Revision procedures for failed Latarjet surgery of the shoulder

1. Outcomes of Revision Procedures
for Failed Latarjet Surgery
Mohammad Hussain
Supervisors: Professor Lennard Funk
Dr. Emma Torrance

2. • 81 Latarjets over 4 year period.
• 9.9% overall complication rate
• 3.7% re-dislocation rate
• Improved functional outcome scores
• Only 1 patient (1.2%) was unable to return to sport at
pre-injury level
• Mean time to return to sport 126 days
The Latarjet Procedure:
A Review of Outcomes and Complications
Mohammad Hussain, Emma Torrance, Lennard Funk

3. Complications
Complication Our Study (%) Gressier et al (%)
Overall 9.9 30.0
Neurovascular
injury
0.0 1.8
Haematoma 1.2 0.5
Recurrent
instability
3.7 8.7
Infection 2.5 1.3
Reoperation rate 9.9 6.9
1Griesser et al. Complications and re-operations after Bristow- Latarjet shoulder stabilization: a
systematic review. Journal of Shoulder and Elbow Surgery 2013 (n=1,904)

4. Reason for Study
• Latarjet failure rate is low [5-12%](Funk et al., 2012; An et al., 2016)
• But failure is difficult to deal with
• Outcomes of revisions procedures are poorly
reported in the literature
– Only 3 papers(Lunn et al., 2008; Castagna et al., 2010; Boileau et al., 2009 )

5. Aims
1. To assess outcomes of revision procedures
2. To recognise how/why they fail
3. To identify correlations between patient history
and outcomes

6. Method
• Retrospective analysis of 16 patients undergoing
revision over a 5-year period (2010-2015)
• Revision definition:
– Any procedure post-Latarjet
– To stabilise the shoulder joint
• EPRs at The Arm Clinic + Wrightington(audit approval obtained)
• Primary Latarjet procedures at 6 institutions

7. Demographics
Parameter Value Comments
Total patients 16 -
Latarjet by Elsewhere : LF 11 : 5 -
Mean age at Latarjet 27.4 (±6.7; range 16 to 41)
Mean age at revision 29.9 (±8.9; range 17 to 50)
Male : Female 12 : 4 -
Right : Left 9 : 7 -
Dominant : Non-dominant 4 : 3 (unreported in 9)
Athletes 11 -
Professional 9 (6 rugby + 2 football + 1 biking)
Amateur 2 (1 rugby/cricket + 1 horse-rider)

8. Direction of Recurrent Instability
0
3
6
8
11
Anterior Posterior Multi-directional
3
2
11

9. Revision for Anterior Instability
Indication for Revision Rate Revision Procedure
Coracoid non-union 7 -
Screw failure 2 1 × E-H, 1 × Latarjet
Without screw failure 3 3 × E-H
Infection + delayed union 1 1 × OI
Infection + Screw failure 1 1 × E-H
Capsular failure 3 3 × AS
Hill-Sachs lesion 1 1 × AR
Note: n = 11; AS = Arthroscopic stabilisation; AR = arthroscopic remplissage; E-H = Eden-Hybinette; OI
= OSIgraft injection

10. Revision for Posterior & Multi-directional Instability
Indication for Revision Rate Revision Technique
Posterior instability 2 -
Capsular laxity + Posterior ALPSA 2 2 × AS
Multi-directional instability 3 -
Capsular laxity 1 1 × AS
Capsular laxity + capsular failure +
reverse Bankart
1 1 × AS
Capsular laxity + reverse Bankart +
coracoid non-union (screw failure)
1 1 × E-H + AS
Note: AS = Arthroscopic stabilisation; E-H = Eden-Hybinette

11. Intraoperative Findings
Parameter Laxity Osteoarthritis Poor TQ Rate
Anterior
✗ ✗ ✗ 2
✓ ✗ ✗ 2
✓ ✓ ✗ 2
✓ ✗ ✓ 2
✗ ✓ ✓ 1
✗ ✗ ✓ 1
Posterior ✓ ✗ ✓ 2
Multi-directional
✓ ✓ ✗ 1
✓ ✗ ✓ 1
✓ ✓ ✓ 1
Total 11 5 8 15
Note: Findings reported in 15/16 patients (unreported in 1 anterior instability); TQ = Tissue quality

12. Beighton Score and Laxity
• Score assessed in 3/11 patients with Laxity at
revision
• Clinical threshold = 4/9
• Mean score = 6/9 (±1; range 5 to 7)

13. Complications of Revision
• 4 in total:
– 2 Post Eden-Hybinette
• Graft fracture + Screw failure
• Anterior instability + Ilioinguinal nerve injury
– 1 Post arthroscopic stabilisation:
• Superficial infection (P. acnes)
– 1 Post remplissage
• Missed graft non-union from Latarjet

14. Second Revision (n=2)
Initial Revision
Indication for
second revision
Second Revision Complications
Eden-Hybinette
Graft fracture +
Screw failure
Insertion BMAC None
Remplissage
Missed Latarjet
non-union
Eden-Hybinette Broken screw1
Note: 1Patient asymptomatic; BMAC = Bone marrow aspirate concentrate

15. Demographics at Second Revision
Parameter Value Comments
Total patients 2 -
Mean age at revision 32.0 (both 32)
Male : Female 2 : 0 -
Right : Left 0 : 2 -
Dominant : Non-dominant 0 : 1 (other unreported)
Athletes 1 -
Professional 1 (rugby player)

16. Return to Sport
0
3
6
9
12
All Professionals Amateurs
4
4
2
5
7
Returned to same level sport
Did not return to same level sport

17. Conclusion
• Anterior instability is the most common direction
of recurrence
– Most due to coracoid non-union
– Notable number due to capsular failure
• When recurrence was due to posterior or multi-
directional instability
– Capsular laxity was implicated in all cases
– Posterior lesions implicated in 80% of cases

18. Acknowledgments
A sincere thank you to Emma Torrance, Lennard
Funk and Tanya Mackenzie for providing me the
opportunity to carry out this project and all the
support in the process.