6.1.6 Fibrous Non-Union

Regardless of the fixation method, a solid osteosynthesis is required for reaching a successful result. This implies a good decortication of the coracoid undersurface and of the glenoid rim to flat surfaces. A coracoid non-union is usually incidentally discovered during routine follow-ups, whereas only few patients require reoperation [2, 8, 22, 25, 26]. Literature reports are inconstant, demonstrating non-union rates from 1.4% up to 9.4% [12], depending on the surgical routine activity of each arthroscopy center.

6.1.7 Graft Remodeling and Resorption

DiGiacomo [27] reported in 2011 a mean of 59.5% osteolysis of the coracoid graft. Newer studies demonstrate a resorption rate of up to 82.7% [4, 28].

It has been proved that the osteolysis process occurs more often at the level of the superior screw (53.3%) than inferiorly (3.3%) [29] and that the graft remodeling process is slower and more discrete in cases with big glenoid bone loss [22, 27, 30, 31], other than in cases with little glenoid defects. There are two current hypothesis explaining this phenomenon, namely the humeral head is creating pressure only on the inferior part of the graft [32] and that the vascularization of the graft is made through the conjoint tendon around the coracoid tip [4, 12, 28, 33, 34]. In most cases with graft osteolysis, there is no clinical significance on recurrence of instability or functional outcome, therefore no revision surgery is needed, fact explained by the persisting sling effect of the conjoint tendon. Generally speaking, graft complications regarding nonunion, graft migration, and graft fracture may occur in 3.2% of cases [3].

6.1.8 Graft Malpositioning, Screw Impingement

Even in experienced hands, a correct positioning of the graft on the glenoid rim remains one of the biggest challenges in the Latarjet procedure. A too high position, above the glenoids’ equator will simultaneously increase the risk of malpositioning the superior screw, thus endangering the SSN. A too low position may predispose to a fibrous non-union because the inferior screw will pass underneath the glenoid neck, creating no biomechanical stability. A too medial graft positioning will be responsible for recurrent instability or chronic subluxation and a too lateral one for early onset osteoarthritis (Fig. 6.2a) [3, 8, 22, 29, 31, 35]. Proeminent screws may also abrade the subscapularis until its destruction or even impinge into the humeral head producing catastrophic outcomes (Fig. 6.2b, c). We consider that screws and graft malposition should be seen more as surgical error than a complication.

6.1.9 Stiffness, Loss of External Rotation

The reportings for loss of external rotation varies from a study to another: Cunningham et al. [35] as well as Hurley [3, 13] demonstrate similar results for open and arthroscopic technique whereas Griesser [12] states a greater loss of mean external rotation in the arthroscopic group (16° vs 12° in open Latarjet group). Lafosse introduced the arthroscopic technique in order to decrease the anatomical damage during the open dissection and he reports no significant persistence of external rotation loss at 5 years of follow up [7, 8]. It is believed that the technique used for splitting the subscapularis muscle and for dissecting the conjoint tendon may influence the postoperative range of motion [29].

6.1.10 Persistent Apprehension, Postoperative Pain or Discomfort

In an open vs arthroscopic latarjet systematic review [3], Hurley reported that up to 35.7% of patients treated with arthroscopic Latarjet may develop a persistent apprehension, with no instability whatsoever. Furthermore, Marion demonstrated that the arthroscopic Latarjet procedure was significantly less painful than the mini-open procedure [24].

6.1.11 Recurrence

The Latarjet procedure is generally associated with low instability recurrence rates, whether it is performed open or arthroscopically [3, 4, 17]. Cerciello reported 2.6% recurrence rate and 6.3% reoperation rate in his latest literature review study [4], whereas Hurley a 2.4% recurrent instability with 1.6% recurrent dislocations [3]. At 5 years follow up, Dumont and Lafosse present a 2% recurrence rate [8]. The revision rate due to recurrent instability is considered to be 2.9% [3].

6.1.12 Osteoarthritis

The cells covering the bony surface of the graft have the potential to differentiate themselves into fibrocartilage, thus creating a cartilaginous continuity with the glenoid surface [31, 32, 34], given the graft was correctly positioned. A proud graft position will definitely impinge the humeral head and finally create an irreversible destruction of the humeral cartilage [22, 26, 31, 34]. Sometimes, the remodeling process makes the superior screw becoming proeminent and a following repetitive contact between humeral head and screws will conduct to early cartilage destruction. As stated before, a subscapularis insufficiency due to screw protrusion may also occur.

Gleno-humeral arthritis can be a short-term complication in cases with screws or graft malplacement, as depicted in Fig. 6.2a. However, we see omarthrosis as a potential long-term consequence of the Latarjet procedure. It remains challenging to distinguish consequences of posttraumatic arthropathy from complications or long-term outcomes of surgical related arthropathy.

