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Open Journal of Orthopedics, 2018, 8, 273-289
http://www.scirp.org/journal/ojo
ISSN Online: 2164-3016
ISSN Print: 2164-3008
DOI:
10.4236/ojo.2018.87031 Jul. 13, 2018 273 Open Journal of Orthopedics
Intraoperative Findings and Outcome of
Latarjet Procedure
Andreas M. Riederer1, Thomas Lattmann2, Christoph Meier3, Heike A. Bischoff-Ferrari4,
Michael Dietrich1, Patrick Grueninger1
1Division of Traumatology/Orthopedics, Department of Surgery, Waid City Hospital, Zurich, Switzerland
2Division of Vascular Surgery, Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
3Division of Traumatology/Orthopedics, Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
4Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
Abstract
Background:
The purpose of this case series was to retrospectively compare
radiological, clinical and functional outcomes and complications of diagnostic
arthroscopy with open Latarjet procedures pre-
and postoperatively within
one year after surgery. Additionally we compared
the pathologic findings
during diagnostic arthroscopy with the radiological findings in preoperative
contrast enhanced CT or MRI scans.
Methods:
Between 07/2009 and 11/2013
46 cases with unidirectional antero-inferior shoulder instability were en
rolled,
4 cases were lost during the follow-up within
one year postoperatively. Plain
radiographs, contrast enhanced multislice studies, Instability Severity Index,
Constant, Duplay and Rowe Scores were obtained preoperatively. Diagnostic
arthroscopy was performed in all cases prior to open Latarjet
procedure. At
one year follow-up Constant, Duplay and Rowe Scores were obtained; pos
i-
tion and consolidation of the coracoid transfer were assessed by conventional
x-ray studies.
Results:
At one year follow-up a
significant improvement of all
scores was recorded (Constant Score 95.8 vs. 86.7; Duplay Score 93.7 vs. 25.2,
Rowe Score 98.1 vs. 31.7, (
p
< 0.001)). During arthroscopy 28 of 42 Hill
-
Sachs-lesions were considered as engaging. 8 HAGL (humeral avulsions of
the
gleno-humeral ligaments) and 4 IGHL (inferior gleno-humeral ligaments) l
e-
sions were detected of which none were suggested during the preoperative r
a-
diological investigation
. Complications observed were: screw migration (5),
hematoma (1), infection (1) and recurrence (1).
Conclusion:
The
Latarjet
procedure is a reliable technique with very good clinical outcomes. Diagnostic
arthroscopy is a valuable tool to detect HAGL- and IGHL-lesions and to v
i-
sualize the engaging potential of Hill-Sachs-lesions. An ad
ditional arthroscopy
may help to indicate a Latarjet procedure and to address concomitant patho
l-
ogies. Level of evidence: Level IV, case series.
How to cite this paper:
Riederer, A.M.
,
Lattmann, T
., Meier, C., Bischoff-
Ferrari,
H
.A., Dietrich, M. and Grueninger, P.
(201
8) Intraoperative Findings and Out-
come of Latarjet Procedure
.
Open Journal
of Orthopedics,
8
, 273-289.
https://doi.org/10.4236/ojo.2018.87031
Received:
May 23, 2018
Accepted:
July 10, 2018
Published:
July 13, 2018
Copyright © 201
8 by authors and
Scientific
Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution
International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
A. M. Riederer et al.
DOI:
10.4236/ojo.2018.87031 274 Open Journal of Orthopedics
Keywords
Shoulder Instability, Shoulder Arthroscopy, Latarjet Procedure, HAGL
Lesion, Bankart Lesion, Instability Severity Index Score, Engaging Hill-Sachs
Lesion
1. Introduction
Shoulder stabilization surgery for antero-inferior shoulder instability has ad-
vanced in the last three decades with further developments in arthroscopy me-
thods and suture anchors to address shoulder instability [1] [2] [3]. Different
shoulder stabilization techniques can be categorized in anatomical or non-
anatomical reconstruction, soft tissue or bony reconstruction and open or arth-
roscopic approaches. One common option consists of soft-tissue repair using
open or arthroscopic capsulolabral repair (Bankart-repair) with the aim to re-
construct native anatomy to ensure sufficient stability of the shoulder, thus rely-
ing on soft tissue quality and sufficient anterior glenoid bone stock [4] [5] [6].
However unsatisfactory outcomes have been described regarding the Bankart-
repair in presence of miscellaneous pathologies associated with shoulder insta-
bility, including humeral avulsions of the gleno-humeral ligaments (HAGL-lesion)
[7] [8], lesions of the inferior gleno-humeral ligaments (IGHL-lesion), bony
glenoid defects/osseous Bankart-lesions and engaging Hill-Sachs-lesions [2] [9].
