Three factors (a tear of the rotator cuff, an intraoperative or postoperative complication, and too lateral placement of the coracoid graft) appeared to lead to symptomatic postoperative glenohumeral osteoarthrosis. The two shoulders that had grade-4 eccentric glenohumeral osteoarthrosis had had a preoperative tear of the rotator cuff, and one of them had had grade-1 glenohumeral osteoarthrosis preoperatively. Symptomatic centered glenohumeral osteoarthrosis developed in three of the four shoulders that had had an intraoperative or postoperative complication.
We conducted a separate analysis of the fifty-two shoulders that had not had a tear of the rotator cuff or an intraoperative or postoperative complication in order to study other factors that led to the development of osteoarthrosis. We found that the placement of the coracoid graft was the most important factor in the development of postoperative glenohumeral osteoarthrosis (p = 0.0016). Symptomatic centered glenohumeral osteoarthrosis (grades 2, 3, and 4) developed in six shoulders that had too lateral placement of the coracoid graft (Table II). The other twenty-two shoulders that had too lateral placement of the graft as well as all twenty-three shoulders that had perfect placement of the graft and the one shoulder that had too medial placement of the graft had grade-0 or grade-1 glenohumeral osteoarthrosis.
The second factor that we found to be significantly associated with the development of postoperative glenohumeral osteoarthrosis was the type of preoperative instability (p = 0.02). The shoulders that had had recurrent anterior dislocation preoperatively had a higher postoperative rate of glenohumeral osteoarthrosis than the shoulders that had had painful recurrent anterior subluxation (Table III). Nevertheless, with the numbers available, we did not find an association between the number of preoperative dislocations (or the delay between the first dislocation and the operation) and glenohumeral osteoarthrosis at the latest follow-up examination (p = 0.35).
With the numbers available for study, we could not detect a significant association between gender, the age at the time of the operation and at the latest follow-up examination, the presence or type of preoperative osseous lesions, osteolysis or pseudarthrosis of the coracoid graft, or the type of preoperative or postoperative participation in sports and the development of glenohumeral osteoarthrosis.
Of the fifty-two shoulders that had no tear of the rotator cuff or postoperative complications, eight had had preoperative glenohumeral osteoarthrosis. At the latest follow-up evaluation, symptomatic glenohumeral osteoarthrosis had developed in two of the eight shoulders. Statistical analysis of this finding was not possible because of the small number of shoulders involved.
The fifty-eight shoulders that had had a Latarjet procedure in the present report were followed clinically and radiographically for an average of 14.3 years (minimum, ten years). Our study differs from other studies of the treatment of recurrent anterior instability of the shoulder2,5,8,11,12,15,16,20,26,29,32-34,37,39,41-43 because, although some of these studies had an adequate duration of follow-up, many included observations that were made on the basis of a short follow-up12,34,41,43 and few included a systematic analysis of radiographs (Table IV).
Other investigators have found, and we confirmed, that transfer of the tip of the coracoid process provides reliable stabilization of the shoulder2,9,27,28,39. The findings in our series also demonstrated that shoulders that are stabilized with this procedure function satisfactorily over time.
We believe that the Latarjet technique has a dual mechanism for maintaining glenohumeral stability. First, the reinforcement effect of the coracobrachialis muscle is predominant with the arm in abduction. Second, the bone block used for reconstruction of the glenoid concavity is very effective at the end of the throwing movement as well as with low abduction of the arm25. Lazarus et al.25 described the importance of anatomical reconstruction of the glenoid concavity, especially in shoulders that have a defect in the bone, cartilage, or labrum; these findings are consistent with our experience with the treatment of glenohumeral instability.
The stabilization of the shoulder achieved by the Latarjet procedure allowed more than 80 per cent of our patients (forty-one of fifty-one shoulders) who had participated in sports preoperatively to return to the same level of activity postoperatively despite an average loss of 15 degrees of external rotation. If these patients had been pitchers, the 15-degree loss of external rotation would have been a severe impairment. Indeed, Jobe et al.21, Collins and Wilde6, and Lombardo et al.27 strongly recommended that pitchers return to their sport only when the shoulder had been perfectly stabilized and complete external rotation had been recovered. The average loss of external rotation is the same after most of the different operative techniques. Except in the series reported by Rowe et al.34, the Bankart procedure has led to a loss of external rotation of less than 15 degrees9,10,30,39,42. The Eden-Hybbinette procedure has caused a loss of approximately 15 degrees of external rotation30,36,40. Only humeral osteotomy19,23,43 and the Boytchev intervention13 has provided better external rotation.
The 7 per cent rate of complications (four of fifty-eight shoulders) in our study was lower than the rates reported in other studies of the Bristow-Latarjet procedure11,31,38,42,44,45. Four shoulders had five complications, which included three infections, a radiating fracture of the glenoid, and a frozen shoulder. Secondary operative intervention was needed to treat the infection in two shoulders, and a pseudarthrosis developed in two shoulders. None of the shoulders had migration of the screws. We believe that the lower rate of complications in our study may be attributed to our use of two screws to fix the coracoid graft to the posterior aspect of the glenoid9,18,39,42 and to provide good compression.
The large number of shoulders (thirty-one) in which the coracoid graft was placed too laterally attests to the difficulty of this operation. Considerable attention must be paid to operative technique. The operative view of the anterior aspect of the glenoid rim must be perfect before the coracoid graft is fixed, and the surgeon must consider the 30-degree anterior obliquity of the scapula on the thoracic skeleton (Fig. 10). After fixation of the coracoid transfer, the placement must be verified. If the position is too lateral, the external part of the graft must be removed. Another option is to fix the graft more medially, even in an extra-articular position (as in the Bristow procedure). However, we agree with Lazarus et al.25 that reconstruction of the glenoid concavity is necessary for stabilization of the shoulder.
Glenohumeral osteoarthrosis developed in 58 per cent (thirty) of the fifty-two shoulders that had no tear of the rotator cuff and no postoperative complications (Table III). This is one of the highest rates of glenohumeral osteoarthrosis reported after the Latarjet (or Bristow) procedure2,8,11,27,39,42 or the Bankart procedure34,39,42. However, most (twenty-four) of the thirty shoulders had grade-1 osteoarthrosis with no functional effect and without an increase in grade after more than ten years of follow-up. Moreover, our study had a longer duration of follow-up than most other studies and 20 per cent of the shoulders in our series had had grade-1 glenohumeral osteoarthrosis preoperatively.
Our conclusions were made with caution because thirty-seven patients (thirty-seven shoulders) of the original ninety-three patients (ninety-five shoulders) either were lost to follow-up or declined to participate in the study. We found that the Latarjet procedure led to symptomatic glenohumeral osteoarthrosis only in the shoulders that had had a preoperative tear of the rotator cuff or an intraoperative or postoperative complication. Thus, we recommend that shoulders be examined for a tear of the rotator cuff preoperatively and that the coracoid graft be placed with care taken to avoid excessively lateral placement. If these two recommendations are followed, it should be possible to improve upon the results in our series, in which the rate of perioperative or postoperative complications was 7 per cent. However, it should be noted that, after more than fourteen years of follow-up, none of the shoulders had recurrent dislocation and 81 per cent (forty-seven) had a normal radiographic appearance (Fig. 11) or only slight glenohumeral osteoarthrosis with no notable functional effects.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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