A comprehensive literature review dedicated to this chapter found very little information about early onset arthropathy after arthroscopic Latarjet. Zhu described one case of early onset osteoarthritis out of 52 patients at minimum 2 years follow up [28]. We believe that osteoarthritis, as well as other complications, is underreported, but from a biomechanical point of view, we can extrapolate to results about the open surgery, where the development of arthritis appears in 20% at 20 years [22, 36] or as reported by Hovelius, in 14% (severe arthropathy) or 35% (mild arthropathy) of cases [37, 38].

6.2 Revision Arthroscopy After Failed Latarjet Procedure

Subsequent revision surgery after a failed arthroscopic Latarjet procedure is a challenging problem that equals dealing with potential complications of an already happened complication. Working in an altered anatomical space may pose new problems and put the patient at even higher risk than during the index procedure. Hardware failure, hematoma, bone block fractures, persistent instability and re-dislocations are common revision causes, among other complications listed above.

Revisions after arthroscopic Latarjet due to recurrent instability were reported by Hurley in his latest meta-analysis: 2.9% of 126 patients [3]. Total revisions were reported at 5.4% out of 412 arthroscopic Latarjet procedures [3, 35].

In a 10 years follow-up study, Meraner and Leuzinger reported a 30% revision rate after the arthroscopic Latarjet [5]. The main causes were stiffness (62% of revision cases), recurrent instability (20% of all revisions) and hardware related reasons (screws or guiding k-wires breakage).

Serial surgical revision options for recurrent instability were described, starting with arthroscopic screws removal, arthroscopic capsulorrhaphy, secondary Hill-Sachs remplissage up to arthroscopic Eden-Hybinette or J-Span with or without concomitant arthroscopic brachial plexus neurolysis. Other techniques describe the potential of using lateral clavicle or tibia allograft [39, 40] instead of an iliac crest autograft. Capsulorrhaphy after failed Latarjet demonstrated 16.7% recurrent instability [41]. On the other hand, Gianakos et al. described better clinical outcomes following the arthroscopic Eden-Hybinette procedure after failed Latarjet and reported no dislocation recurrence but a high incidence of apprehension and subluxation [31].

Poor outcomes after revision surgery include glenohumeral arthritis, two or more previous instability procedures and age over 30. The most challenging revision cases are the post-Latarjet gleno-humeral arthritis in young patients, with or without persistent instability [31]. A comprehensive arthroscopic management (CAM) procedure may result in temporary symptomatic relief [22, 42]. A definitive solution can be the gleno-humeral arthroplasty, however, this is a challenging indication in younger subjects and in persistent instability cases.

While technically complex, the arthroscopic Latarjet procedure is a viable and safe technique that permits the surgeon to have a complete visual control over the anatomic structure of interests, thus avoiding unnecessary surgical errors and complications.

However, in our hands, each arthroscopic Latarjet or its revision remains a challenging procedure. It is always possible, at any stage of the surgery, to convert arthroscopy to an open procedure. Ideally one should be able to perform the both open and arthroscopic techniques, or at least to keep using the technique he masters well. A good open Latarjet is much better than a badly performed arthroscopic Latarjet. Nevertheless, mastering the complications and avoiding risks, carefully passing through the learning curve while having the support of a high-volume arthroscopy center, will offer the best possible care for our patients.

6.3 The arthroscopic Eden-Hybinette Procedure

Various bone grafting techniques and approaches were historically designed as mechanical dislocation barriers for shoulder instability cases. One of the oldest used principle is to augment the glenoid surface with a free bone block that can be harvested from the iliac crest. During the last 100 years, multiple fixation methods were developed [43]. As a consequence of advancements in arthroscopy and osteosynthesis, the autologous iliac crest bone grafting of the glenoid can be nowadays performed arthroscopically [44].

Although most of the shoulder surgeons today prefer to keep the Eden-Hybinette procedure for revision cases, after a failed Latarjet for example [5, 31], one can choose this technique as a first treatment option. Knowing that the open procedure renders similar low complications and recurrences rates as the open Latarjet procedure [45], it is interesting to discuss the early and mid-term follow up case series publications on the arthroscopic bone block technique as an alternative to the arthroscopic Latarjet.

Scheibel et al. described in 2008 an all arthroscopic reconstruction of chronic antero-inferior glenoid defect using an autologous iliac crest bone block [46]. In his initial study on 15 patients he reported only one recurrent instability case which required a secondary capsular plication [44]. At 20 months mean follow up period, the same research group described in a secondary study no recurrence and good to excellent clinical results, having one neurological complication regarding the hypoesthésia around the anterior thigh. Because of the small group study and short term follow up, a clear conclusion on graft resorption or general graft complications couldn’t be drawn. However, postoperative CT scans demonstrated, accordingly to Wolff’s law, that the extra-articular part of the graft resorbs completely [47]. Similar results were reported by Taverna et al. in a study on 26 patients at 29.6 months of mean follow up. There were no recurrent dislocations, the satisfaction rate was 88%, an average loss of 4.4° of external rotation and a demonstrated high healing rate of the graft [48].

However, in a meta-analysis on instability procedures, arthroscopic and open, Longo et al discovered an overall complication rate (including osteoarthritis) of 17.6% (12 of 68) and a 9.8% of instability recurrence for the Eden-Hybinette procedure [45].

