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Static anterior subluxation with avascular necrosis of humeral head (A) due to failed combined Latarjet procedure with rotator cuff repair, which was treated with reverse total shoulder arthroplasty (B, C).
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Background:
The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability w...
Context in source publication
Context 1
... received diagnoses of transient inferior subluxations. All were treated conservatively. In another patient, avascular necrosis developed owing to failed rotator cuff repair and static anterior subluxation. This was revised successfully with a reverse shoulder arthroplasty 6.5 years after the combined Latarjet and open cuff repair procedure (Fig. ...
Similar publications
Posterior shoulder dislocation is rare and often represents a diagnostic and therapeutic challenge. An impaction fracture of the anteroinferior aspect of the humeral head (called a reverse Hill-Sachs (RHS) fracture) is always present in case of chronic locked posterior dislocation. Surgical management is required and decided on the delay between th...
Abstract
Background: Shoulder MRI is now considered the standard among the imaging methods to diagnose the etiology of shoulder pain as MRI allows the direct visualization of the rotator cuff tendons, their tears and abnormalities, their relationship to the undersurface of the acromion and the acromioclavicular (AC) joint and also identifies tears...
Citations
... Although Bankart lesion is the primary pathology of anterior shoulder instability regardless of age, in patients older than 40 years, the incidence of rotator cuff tears is also high. 2,[4][5][6][7] There is limited information on other pathologies of shoulder instability in middle-aged and elderly patients such as glenoid morphology. Through our clinical experiences, we are under the impression that these pathologies, including the incidence of rotator cuff tears and glenoid morphology, will be different by age at initial dislocation. ...
... 31,32 Third, we used 4 suture anchors for capsulolabral complex repair, whereas only 2 or 3 suture anchors were used in previous studies. 1,7 The larger number of suture anchors should provide better initial fixation strength. 33 Finally, concomitant rotator cuff repair may be another factor for the better shoulder stability. ...
... Elle reste contre-indiquée [20] chez les patients présentant une instabilité antérieure volontaire, les épilepsies non contrôlées, en l'absence de lésion osseuse de Bankart et lorsque des lésions se trouvent sur le côté de l'humérus comme dans une avulsion humérale du ligament glénohuméral inférieur. La technique de Patte a été pendant longtemps réservée pour les sujets d'âge moyen ; or deux études récentes [30,31] ont démontré sa fiabilité et sa sécurité à long-terme à la fois chez les sujets à squelette immature et chez les sujets âgés de plus de 40 ans. La butée coracoïdienne à ciel ouvert est encore la technique de référence dans notre formation même si les techniques arthroscopiques se développent [32]. ...
... When performed in patients older than 60 years, the Latarjet procedure has an increased risk of complications including coracoid fracture, avulsion fracture, and nonunion. 10 In older patients, performing a coracoid transfer via a subscapularis split may also cause subscapularis injury and potentially result in shoulder pseudoparalysis. 10 Furthermore, because older patients might have more extensive glenoid and humeral bone lesions owing to reduced bone quality and a higher rate of infraspinatus tear, the Bankart procedure alone or combined with remplissage can lead to poor outcomes. ...
... 10 In older patients, performing a coracoid transfer via a subscapularis split may also cause subscapularis injury and potentially result in shoulder pseudoparalysis. 10 Furthermore, because older patients might have more extensive glenoid and humeral bone lesions owing to reduced bone quality and a higher rate of infraspinatus tear, the Bankart procedure alone or combined with remplissage can lead to poor outcomes. 11,12 The Trillat procedure has been proposed as an alternative option in these patients owing to the higher success rate and lower complication rate. 1 Distalizing and medializing the coracoid tip places the conjoint tendon anterior to the glenohumeral joint. ...
The Trillat procedure has been described for the management of shoulder instability in younger patients but also for shoulder instability in older patients with irreparable rotator cuff tears. We describe an all-arthroscopic technique using screw fixation. This technique allows for safe dissection, clearance and osteotomy of the coracoid, and direct visualization during screw tensioning and fixation to minimize the risk of subscapularis impingement. We outline our stepwise approach to medialize and distalize the coracoid process using arthroscopic screw fixation and present pearls to avoid fracture through the superior bone bridge.
