaged 2.6, compared with 1.2 in the primary group; their mean Walch-Duplay score was 52, compared with 72; and their mean Simple Shoulder Test (SST) rating was 9.3, compared with 10.7.
The authors’ main conclusion is that patients undergoing a Latarjet procedure after a failed Bankart procedure should not be expected to do as well as those who have the Latarjet as their first operation. Although a 2018 Argentine study of the Latarjet in rugby players reported similar results in both primary and revision procedures, 19 the outcomes reported by Werthel et al 24 are not surprising. The results of orthopaedic revision operations are rarely as good as primary procedures. This may be because more extensive damage has occurred by the time the revision procedure is undertaken or because there is something about these patients, whether quantifiable or elusive, that predisposes them to a poorer result. The authors opine that, given the available information, the revision patients had been properly selected to undergo their initial Bankart procedure. Unfortunately, there is not sufficient detail to determine if some of the individual patients could have been identified prospectively as likely to fail a Bankart procedure.
It is notable that a multicentric group of French surgeons only accumulated 20 patients who underwent a revision Latarjet procedure following a failed Bankart operation. One possibility is that the Bankart is used very selectively in France, and hence, the failure rate is very low; another is that the failure rate is similar to other nations, but there just are not very many Bankart repairs being performed there these days. A 2010 article by Thomazeau and colleagues 22 of the French Arthroscopy Society reported the results of a survey of European, American, and South African arthroscopy society members. The contrast between French respondents and the rest of the participants was stark: 72% of French surgeons stated that the Latarjet was their preferred anterior stabilization procedure, compared with only 8% of surgeons from other countries.
French surgeons may be wondering why their colleagues from elsewhere are so hesitant to embrace the Latarjet more fully. Indeed, a 2018 Korean study that compared the 2 procedures in patients with 15% to 20% glenoid bone loss reported similar outcome scores but a substantially higher recurrence rate following the Bankart: 22.9% versus 6.5%. 11 Similarly, a 2016 systematic review of 8 studies comprising 416 Bankart repairs and 279 Latarjets performed as primary or revision surgery reported better performance from the Latarjet. 2 The recurrence rate from the Latarjet was 11.6%, compared with 21.1% for the Bankart. The Bankart patients also scored about 6 points lower on the Rowe scale and lost about 9° more external rotation. 2
Nevertheless, there are several reasons that surgeons might be reluctant to expand their use of the Latarjet. Today’s patients often expect to have an arthroscopic procedure and may be resistant to the idea of an open operation. Of course, the Latarjet can also be performed arthroscopically,4,10 but this is definitely a more complex undertaking than an arthroscopic Bankart. A recent systematic review of 6 studies that compared the open with the arthroscopic Latarjet noted similar rates of recurrence, revision stabilization surgery, and complications between the 2 techniques. 10 In 2 included studies that reported the persistence of apprehension postoperatively, a greater prevalence of apprehension was found among patients who had an arthroscopic operation. Citing one study that documented the surgeon’s learning curve when converting from an open to an arthroscopic technique, the authors of this review concluded, “The significant learning curve associated with this procedure suggests the arthroscopic procedure may be advisable to perform only in high-volume centers with experienced arthroscopists.”10(p1248)
Another concern about the Latarjet has been the risk of secondary arthropathy over the long term.1,7,12,15 This concern is not unique to the Latarjet, 16 and the risk may be even greater in older patients. A Swiss study published a few months ago in AJSM reported a mean 11-year follow-up in 39 patients who were 40 years of age or older at the time of their open Latarjet procedures. 7 No patient experienced a postoperative dislocation, while 3 reported subluxations, and 5 were noted to exhibit apprehension on examination. The Walch-Duplay score averaged 89, and 36 patients rated their result as excellent. However, radiography detected severe dislocation arthropathy in 14 patients (37%) and the progression of arthropathy by at least 2 grades in 17 (45%).