In these aforementioned situations or previous failed Bankart-repair the Latarjet
procedure, the transfer of the coracoid with the attached conjoined tendon to the
anterior glenoid rim, has been described as useful alternative technique for ante-
rior shoulder stabilization [1] [10] [11] [12]. Notably, also the Latarjet procedure
improved since its first description in 1954 [13]. The stability of the shoulder af-
ter Latarjet procedure is supported by several factors. The transferred coracoid
graft reconstructs the anterior glenoid rim in bone deficient cases and prevents
an engaging of a Hill-Sachs-lesion at the antero-inferior glenoid rim through an
increased articular glenoid surface [2] [3] [14]. In addition the also transferred
conjoined tendon acts in combination with the lowered part of the subscapula-
ris-split as a dynamic reinforcement of the antero-inferior joint section in ab-
duction and external rotation. The Latarjet-procedure biomechanically supports
both ligamentous and osseous insufficiencies and is therefore indicated for
treatment of both conditions [15]. The development of the Instability Severity
Index Score (ISI-Score) [16] aimed at selection of patients with anterior shoulder
instability who would benefit from surgery. Furthermore, the use of multi-slice
radiological investigations offers a 3 dimensional view and detailed structural
information to help select patients who will benefit from surgery. However, de-
spite technical improvements certain pathologies such as HAGL-lesions, IGHL-
lesions or the significance of an engaging Hill-Sachs-lesion may be underesti-
mated in CT and MRI investigations, as these are static and not dynamic inves-
A. M. Riederer et al.
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10.4236/ojo.2018.87031 275 Open Journal of Orthopedics
tigations. The main goal of this case series was to compare radiological, clinical
and functional outcomes and complications of diagnostic arthroscopy followed
by open Latarjet procedures pre- and postoperatively. Additionally we compared
pathological findings during diagnostic arthroscopy with the radiological find-
ings in preoperative contrast enhanced CT or MRI scans. The primary endpoint
of this study was the final follow-up one year postoperative. We hypothesized
that at final follow-up the clinical global function (Constant Score) as well as the
subjective shoulder stability (Duplay and Rowe Score) should improve. Our
second hypothesis was that despite extensive preoperative investigations the ex-
tent of injury accountable for the resulting antero-inferior shoulder instability is
underestimated and diagnostic arthroscopy helps in decision finding for Latarjet
procedure and to address concomitant pathologies.
2. Material and Methods
2.1. Patients
Between July 2009 and November 2013 diagnostic shoulder arthroscopy with
subsequent open Latarjet procedure was performed on 45 patients with ante-
ro-inferior instability in 46 shoulders at the Department of Surgery in the Waid
City Hospital in Zurich. Forty-one patients with 42 affected shoulders with a
minimum follow-up of 11 months were included in this case series. Excluded
were 4 of the initial 45 patients that were lost to follow-up at 3 months postope-
ratively. These 4 patients had “perfect” results regarding postoperative Constant,
Duplay and Rowe Scores as well as “perfect” radiological follow-up 3 months
postoperatively but wished to conclude therapy at this time and leave the study.
The local ethics committee approved this study (Req-2017-00412). All patients
signed informed consents for the operative treatment, possible supplement sur-
gery in case of unanticipated pathologies or conversion to an appropriate tech-
nique referring to the intraoperatively found pathologies and all follow-up in-
vestigations. Clinical examinations and plain radiological studies were evaluated
and compared pre-operatively and at follow-up. Patients receiving other stabili-
zation procedures were not included in this study.
2.2. Operative Procedure
All procedures were performed with patients under general anesthesia with an
interscalene catheter for postoperative pain control (Perifix catheter, B. Braun
Medical AG, Switzerland, Accufuser Silicone Baloon Infuser-Continuos Type,
Woo Young Medical Co, LTD, France/Korea, Ropivacain 0.2% continuous, Ro-
pivacain 0.6% boli). The patient was placed in a standardized beach-chair posi-
tion, arm traction of 2 to 3 kg depending on the patient’s build was applied dur-
ing diagnostic shoulder arthroscopy. Cefuroxime as antibiotic prophylaxis was
routinely administered perioperative in patients without previous shoulder sur-
gery. In revision surgery procedures tissue samples regarding low grad infections
were obtained before administration of cefuroxime. The gleno-humeral joint
A. M. Riederer et al.
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10.4236/ojo.2018.87031 276 Open Journal of Orthopedics
was infiltrated with 20ml of diluted epinephrine (1ml of epinephrine (1 mg/ml)
and 19ml of normal saline solution) to decrease intraoperative bleeding. A stan-
dardized survey of the glenohumeral joint documented typical instability asso-
ciated pathologies, in particular bony pathologies such as Hill-Sachs-, bony
Bankart-lesions and defects of the glenoid or inverted pear formation. In addi-
tion the engaging potential of Hill-Sachs-lesions was visualized by positioning
the arm in 90o abduction and maximal external rotation. A positive engaging
was recorded when the Hill-Sachs-lesion cavity fell in the glenoid without any
additional force [2]. Secondary intraarticular pathologies requiring mandatory
surgery were addressed arthroscopically in the same session. For tenodesis of the
long head of the biceps tendon (LHBT) or reconstruction of an isolated subsca-
pularis lesion the technique described by Grueninger
et al.