In a mid-term outcome study (at 42 months), Bockmann et al. demonstrated on a group of 32 patients low pain levels and ‘acceptable complications levels’: 9% (3 patients) of re-dislocation after secondary traumatisms, 7% (1 patient) of postoperative graft fracture, 7% (1 patient) persistent instability sensation [49].

Though current evidence is somewhat limited, the arthroscopic Eden-Hybinette procedure as the first choice in treating anterior shoulder instability re-creates the anatomy of the anteroinferior glenoid and leads to good functional results.

6.4 The Implant-Free, Autologous, Iliac Crest Bone Graft Procedure (J-Bone Graft)

The J-bone graft is a feasible alternative bony procedure for the treatment of anterior shoulder instability caused by glenoid bone loss [50, 51]. Several authors presented good clinical outcomes for short, medium and long term follow up with overall little complications and high rates of return to sports [51–53]. The advantage of an implant-free anatomic glenoid augmentation technique is the avoidance of hardware complications, such as screws protrusion or impingement [51, 54]. The reverse of the medal represents, however, a technical demanding procedure with a steep learning curve, donor site morbidity at the iliac crest and specific intraoperative risks and complications [51].

6.5 The Posterior Bone Block Procedure

Posterior shoulder instability only accounts for 5% of shoulder instabilities. Acute posterior dislocation is a rare condition and may result from high-energy trauma, seizures or electric shock [57]. In case of chronic posterior instability, conservative treatment can obtain good functional results, and is considered the gold standard in voluntary instability related to hyper-laxity. Because of the low incidence of chronic instability, the optimal surgical treatment is still debated and several approach, from capsular plication to open or arthroscopic bone block augmentation, have been described. Already in 1952, McLaughlin described a bone block procedure in combination with capsular augmentation for posterior gleno-humeral instability [58]. In the last years, several techniques with promising results have been described. A bony procedure is required in case of relevant humeral and/or glenoid bone loss. Glenoid osteotomy [59] can be performed in case of glenoid retroversion more than 15°, as already described in the 60’s, but in the last years, bone block augmentation techniques have been often preferred. Gerber et al. showed that after glenoid osteotomy the humeral head could even migrate anteriorly and that this procedure is related to high intraoperative complication rate such as glenoid fracture or postoperative loss of correction [60]. Surgical treatment can be necessary if non-operative treatment fails. Surgical indication for posterior bone block augmentation, with iliac crest or a pedicle acromial flap, are the following: recurrent post-traumatic posterior dislocations with associated bone defects (reverse Hill Sachs and/or posterior glenoid bone loss), hyperlaxity, glenoid dysplasia and involuntary instability [61].

6.5.1 Complications After Posterior Bone Block Procedure

The posterior bone block procedure is a good treatment option for posterior dislocation, significantly improving shoulder stability after the procedure. The risk of recurrent dislocation is low. Despite that, postoperative complications and surgical revision after bone augmentation are high and the learning curve for this technique is steep. Both open and arthroscopic techniques show a higher revision rate, if compared to other standardized procedures for anterior instability as Bankart repair and Latarjet procedure. Schwartz et al. reported complication requiring revision surgery in 36.8% of patients after arthroscopic bone block procedure [61]. Intraoperative complications can be related to hardware breakage, vascular or neurological damage. Immediate postoperative complications such as haematoma or swelling are rare and usually do not require a surgical revision. Delayed postoperative complications such as infection and brachial plexus palsy are not frequently reported.

Several studies report a low recurrence rate after this procedure [61, 62]. Sirveaux et al. did not observe any recurrent dislocation or subluxation at longterm follow up after 13.5 years, but postoperatively 6 out of 18 patients described apprehension [63]. Servien et al. reported similar results with one out of 21 patients with postoperative recurrent dislocation and two patients with subjective shoulder instability and positive apprehension [64]. Clavert et al. recently reported the clinical outcome after posterior bone block procedure in a multicenter retrospective study of 66 patients, showing a significant postoperative improvement of the Constant score, with good postoperative Walch-Duplay (81.5) score and Rowe score (86.5) [65].

The major concerns at the long-term follow up are related to gleno-humeral osteoarthritis and graft osteolysis. The correct graft position is still debated during international shoulder meetings and in the recent literature. Since the bone block should fill the bony defect at the glenoid, the decision of the correct superior-inferior graft positioning is often done during surgery. Preoperative CT assessment, in order to anticipate the better graft position, is mandatory and should be performed in a standard fashion. Similarly to the Latarjet procedure, where the coracoid graft is usually placed flush to the subchondral glenoid bone, the posterior bone block should not be placed proud (Fig. 6.3). Too lateral grafts and incorrect hardware position can accelerate/produce postoperative gleno-humeral osteoarthritis. An ongoing study at the Alps Surgery Institute in Annecy (France), under the supervision of Laurent Lafosse, show partial graft osteolysis 6 months after surgery (Fig. 6.4), similar to the results already published for postoperative graft osteolysis after open or arthroscopic Latarjet procedure[32].

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