These authors noted that patients with severe arthropathy had already shown some degenerative changes at the time of surgery; older age and lateral graft positioning of more than 1 mm were associated with the progression of signs of arthropathy. They concluded that the progression of arthropathy was more related to the preoperative state of the shoulder than to the procedure itself, as long as the graft was not malpositioned. A 2013 study with a mean 16 years of follow-up also identified lateral coracoid placement, as well as age over 40 years, as factors that increased the risk of arthropathy. 12 Contrasting with these findings is a study in this month’s AJSM that imaged patients with computed tomography a mean 40 months after surgery. 26 These authors noted that 11 grafts that were laterally placed at the time of surgery seemed to remodel without evident arthropathy.
A landmark 25-year follow-up study of 255 patients following a primary anterior shoulder dislocation by Hovelius and Saeboe 9 lends support to the opinion that the instability itself may be a major factor in the pathogenesis of arthropathy, regardless of the ensuing treatment. Only 62 of the 257 shoulders available for study had undergone a surgical stabilization, of which 27 were identified as a Bristow-Latarjet procedure. Although arthropathy was observed across all groups of patients, regardless of the treatment, it was less likely to occur in shoulders that never experienced a second instability event. Furthermore, shoulders that were surgically stabilized had a lower prevalence of arthropathy than those that simply became stable over time, and although the numbers were small, patients who had bone block procedures were not more likely to develop arthropathy than those undergoing soft tissue stabilization.
Another potential concern with the Latarjet is the possibility of absorption or osteolysis of the coracoid after surgery. It’s not surprising that such a process should occur; other glenoid bone grafts have been shown to remodel, most commonly down to the original glenoid contour.16,25 As screws are often used to fix the coracoid in place, a theoretical consequence of excessive absorption is exposure of the screws 18 and subsequent pain or secondary injury. 8 Graft absorption may be more likely when the Latarjet is used in shoulders with little to no glenoid bone loss.5,6 In 2011, Di Giacomo and colleagues 5 reported their findings from computed tomography scans of 26 shoulders an average of 17.5 months postoperatively. On average, they found that more than half of the graft had been resorbed, although they did not document any resulting clinical complications. A subsequent comparative study by many of the same authors found 65.1% mean resorption in patients who had no glenoid deficiency, compared with 39.6% among those with more than 15% glenoid bone loss. 6 A recent study of revisions of failed Latarjet procedures by Provencher and colleagues 18 found that a mean 78% of the graft bone had resorbed, raising the possibility that this resorption may in some cases increase the risk of recurrent instability.
Although the success rate of the Latarjet procedure is high, failures do occur and can be challenging to treat. A 2008 study from Lyon reported the outcomes of 34 patients whose failed Latarjets were revised with a modified Eden-Hybinette procedure. 13 The revision was generally successful, but when the patients were reassessed at a mean 6.8 years after surgery, 4 had recurrent instability, 13 had a positive apprehension sign, and 7 had results graded as fair or poor on the Rowe scale. The study by Provencher and colleagues 18 just referenced reported revisions of 31 failed Latarjet procedures utilizing fresh distal tibia allografts. At a mean 47 months after surgery, there had been no further recurrences, and clinical outcome scores were greatly improved.
The Latarjet procedure has shown itself to be a successful choice in the treatment of anterior shoulder instability associated with glenoid bone loss. Although there is concern for the prospect of late secondary arthropathy, if the procedure is properly performed much of that risk may be related to the instability itself rather than the operation undertaken to treat it. Its use as a primary treatment in the absence of bone loss may be more controversial. Many surgeons would like an alternative to the arthroscopic Bankart repair in patients without bone loss whose preferred activities place them at greater risk for recurrence, and some are choosing the Latarjet to fill that role. Clinical research, especially studies with long-term follow-up, will continue to define the place of the Latarjet procedure in the treatment of anterior shoulder instability.