was used [17]. After
complete survey of the gleno-humeral joint an open Latarjet procedure was per-
formed with at least one of the following pathologies present: Engaging Hill-
Sachs-lesion, HAGL-, IGHL-lesion, bony Bankart-lesion/glenoid bone deficien-
cy (>25% of anterior-posterior glenoid diameter or <25% of anterior-posterior
glenoid diameter plus other above named lesion), or revision surgery after failed
Bankart-repair. The Latarjet procedure was performed as a standardized adapted
mini-open procedure [18] using the “Bristow Latarjet Instability Shoulder Sys-
tem” of DePuy Synthes Mitek Sports Medicine as described by Lafosse
et al.
2007, who developed and is using this system in an arthroscopic technique [3].
In particular, attention is given to place the coracoid graft flush with the glenoid
surface and to place the implanted screws at least 7mm from the glenoid margin
to result in the desired graft placement and to avoid lateral overhang of the graft
[19]. All operations were performed by senior surgeons, 33 of 42 operations by
the senior author, 9 by the third author.
2.3. Rehabilitation
All patients were immobilized postoperatively in a sling for 7 days. On the first
postoperative day physiotherapy was initiated with active hand and elbow
movement and passive shoulder pendulum without strain. From the 2nd until the
6th postoperative week shoulder motion was increased to active mode without
immobilization with restricted external rotation at 0° with elbow at the side. At 7
weeks postoperatively pain adapted weight bearing, free external rotation and
active motion were allowed, patients also started recreational activities like
swimming, jogging and cycling. At 3 months postoperatively patients regained
full weight bearing. Patients who reached full range of motion could begin with
contact sports, over-head sports, martial arts and sking.
2.4. Clinical and Radiological Evaluation
All patient’s medical history of dislocations, beginning of shoulder instability
and the Instability Severity Index Score (ISI-Score) [16] were recorded preopera-
tively. Either the operating surgeon or the first author performed a standardized
A. M. Riederer et al.
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10.4236/ojo.2018.87031 277 Open Journal of Orthopedics
clinical examination preoperatively and during final follow-up including the
Constant, Duplay and Rowe Score [6] [20] [21]. Pre- and postoperative all pa-
tients underwent a plain radiographic evaluation including antero-posterior
view in neutral rotation, Neer projection and Bernageau view [22]. Preoperative
contrast enhanced CT scans in 34 cases and contrast enhanced MRI scans in 8
cases were obtained of the affected shoulder. The position and consolidation of
the coracoid grafts were assessed by conventional radiograph studies using an-
tero-posterior view in neutral rotation, Neer projection and Bernageau view at
final follow-up 1 year postoperative, measurement of coracoid placement was
accomplished by the first author. Development of osteoarthritis was measured
according to the Samilson/Prieto classification [23].
2.5. Statistical Analysis
Statistical analysis in this study was performed using the paired
t
test under su-
pervision of an epidemiologist at the Centre of Aging and Mobility at the Uni-
versity of Zurich. All results are presented as means with standard deviations,
with ranges in parentheses. A double-sided
P
< 0.05 was considered statistically
significant.
3. Results
3.1. Preoperative Evaluation and Intraoperative Findings
Between July 2009 and November 2013 diagnostic shoulder arthroscopy with
subsequent open Latarjet procedure was performed on 45 patients with ante-
ro-inferior instability in 46 shoulders. Of these 45 patients 4 were lost to fol-
low-up and therefore excluded. Of the remaining 41 patients there were 42
shoulders with antero-inferior instability. Of those 5 were female and 36 patients
were male. The mean age was 30.3 ± 9.9 (range 17 - 52 years). Affected were 14
right and 28 left shoulders, one patient had bilateral antero-inferior shoulder in-
stability (Table 1). On average the patients reported 3.1 (range 1 - 10) disloca-
tions in their history and 10 patients received previous surgery (7 Bank-
art-repairs, 2 with Re-Bankart-repairs, 1 with Re-Bankart-repair and Eden-
Hybinette).
Table 1. Study population.
No patients/gender/cases 41 patients/36 male, 5 female/42 cases
Affected Side 14 right/28 left/1 bilaterally
Age 30.3 ± 9.9 years (range 17 - 52 years)
Quantity of dislocations 3.1 (range 1 - 10)
Number of cases with previous surgery 10
Type of previous surgery 7 × Bankart-repair, 2 × 2 Bankart-repair, 1 × 2
Bankart-repair and 1 Eden-Hybinette
Values are given as numbers with standard deviation and range in parentheses.