... F ailure of the Latarjet procedure, in the form of recurrent anterior instability, occurs in only 1% to 5% of cases. [1][2][3][4][5] However, this is a challenging surgical problem 6-8 due to (1) glenoid bone loss (with or without associated humeral bone loss), (2) the fragility or absence of anterior capsuleelabral structures, (3) the presence of anterior scarring around the subscapularis and the absence of conjoint tendon as a medial landmark placing neurovascular structures at risk, (4) deterioration of the subscapularis muscle-tendon unit, and (5) hardware management from the previous coracoid fixation (screws or cortical button). ...
... Guided glenoid drilling technique from posterior to anterior prevents brachial plexus injury anteriorly and suprascapular nerve injuries posteriorly. 22,23 Moreover, the use of suturebutton fixation provides some advantages in revision surgery because (1) requires small glenoid tunnels taking into account the potentially misplaced tunnels of the previous procedure; (2) in cases in which removal of glenoid screws is not technically possible, fixation can be performed even in the presence of reaming screws; and (3), as we have seen in our study, buttons used in previous surgery can be left in place without causing any problem in the final position of the ICBG. ...
Purpose
To report clinical and radiological outcomes of arthroscopic Eden-Hybinette using two cortical suture-buttons in a series of patients with prior failed Latarjet and persistent glenoid bone loss.
Methods
Between 2015 and 2019, patients with recurrent anterior instability after failed Latarjet underwent arthroscopic Eden-Hybinette procedure using two cortical buttons for graft fixation. Exclusion criteria were open and primary Eden-Hybinette and less than one year follow-up. Functional assessment was performed using Rowe and Walch-Duplay scores, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS) and degree of satisfaction. Iliac crest bone graft (ICBG) placement and healing were assessed postoperatively with computed tomography (CT) imaging.
Results
A total of 17 patients with a mean age of 28 years (range, 21-43) at time of revision were included. The mean glenoid bone loss was 23% (range, 18-42%). Medium or deep Hill-Sachs (HS) lesion (Calandra 2 and 3) was present in 65% of cases. At a mean follow-up of 3±1.6 years, all but 1 patient (94%) considered their shoulder stable, and 15 patients (88%) were satisfied or very satisfied. The SSV increased from 51% to 87% (p<0.05), the Walch-Duplay increased from 23 to 86 points (p<0.05) and Rowe scores improved from 30 to 92 points (p<0.05). Apprehension was still positive in 3 patients (17.6%), being this percentage higher in the presence of HS Calandra 3 (p=0.02). Postoperative CT-scans showed optimal bone autograft position in all patients (below the glenoid equator and flush to the glenoid rim). ICBG healed to the anterior glenoid neck in 16 shoulders (94%). The rate of recurrent instability was 11.7% but only one patient required revision surgery (5.8%).
Conclusion
Arthroscopic Eden-Hybinette using two cortical buttons leads to satisfactory clinical outcomes and a low recurrence rate after failed Latarjet, allowing successful reconstruction of the anterior glenoid rim and simultaneous treatment of capsular deficiency and humeral bone loss.
... 57 The contraindications for the Letarjet procedure are recurrent anterior instability in patients above the age of 50 years, elderly patients with an associated massive irreparable rotator cuff tear, first-time dislocation in the elderly without large glenoid rim fracture, voluntary anterior dislocations, uncontrolled epileptic patients, young patients with superior labral tear from anterior to posterior (SLAP) lesions, prosthetic anterior instability, and posttraumatic inferior dislocation. 1 There are many complications like recurrent instability, infection, hardware failure, fracture and nonunion coracoid process, loss of external rotation, and osteoarthritis of the shoulder. 58 The Eden-Hybinette procedure is the reconstruction of the anterior glenoid using the iliac crest graft. It has got clinical outcomes similar to Letarjet but has a high recurrence rate and a higher rate of postoperative osteoarthritis. ...
Instability of the shoulder joint is common but most of the time it is unrecognized by the treating surgeon. The symptoms can vary from subtle pain to shoulder dislocation. In many cases, there is no history of trauma. The shoulder joint is stabilized by both static and dynamic factors, and treatment is complex, with recurrence more common in young athletic individuals. Open and arthroscopic techniques of stabilization are available with specific indications for each of these methods. In this narrative review of shoulder instability, we describe the pathological anatomy, evaluation, natural history, classification, and treatment of shoulder instability.
... Other identified risk factors included epilepsy and age > 40 years old. 14,21,22 Although some authors report an increased complication rate in patients with a history of previous surgeries, we did not observe such correlation ...
