Management of the Failed Latarjet Procedure: Outcomes of Revision Surgery With Fresh Distal Tibial Allograft

Abstract

Background: Patients with recurrent anterior glenohumeral instability after a failed Latarjet procedure remain a challenge to address. Complications related to this procedure include large amounts of bone loss, bone resorption, and issues with retained hardware that necessitate the need for revision surgery. Purpose: To determine the outcomes of patients who underwent revision surgery for a recurrent shoulder instability after a failed Latarjet procedure with fresh distal tibial allograft. Study Design: Case series; Level of evidence, 4. Methods: All consecutive patients who underwent revision of a failed Latarjet procedure with distal tibial allograft were prospectively enrolled. Patients were included if they had physical examination findings consistent with recurrent anterior shoulder instability. Patients were excluded if they had prior neurologic injury, a seizure disorder, bone graft requirements to the humeral head, or findings of multidirectional or posterior instability. History of shoulder instability was documented, including initial dislocation history, duration of instability, number of prior surgeries, examination findings, plain radiographic and computed tomography (CT) data, and arthritis graded with Samilson and Prieto (SP) classification. All patients were treated with hardware removal, capsular release with subsequent repair, and fresh distal tibial allograft to the glenoid. Outcomes before and after revision were assessed according to the American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), and Western Ontario Shoulder Index (WOSI) and statistically compared. All patients underwent a CT scan of the distal tibial allograft at a minimum 4 months after surgery. Results: There were 31 patients enrolled (all males), with a mean age of 25.5 years (range, 19-38 years) and a mean follow-up time of 47 months (range, 36-60 months) after revision with distal tibial allograft. Before distal tibial allograft augmentation, the mean percentage glenoid bone loss was 30.3% (range, 25%-49%). All patients after their Latarjet stabilization had recurrent shoulder dislocation (11/31, 35.5%) or subluxation (20/31, 64.5%), and all patients had symptoms consistent with recurrent shoulder instability upon physical examination. Radiographs demonstrated 2 fixation screws in all cases, mean SP grade was 0.5 (range, 0-3), and CT scans revealed that a mean 78% of the Latarjet coracoid graft had resorbed (range, 37%-100%). Patient-reported outcome scores improved significantly pre- to postoperatively for ASES (40 to 92, P = .001), SANE (44 to 91, P = .001), and WOSI (1300 to 310, P = .001). There were no cases of recurrence, and a final CT scan of the distal tibial revision demonstrated a complete union at the glenoid–distal tibial allograft interface in 92% of patients. Conclusion: The majority of the failed Latarjet procedures included in this study had near-complete resorption of the coracoid graft and hardware complications. At a minimum follow-up time of 36 months, patients who underwent revision treatment for a failed Latarjet procedure with a fresh distal tibial allograft demonstrated excellent clinical outcomes and near-complete osseous union at the glenoid-allograft interface. Although patients evaluated with recurrent anterior shoulder instability after a failed Latarjet procedure remain a challenge to address, fresh distal tibial allograft augmentation is a viable and highly effective revision procedure to treat this patient population.

Outcomes of the Latarjet Procedure Versus Free Bone Block Procedures for Anterior Shoulder Instability: A Systematic Review and Meta-analysis

“…‖ Sources of autograft include iliac crest bone graft (ICBG), ¶ distal clavicle, 92 and free partial-thickness coracoid (leaving the conjoint tendon attached to the remaining anatomic coracoid and not transferred with the graft as performed during a Latarjet/Bristow procedure). 7,95 Sources of allograft include the distal tibia, 40,73,75 proximal tibia, 87 distal femur, 87 iliac crest, 2,90,108 and femoral head. 98 The use of autografts may be associated with donor site morbidity, including risk for infection, hematoma, sensory disturbances, and an additional scar.…”

Management of Recurrent Anterior Shoulder Instability After Surgical Stabilization in Children and Adolescents

“…Similarly, the Latarjet for glenoid bone loss and remplissage procedure for humeral head bone loss have been reported with success in the adolescent population [14, 30•]. Additionally, the use of Iliac crest and distal tibia allograft have been described in adult populations for the treatment of glenoid bone loss, but never in children [35,40]. Distal clavicle autograft has also been utilized in adults for glenoid bone loss; however, the open distal clavicular physes would likely make this undesirable in adolescent patients [41].…”

Placing the Latarjet in Context

“…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.…”

“…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.…”

“…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.…”