A. M. Riederer et al.
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Preoperatively Constant, Duplay, Rowe and ISI-Score were obtained. The de-
termined preoperative scores were: Constant Score 86.7 ± 14.2 (range 22 - 100),
Duplay Score 25.2 ± 15.3 (range −20 - 50) and Rowe Score 31.7 ± 10.3 (range 5 -
55). The mean ISI-Score was 5.8 ± 1.8 (range 1 - 10), 6 (14.3%) patients were
under 20 years old, 24 (57.1%) patients were athletes in competitive sports, 38
(90.5%) patients took part in contact sports or in sports with forced overhead
movements, 19 (45.2%) patients had a positive Gagey-Test [24]. Fifteen (35.7%)
patients had an ISI-Score of greater than 6, indicating preoperatively a Latarjet
procedure. The dynamic arthroscopic evaluation of the 42 shoulders showed the
following pathologies: During arthroscopy all of the 42 radiological diagnosed
Hill-Sachs-lesions could be confirmed. 28 of these 42 (66.7%) Hill-Sachs-lesions
were considered as engaging Hill-Sachs-lesions. The direct visual examination
with the arthroscope confirmed that the Hill-Sachs-lesion was located parallel to
the anterior glenoid and the Hill-Sachs-lesion engaged the corner of the glenoid
in a functional position e.g. abduction and external rotation as mentioned above
[2]. Additional 8 HAGL (19.0%) and 4 IGHL (9.5%) lesions were detected from
which none were suggested in the preoperative radiologic investigation. In addi-
tion 11 (26.2%) bony Bankart-lesions or chronic glenoid bone deficiencies were
visualized, one with a glenoid bone deficiency of 25%, the remaining 10 cases
had a glenoid bone deficiency of 10% - 15% and at least one other pathology in-
dicating a Latarjet procedure (engaging Hill-Sachs-lesion, HAGL-, IGHL-lesion
or revision surgery after failed Bankart-repair). In one case (2.4%) a reversed
Bankart-lesion not diagnosed during the preoperative evaluation was surpri-
singly detected. This lesion was simultaneously treated arthroscopically with
posterior labral repair using suture anchors and showed uneventfully for the
further course. During arthroscopy 6 (14.3%) SLAP II lesions were identified
and treated with tenodesis of the long head of the biceps tendon with suture
anchors, 1 (2.4%) SLAP lesion was repaired arthroscopically with suture anc-
hors. Only 4 of these 7 SLAP-lesions were found during the preoperative evalua-
tion. Intraoperative 2 (4.8%) isolated Lafosse type II subscapularis-lesions were
found, of which one was detected in the preoperative evaluation. Both were re-
paired arthroscopically [25]. After diagnostic arthroscopy an open Latarjet pro-
cedure was performed with at least one of the following pathologies present:
Engaging Hill-Sachs-lesion, HAGL-, IGHL-lesion, bony Bankart-lesion/glenoid
bone deficiency (>25% of anterior-posterior glenoid diameter or <25% of ante-
rior-posterior glenoid diameter plus other above named lesion), or revision sur-
gery (Table 2). Patients receiving revision surgery showed in 6 out of 10 (60%)
cases a low-grade infection with Propionibacterium acnes and were treated with
a double antibiotic therapy of Rifampicin plus Ciprofloxacin or Levofloxacin or
Clindamycin orally for 3 months.
3.2. Clinical and Radiological Outcome
The mean follow-up time for the 42 cases in this series was 14.6 months ± 6.4
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Table 2. Found pathology.
Pathology Suggested in
CT/MRI
Arthroscopic
Visualization
Supplementary
Surgery
Hill-Sachs-lesion 42 42 -
Engaging
Hill-Sachs-lesion - 28 -
HAGL-lesion 0 8 -
IGHL-lesion 0 4 -
SLAP 4 7 6 × arthroscopic tenodesis of LHBT
for SLAP II, 1 × SLAP Repair
Rotator-Cuff-lesion 1 2
2
×
arthroscopic double row repair of
M. subscapularis
Found pathology according to CT/MRI, under arthroscopic direct visualization and supplementary surgery,
Abbreviation: LHBT, Long Head of Biceps Tendon.
months (range 11 - 43 months). At follow-up a significant (
p
< 0.001) improve-
ment of all scores was recorded (Table 3 and Figure 1). The Constant Score im-
proved from preoperatively 86.7 ± 14.2 (range 22 - 100) to postoperatively 95.8 ±
4.4 (range 79 - 100), Duplay Score improved from preoperatively 25.2 ± 15.3
(range −20 - 50) to postoperatively 93.7 ± 9.4 (range 55 - 100). Likewise Rowe
Score increased from preoperatively 31.7 ± 10.3 (range 5 - 55) to 98.1 ± 3.1
(range 90 - 100) postoperatively. Table 4 shows the different scores categorized
as excellent, good, fair and poor (excellent: 91 - 100 points, good: 76 - 90 points,
fair: 51 - 75 points and poor: < 51 points). Revision surgery was performed in
three cases (7.1%). In one (2.4%) case, a 23 years old male patient had to under-
go revision surgery 3 weeks postoperative due to a postoperative hematoma. One
patient (2.4%), a 17 years old male, acquired a tattoo in the surgical incision area
two weeks after surgery likely resulting in a purulent infection with Propioni-
bacterium acnes. After revision surgery the infection was treated successfully
with Rifampicin plus Clindamycin orally for 3 months. One (2.4%) ante-
ro-superior recurrence was recorded in the patient in our series with bilateral
antero-inferior shoulder instability. The 52 years old patient had to undergo re-
vision surgery on his right shoulder and was treated with arthroscopic remplis-
sage of the M. infraspinatus and open anatomic glenoid restoration using a
J-shaped iliac crest bone graft.