Resumo
Objetivo A cirurgia de Latarjet é bem estabelecida para o tratamento da instabilidade anterior do ombro. Apresenta complicações específicas com taxas de até 30%. Nosso objetivo é avaliar a incidência e os fatores de risco associados às complicações após a cirurgia de Latarjet.
Métodos Analisamos retrospectivamente 102 pacientes submetidos ao procedimento. Dividimos as complicações em três tipos: clínicas, relacionadas ao enxerto e relacionadas aos implantes. Todos os pacientes foram submetidos a radiografias e tomografia computadorizada (TC). Os fatores de risco analisados foram gênero, idade, cirurgia prévia, epilepsia e experiência do cirurgião.
Resultados Um total de 102 pacientes consecutivos (108 casos) foram avaliados. A média de idade foi 33,7 anos (18 a 61 anos), com 88 homens e 14 mulheres. A taxa de complicações foi de 21,2%, sendo 12% clínicas, 7,4% relacionadas ao enxerto e 2,7% relacionadas ao implante. As mais frequentes foram apreensão anterior (oito casos) e posicionamento lateral do enxerto, em seis casos. A TC foi realizada com o mínimo de 6 meses em 79 casos (73%), evidenciando a consolidação do enxerto em 75 pacientes (94.9%). Nenhum caso de não união apresentou instabilidade. Dez pacientes (9.2%) precisaram de cirurgia de revisão. Os fatores de risco relacionados às complicações foram epilepsia (p = 0.0325), experiência do cirurgião (p = 0.0499) e pacientes ≥ 40 anos (p = 0.0151). Não houve correlação com gênero e cirurgia prévia.
Conclusão A taxa de complicações após a cirurgia de Latarjet foi de 21,2%, com 9% necessitando de revisão cirúrgica. Epilepsia, idade > 40 anos e experiência do cirurgião foram fatores de risco.
... Recurrent anterior shoulder instability in elderly patients is rare, 9,11,21 and patients aged .40 years account for \10% of patients with recurrent anterior shoulder dislocations. 14,21 Given this significantly lower risk for recurrent instability with increasing age at first-time dislocation, 2,14 the need for surgical stabilization of recurrent instability shows a reverse linear relationship: only 14% of firsttime traumatic anterior dislocations sustained in patients aged 30 to 40 years ultimately need an operation, as opposed to 50% of those sustained in adolescent patients. ...
... Their mean age was 47.3 years (range, 40-69) at the time of the arthroscopic Bankart repair. Patients were interviewed and examined at a mean follow-up of 13.2 years (range, [8][9][10][11][12][13][14][15][16][17][18]. The dominant shoulder was affected in 25 cases (61%). ...
... 11 This reviewed cohort consisted of 39 patients (30 men and 9 women) and 40 shoulders with a mean age of 48.2 years (range, 40-66) at the time of the Latarjet procedure. Their mean follow-up was 11.0 years (range, [8][9][10][11][12][13][14][15][16], and the dominant shoulder was affected in 22 cases (58%). The mean age at firsttime dislocation was 33.1 years (range, 15-63), and the mean number of recurrent anterior dislocations before the Latarjet procedure was 17 (range, 2-90). ...
Background
Long-term results of the arthroscopic Bankart repair in patients older than 40 years are unknown and may be favorable in terms of postoperative glenohumeral arthritis as opposed to the long-term results of the open Latarjet procedure in patients older than 40 years.
Purpose
To analyze our long-term results of the arthroscopic Bankart repair for recurrent anterior shoulder instability in patients older than 40 years of age and to compare these results with previously published long-term results of the Latarjet procedure in a cohort of similar age.
Study Design
Cohort study; Level of evidence, 3.
Methods
A total of 35 consecutive patients (36 shoulders) with a mean age of 47 years (range, 40-69) at time of the arthroscopic Bankart repair were studied at a mean 13.2 years (range, 8-18) after surgery. Clinical and radiographic results were then compared with those of our previous study of 39 consecutive patients (40 shoulders) of a same age group who had been treated for the same pathology with an open Latarjet procedure.