At follow-up one year postoperatively position and consolidation of the cora-
coid graft was assessed by conventional x-ray studies using antero-posterior view
in neutral rotation, Neer projection and Bernageau view. In 5 (11.9%) cases a
partial loosening of screws without clinical significance (no symptoms, no re-
currence, no subluxation, no local irritation) was observed. One total (2.4%) and
two partial lyses (4.8%) of the coracoid were observed in these 5 cases, all of
them without clinical impact. Other cases of coracoid lyses were not found.
Measurement of the graft position in ap and Bernageau position showed 2
(4.8%) grafts not in a 2 - 5 o’clock position but in a 1 - 4 o’clock position (for a
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Table 3. Scores preoperatively and postoperatively.
ISI-Score Constant Score Duplay Score Rowe Score
Preoperatively 5.83 ± 1.78
(1 - 10)
86.7 ± 14.2
(22 - 100)
25.2 ± 15.3
(−20 - 50)
31.7 ± 10.3
(5 - 55)
Postoperatively - 95.8 ± 4.4
(79 - 100)
93.7 ± 9.4
(55 - 100)
98.1 ± 3.1
(90 - 100)
p
-value - < 0.001 < 0.001 < 0.001
Values are given as mean with standard deviation and range in parentheses.
Table 4. Score results.
Excellent Good Fair Poor
Constant Score 39 (92.9%) 3 (7.1%) 0 0
Duplay Score 24 (57.1%) 16 (38.1%) 2 (4.8%) 0
Rowe Score 39 (92.9%) 3 (7.1%) 0 0
Score results 1 year postoperatively graded into excellent (100 - 91 points), good (90 - 76 points), fair (75 -
51 points), poor (< 51 points) given as number of cases with percentage in parentheses.
Figure 1. Scores preoperatively and postoperatively.
right shoulder). Furthermore 4 (9.5%) of the coracoid grafts were located 2 -
4mm medial of the anterior glenoid rim rather than being positioned flush with
the glenoid surface which was detected in 38 cases (90.5%). None of the 42 co-
racoid grafts were positioned laterally of the glenoid rim (Figure 2).
Additionally we investigated for signs of instability arthropathy according to
the Samilson classification [23]. In our series one case (2.4%), with preexisiting
chronic nervus axillary neuropraxy and plexus brachialis injury after spine sur-
gery and multiple shoulder dislocations, was graded as mild osteoarthritis Sa-
milson I˚. At follow-up this case progressed to a severe shoulder osteoarthritis
Samilson III˚ evidently due to the excentric position of the humeral head
(Figure 3 E/F).
86.7
25.2
31.7
95.8
93.7
98.1
0
20
40
60
80
100
Constant Score
Duplay Score
Rowe Score
Points
preoperatively
postoperatively
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Figure 2. Examples of postoperative radiographs. Postoperative radiographs of coracoid
graft position at final follow-up. A: Antero-posterior view of the left shoulder of a 28-year
male patient, coracoid graft in perfect position; B: Bernageau view of the left shoulder of a
28-year male patient, coracoid graft in perfect position; C: Antero-posterior view of the
right shoulder of a 17-year old female patient, coracoid graft in high position; D: Berna-
geau view of the left shoulder of a 22-year old male patient, coracoid graft in medial posi-
tion.
Figure 3. Example of osteoarthritis. E and F: Antero-posterior view of a patient with ex-
centric humeral head position due to pre-existing N. axillaris and plexus brachialis injury
developing osteoarthritis; E: 1st day postoperative; F: 9 months postoperative; G: Intra-
operative visualization of HAGL-lesion; +: Humeral head, *: HAGL-lesion, $: IGHL.
AB
CD
F
G
+
*
$
E
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4. Discussion
4.1. Preoperative Evaluation and Intraoperative Findings
According to the preoperatively determined ISI-Score only 15 patients had an
ISI-Score greater than 6 (ISI-Score maximum 10) where an open Latarjet proce-
dure would be indicated [16]. One disadvantage of the ISI-Score is that it accen-
tuates young athletes in competitive sports, as both circumstances (Age under 20
and competitive sports) contribute to the ISI-Score with 2 points each. Regard-
ing the ISI-Score a Latarjet procedure is therefore not indicated when the pa-
tient’s age exceeds 20 years and the patient is not participating in competitive
sports. In our study 6 (14.3%) patients were under 20 years old and 24 (57.1%)
patients were athletes in competitive sports. Furthermore preoperative radiolog-
ical multislice examination with contrast enhanced CT or MRI studies suggested
none of the 8 HAGL-, none of the 4 IGHL-lesions and none of the 28 engaging
Hill-Sachs-lesions. As already mentioned in the introduction, the significance of
an engaging Hill-Sachs-lesion may be underestimated in CT and MRI investiga-
tions, as these are static and not (like during arthroscopy) dynamic investiga-
tions. Additional rotator cuff lesions during antero-inferior shoulder dislocation
are age depending and occur mainly in patients older than 40 years [26] [27]
[28] [29]. Therefore in patients with an age above 40 years contrast enhanced
MRIs were obtained preoperatively to specify potential additional rotator cuff le-
sions. Patients with an age under 40 years were evaluated preoperatively with
contrast enhanced CTs.
Arthroscopy is the diagnostic reference standard for the detection of
HAGL-lesions (example of intraoperative visualization of HAGL-lesion in Fig-
ure 3 G) [8] [30] [31]. Three large clinical series describe the prevalence of
HAGL-lesions in MRI scans ranging from 2% (6 of 307 patients) to 7.5% (41 of
547 patients) to 9.4% (6 of 64 patients) [8] [32] [33]. However a sensitivity of
0.50 for the MRI diagnosis is only mentioned in one study [33]. One recent
study reports a prevalence of HAGL-lesions of 4.64% (9 of 194 patients) with a
sensitivity of MRI in detecting HAGL-lesions of 0.44 and a specificity of 0.97
[31]. In our series 4 of the 8 cases with HAGL-lesions received a preoperative
MRI, the other 4 received a preoperative CT according to the study protocol
listed in Methods (Age < 40 = CT, Age > 40 = MRI). Therefore it is possible that
we could have diagnosed more HAGL-lesions preoperatively if all patients
would have received a preoperative MRI. Of the cases with previous stabilization
surgery only 4 were not included in the aforementioned patients with an
ISI-Score above 6 and radiological indication for a Latarjet procedure. Relating
to the preoperative evaluation of ISI-Score, previous stabilization surgery and
radiological suggestion of HAGL- or IGHL-lesions or engaging Hill-Sachs-
lesions or glenoid bone deficiencies, 21 cases (50%) showed a proper indication
for a Latarjet procedure. The value of diagnostic arthroscopy could be seen in
our case series as we found pathologies during arthroscopy not diagnosed in our
preoperative evaluation with multislice studies and therefore strengthening the
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indication for a Latarjet procedure in all cases. According to literature these in-
dications consist of existence of at least one of the following pathologies: Pre-
vious surgery, engaging Hill-Sachs-lesion, HAGL- or IGHL-lesion or glenoid
bone deficiency, where a Bankart-repair would have lead to inferior results [1]
[10] [11] [12]. The particular advantage of diagnostic arthroscopy is the dynamic
exanimation unlike the static setting of CT or MRI studies offering a direct visu-
alization and assessment of the underlying pathology. Moreover supplement
surgeries for 7 SLAP-lesions, 2 subscapularis-lesions and 1 reversed Bank-
art-lesion were performed, only 4 of the 7 SLAP-lesions, resp. 1 of the subscapu-
laris-lesions were suggested during the preoperative radiological workup.
Therefore 5 of the 42 patients (11.9%) would most likely have unsatisfactory
outcomes if these pathologies would not have been detected and addressed dur-
ing the arthroscopy. Arrigoni
et al.
[34] published a case series of 33 patients
who underwent diagnostic arthroscopy before open Latarjet procedure. In this
case series 55% of the patients had previous surgery, 73% showed associated in-
tra-articular lesions (64% sustained a type II SLAP lesion) and 64% had engaging
Hill-Sachs-lesions. Arrigoni’s study supports our results of a high incident of
engaging Hill-Sachs-lesions and demonstrates the value of arthroscopy to ad-
dress simultaneous shoulder lesions. Our study strengthens not only the already
described usefulness of arthroscopy to address these concomitant lesions but
may also contribute aid in decision finding for the proper stabilization proce-
dure as above mentioned lesions like HAGL- or IGHL-lesions are often over-
looked when not particularly seeked for [7] [8]. Our intraoperative diagnostic
findings also support the findings of a biomechanical cadaver study of the IGHL
published by Bigliani
et al.
[35] in 1991, where lesions of the IGHL were detected
in 40% at the glenoid insertion, 35% in the ligament midsubstance and 25% at
the humeral insertions site.