Results
Six shoulders (17%) sustained a recurrent shoulder dislocation after a mean 5.3 years; subluxation occurred in 3 shoulders (8%); and apprehension persisted in 3 shoulders (8%). Revision surgery was performed in 8 patients (22%): 2 Bankart and 6 open Latarjet. The relative preoperative Constant score and Subjective Shoulder Value were significantly improved ( P < .001) at final follow-up. Arthropathy of stabilization was advanced in the shoulders of 16 patients (47%) and had progressed by at least 2 grades in 21 patients (62%). There were significantly higher rates of redislocation and subluxation when compared with the open Latarjet procedure (9 vs 3; P = .037), and the mean final Subjective Shoulder Value was significantly lower in the Bankart group (86% vs 91%; P = .011). There were no significant differences in final advanced arthropathy (16 vs 14; P = .334) and revision rates (8 vs 7; P = .409) when compared with the Latarjet procedure.
Conclusion
Arthroscopic Bankart repair for recurrent anterior shoulder instability in patients older than 40 years was associated with reliable pain relief and patient satisfaction similar to that after the open Latarjet procedure. Restoration of stability was significantly less successful and development of arthropathy no better than the open Latarjet procedure in patients older than 40 years.
... Recurrent anterior shoulder instability in elderly patients is rare, 9,11,21 and patients aged .40 years account for \10% of patients with recurrent anterior shoulder dislocations. 14,21 Given this significantly lower risk for recurrent instability with increasing age at first-time dislocation, 2,14 the need for surgical stabilization of recurrent instability shows a reverse linear relationship: only 14% of firsttime traumatic anterior dislocations sustained in patients aged 30 to 40 years ultimately need an operation, as opposed to 50% of those sustained in adolescent patients. ...
... Their mean age was 47.3 years (range, 40-69) at the time of the arthroscopic Bankart repair. Patients were interviewed and examined at a mean follow-up of 13.2 years (range, [8][9][10][11][12][13][14][15][16][17][18]. The dominant shoulder was affected in 25 cases (61%). ...
... 11 This reviewed cohort consisted of 39 patients (30 men and 9 women) and 40 shoulders with a mean age of 48.2 years (range, 40-66) at the time of the Latarjet procedure. Their mean follow-up was 11.0 years (range, [8][9][10][11][12][13][14][15][16], and the dominant shoulder was affected in 22 cases (58%). The mean age at firsttime dislocation was 33.1 years (range, 15-63), and the mean number of recurrent anterior dislocations before the Latarjet procedure was 17 (range, 2-90). ...
... Recurrent anterior shoulder instability in elderly patients is rare, 9,11,21 and patients aged .40 years account for \10% of patients with recurrent anterior shoulder dislocations. 14,21 Given this significantly lower risk for recurrent instability with increasing age at first-time dislocation, 2,14 the need for surgical stabilization of recurrent instability shows a reverse linear relationship: only 14% of firsttime traumatic anterior dislocations sustained in patients aged 30 to 40 years ultimately need an operation, as opposed to 50% of those sustained in adolescent patients. ...
... Their mean age was 47.3 years (range, 40-69) at the time of the arthroscopic Bankart repair. Patients were interviewed and examined at a mean follow-up of 13.2 years (range, [8][9][10][11][12][13][14][15][16][17][18]. The dominant shoulder was affected in 25 cases (61%). ...
... 11 This reviewed cohort consisted of 39 patients (30 men and 9 women) and 40 shoulders with a mean age of 48.2 years (range, 40-66) at the time of the Latarjet procedure. Their mean follow-up was 11.0 years (range, [8][9][10][11][12][13][14][15][16], and the dominant shoulder was affected in 22 cases (58%). The mean age at firsttime dislocation was 33.1 years (range, 15-63), and the mean number of recurrent anterior dislocations before the Latarjet procedure was 17 (range, 2-90). ...
Background
Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy.
Purpose
To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age.
Study Design
Case series; Level of evidence, 4.
Methods
39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up.
Results
No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly ( P < .001). In total, 36 patients rated their result as excellent, 3 as good. Further, 6 patients (15%) underwent joint-preserving reoperation, and 1 patient (3%) had reverse total shoulder arthroplasty for severe dislocation arthropathy. Dislocation arthropathy was severe in 14 patients (37%) and had progressed by at least 2 grades in 17 patients (45%). Patients with severe dislocation arthropathy had already shown degenerative changes preoperatively as opposed to those who ultimately had no or moderate dislocation arthropathy (n = 24) ( P < .001). Progression of dislocation arthropathy was associated with lateral (>1 mm) graft positioning ( P < .001) and older age at surgery ( r = 0.58; P < .001).
Conclusion
The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.