4.2. Clinical and Radiological Outcome in Comparison to
Literature
At follow-up the collected Constant, Duplay and Rowe Scores all showed a sig-
nificant (
p
< 0.001) improvement. Unfortunately, a direct comparison to other
studies is limited due to the heterogenic follow-up and the use of different scor-
ing methods (Table 5). Burkhart
et al.
[36] reported in 2007 a case series of 102
Latarjet procedure of whom 47 patients were available for postoperative exami-
nation at a mean follow-up of 59 months. In Burkhart’s study the patients un-
derwent diagnostic arthroscopy to quantify glenoid bone loss and to identify and
address concomitant pathologies arthroscopically. In case of a glenoid bone loss
of >25% or a concomitant engaging Hill-Sachs-lesion, Burkhart proceeded to an
open Latarjet procedure as these were considered indications for a Latarjet Pro-
cedure. At follow-up a mean Constant Score of 94.4 and a mean Duplay Score of
91.7 could be shown. Complications noted were 2 hematomas and a recurrence
rate of 4%. Radiological signs of 2 screw loosenings and 1 fibrous union were
described. Schmid
et al.
[11] published in 2012 results of a case series of 49 cases
A. M. Riederer et al.
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10.4236/ojo.2018.87031 284 Open Journal of Orthopedics
Table 5. Comparison of studies reporting outcomes of Latarjet procedures.
No of
Cases
Follow-up
(Months) Recurrence Subluxation
Constant
Score
Duplay
Score Rowe Score
Complications
Coracoid
Graft/Implant
Allain
et
al.
1998 58 171
(120 -
276)
0 1 (2%) 84 - -
Total 5 (9%)
3 (5%)
Infection
1 (2%)
Frozen shoulder
1 (2%)
Humeral fracture
2 (3%)
Non-union
10 (17%) Partial
lysis
Schmid
et al.
2012
49 (41
clinical/radiological,
8 telephone survey)
38
(23 - 63) 0 2 (4%) 84.6
(40 - 100) - -
Total 6 (12%)
4 (8%)
Delayed wound
healing
2 (4%)
Frozen shoulder
1 (2%) Non-union
Burkhart
et al.
2007
102
(47 clinical, 55
telephone survey)
59 ± 18.5
(32 - 108) 4 (4%) 0 94.4
(82 - 100)
91.7
(75 - 100) -
Total 6 (6%)
2 (2%)
Hematomas
4 (4%)
Recurrence
2 (2%)
Screw loosening
1 (1%)
Fibrous union
Shah
et
al.
2012
48
(45 follow-up, 3 lost)
9.4
(6 - 55) 4 (8%) 0 - - -
Total 12 (25%)
3 (6%)
Infections
4 (8%)
Recurrence
5 (10%)
Nerve damage
8 (18%)
Non-union
Riederer
et al.
2018
42 14.6 ± 6.4
(11 - 43) 1 (2.4%) 0 95.8 ± 4.4
(79 - 100)
93.7 ± 9.4
(55 - 100)
98.1 ± 3.1
(90 - 100)
Total 3 (7.1%)
1 (2.4%)
Hematoma
1 (2.4%)
Infection
1 (2.4%)
Recurrence
1 (2.4%)
Total lysis
2 (4.8%) Partial
lysis of coracoid
graft
5 (11.9%) Screw
loosening
Data with standard deviation and range in parentheses where available.
for open Latarjet procedure without concurrent diagnostic arthroscopy after
previous shoulder stabilization of whom 41 cases were available for postoperative
examination with a mean follow-up of 38 months (the remaining 8 were con-
tacted by telephone survey) showing a mean Constant Score of 84.6. Schmid
considered recurrence shoulder instability, glenoid bone loss of at least one-third
of the antero-posterior glenoid diameter and absence of fatty infiltration of the
subscapularis muscle greater than Goutallier stage II as indications for an open
Latarjet procedure. Schmid reported no recurrence, a subluxation rate of 4% and
a total complication rate of 12% consisting of 4 delayed wound healing, 2 frozen
shoulders and 1 malunion with pain. Schmid described the position of the cora-
coid graft as flush in 73%, medial in 15%, lateral in 12%. Likewise osteoarthritis
in 11 patients (27%), of which 9 had already preoperative osteoarthritis, was de-
A. M. Riederer et al.
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10.4236/ojo.2018.87031 285 Open Journal of Orthopedics
scribed. Shah
et al.
[37] reported a case series of 48 cases (of whom 45 were
available for follow-up) receiving an open Latarjet procedure with a mean fol-
low-up of 9.4 months with a recurrence rate of 8% in 2012. Shah considered
glenoid bone loss > 30% and unsuccessful arthroscopic or open capsule and la-
bral repair as indications for open Latarjet procedure. According to Shah diag-
nostic arthroscopy prior to the Latarjet procedure was performed in 18 of these
48 cases (37.5%) to assess soft tissue quality and bone involvement that had not
been appreciated on preoperative imaging in patients having undergone unsuc-
cessful arthroscopic Bankart-repair. Shah described a rather high total complica-
tion rate of 25% with 6% infection, 8% recurrence and 10% neurological com-
plications. Furthermore Shah reported non-union of the coracoid graft in 8
(18%) cases. Long term results of 58 shoulders after open Latarjet procedure
without prior diagnostic shoulder arthroscopy with a mean follow-up of 14.3
years (171 months) were published by Allain
et al.
[38] in 1998. No recurrence, a
subluxation rate of 2% and a total complication rate of 9% consisting of 3 infec-
tions, 1 frozen shoulder and 1 humeral fracture were mentioned. Allain
et al.
al-
so reported the position of the coracoid graft: the results were graded as perfect
(0 - 5 mm medial of the anterior glenoid rim) in 41%, lateral of the anterior gle-
noid rim in 53% and more than 5mm medial of the glenoid rim in 5%. Allain
also reported non-union of the coracoid graft in 3% and partial lysis in 17%. As-
signing the grading of the coracoid position according to Allain, we found all
coracoid grafts in our case series in a perfect position, as we report 38 (90.5%) of
the transferred coracoid being flush with the glenoid rim, 4 (9.5%) of the cora-
coid grafts were located medial of the anterior glenoid rim (range 2 - 4 mm) and
none of the 42 coracoid grafts in our study were positioned laterally of the gle-
noid rim. According to Allain
et al.
the correct position of the coracoid graft is
the most important factor in the development of postoperative glenohumeral
osteoarthritis, the other 2 factors identified are untreated rotator cuff lesions and
intra- or postoperative complications like infection or recurrence. Table 5 shows
the results of our study in comparison to these aforementioned studies. In our
series especially no neurological complications were noted in the postoperative
course and follow-up. One patient suffered from pre-existing brachial plexus
and axillary nerve damage due to cervical spine injury and cervical disc prolapse
without association with the performed shoulder surgery. Allain
et al.
showed
that a high rate of lysis of the coracoid graft is not related to a high recurrence
rate as he reported 10 cases of partial coracoid lysis and no recurrence in his
long-term study. Our results support that finding as the radiological detected ly-
sis of the coracoid had no influence on clinical outcome in our series, which also
supports that the sling effect of the conjoint tendon crossing the subscapularis
seems to have a significant effect on the stability of the shoulder in external rota-
tion in 90° abduction. We, as Allain and Burkhart as well, did not augment the
anterior capsule with the stump of the coraco-acromion ligament [36] [38]. Shah
and Schmid used the coraco-acromion ligament to augment the anterior capsule
A. M. Riederer et al.
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10.4236/ojo.2018.87031 286 Open Journal of Orthopedics
as described by others [37] [39]. The Constant Score mobility subscore in our
series showed no restriction in external rotation.
4.3. Strength and Limitations
Compared to the aforementioned studies [11] [36] [37] [38] our case series in-
cludes similar quantity of controlled patients and indicates comparable results
relating to recurrence and subluxation rate. Moreover we report significant im-
provements of the 3 measured scores (Constant, Duplay, Rowe) with a low com-
plication rate. One limitation of our study is the short follow-up compared to the
studies of Burkhart [36], Schmid [11] and Allain [38]. Possible development of
osteoarthritis despite perfect placement of the coracoid graft is described by Al-
lain
et al.
and is not regularly monitored beyond our follow-up. Therefore the
later development of osteoarthritis cannot be ruled out despite our promising
short-term results. In the compared studies the majority of recurrence occurred
within 12 months, but also recurrences later on in follow-up have been reported
[11] [36] [37] [38] Potential higher recurrence rates are therefore possible in
long-term results.
5. Conclusion
Progress in arthroscopic skills lead to technical notes and reports of arthroscopic
Latarjet-procedure that allowed an all-arthroscopic approach in treatment of
anterior shoulder instability [3] [14] [40]. However despite high number of cases
these reports lack long-term results. Moreover the arthroscopic approach to the
Latarjet procedure and to this complex pathology can be demanding and com-
plications due to the proximity of the axillar and musculocutaneous nerve and
the brachial plexus to the coracoid can be severe and hazardous. Therefore the
arthroscopic Latarjet procedure will be reserved for all but the most experienced
and able arthroscopic surgeons in high volume centers. Another reason to still
perform mini open Latarjet procedure is to teach young colleagues in open
shoulder stabilizing surgery. This would not be possible in a low or medium vo-
lume center for the arthroscopic Latarjet procedure. The Latarjet procedure is a
reliable technique with very good clinical outcomes and no neurological com-
plication occurred in our series. Of interest lysis of the coracoid had no influence
on clinical outcome in our series. Diagnostic arthroscopy is a valuable tool to
detect HAGL and IGHL lesions and to visualize the engaging potential of
Hill-Sachs-lesions. An additional arthroscopy may help to indicate a Latarjet
procedure, despite missing indications in multislice examinations or in
ISI-Score.
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