Rockwood Adults CH34

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SECTION TWO • Upper Extremity

versus Latarjet procedures. At mean follow-up of 5.3 years, the authors reported better return to sport (SPORTS score: 8 vs. 6; P = 0.02), ROM in the throwing position (86 degrees vs. 79 degrees; P = 0.01), and better subjective perception of the shoulder (subjective shoulder value [SSV]: 86% vs. 75%; P = 0.02) in favor of the Bankart repair. A recent meta-analysis evaluating the available data on return to sport concluded that Latarjet and arthroscopic Bankart repairs had a similar return to sport at the same level following surgery (73% vs. 71%, respec- tively). 100 The data, however, did not stratify with respect to types of sports/athletes involved in the analyses (i.e., overhead versus nonoverhead sports). This may explain the underlying discrepancy on return to sport after Latarjet. Anterior Glenohumeral Instability: COMMON ADVERSE OUTCOMES AND COMPLICATIONS • Recurrent anterior instability • Postoperative stiffness • Bone graft failure (Latarjet or bone block augmentation): graft fracture, lysis, nonunion • Neurologic injury (musculocutaneous and axillary nerve) • Glenohumeral arthrosis The overall complication rate for arthroscopic Bankart surgery is low. Data from the American Board of Orthopaedic Surgery has shown that perioperative morbidity such as infection (0.2%) and neurologic injury (0.3%) is exceedingly low. 177 Comparatively, open procedures such as open Bankart and Latarjet procedures are associated with higher complication rates (open Bankart: 4.3%; open Latarjet: 10.6% to 15%; bone block: 17.6%). 24,140,194 Recurrent anterior instability after arthroscopic Bankart repair surgery is likely the most common adverse outcome after repair. Careful physical examination and assessment of imaging for underappreciated bone loss from either the glenoid or the humeral head is paramount for success in revision surgery. For scenarios where there is no critical bone loss, revision surgery with arthroscopic or open Bankart repair can be successful. 14,41,164 Neviaser et al. 164 reported their experience of 30 patients who had failed prior arthroscopic repair for anterior instability and underwent an open repair. None of the patients had bone loss on the glenoid or humeral side that was clinically significant. At an average of 10.2 years of follow-up, no patients had an appre- hension sign, pain, or instability. Of 23 who played sports, 22 resumed after surgery. Outcomes scores were as follows: ASES, 89.44 (90% good/excellent); Rowe, 86.67 (93.3% good/excel- lent); Western Ontario Shoulder Instability Index, 476.26 (80% good/excellent). In cases where significant glenoid bone loss is present, revision with either Latarjet or bone block augmenta- tion would be the treatment of choice. Schmid et al. 205 evaluated their group of 49 patients who had failed one or more instability repairs with associated glenoid rim deficiencies and underwent the Latarjet procedure. The authors reported no further disloca- tion in their series, and two patients with subluxation did not Management of Expected Adverse Outcomes and Unexpected Complications Related to Anterior Glenohumeral Instability

require further intervention. Forty-three shoulders (88%) were subjectively graded as excellent or good; three, fair; and three, poor. The mean SSV increased from 53% preoperatively to 79% at the time of follow-up ( P < 0.001), and the Constant–Murley score remained high (80% preoperatively and 85% at the time of follow-up; P = 0.061). Recurrent subluxation and dislocation after Latarjet occurs at a less frequent basis compared with Bankart repair. 21,90,279 Recurrent subluxation and dislocation after Latarjet is esti- mated to be approximately 5.8% and 2.9%, respectively. 76 In rare cases of frank dislocation, closed reduction and conserva- tive management has yielded satisfactory outcomes. 279 Clinical scenarios of recurrent anterior shoulder instability after Latarjet or bone block augmentation are challenging. Positioning of the coracoid or bone block graft should be carefully evaluated as malposition has been associated with recurrent instability after these procedures. 71,94 Revision reconstruction with autograft or allograft bone block has been described and successful in this challenging subset of patients who failed a prior Latarjet proce- dure. 71,141,203,235 Appropriate loss of ROM after Bankart repairs and open bone block procedures, including Latarjet procedures, is expected. Typical decrease in postoperative ROM can be expected follow- ing arthroscopic Bankart repair, particularly in external rotation both with the arm down at the side and in 90 degrees of abduc- tion. A recent meta-analysis reported this to be 3 to 9 degrees with the arm at the side and 3.5 to 6 degrees with the arm in 90 degrees of abduction. 40 In terms of Latarjet procedures, An et al. 6 reported a mean loss of 11.5 degrees of external rotation in their systematic review of eight comparative studies. These ROM deficits are typically not to the extent that needs further surgical intervention and can be successfully managed with therapy and corticosteroid injections into the glenohumeral joint. In extreme cases, arthroscopic lysis of adhesions can be performed if conservative approaches have been exhausted. Incidence of secondary surgery for capsular release after Ban- kart surgery (0.5%) or open bony augmentation procedures is rare (0.7%). 6,18 Bone graft complications with bone augmentation proce- dures can occur intraoperatively and postoperatively. Stable nonunion of a coracoid graft or bone block is a recognized complication of the bony glenoid augmentation procedures. The patients can have good functional results with an inci- dental finding of stable fibrous nonunion and may not require a reoperation. 18,79 In a recent systematic review by Griesser et al. 76 that included an analysis of 45 studies (1,904 shoul- ders) demonstrated 174 cases of nonunion or fibrous union, an overall nonunion rate of 9.1%. Mizuno et al. 157 in their cohort of 68 patients with a mean follow-up of 20 years reported a fibrous nonunion rate of 1.5% with no recurrence of instability. Dumont et al. 62 in their 5-year review of 62 patients reported that 1 patient (1.7%) required a reoperation as a result of graft nonunion. A recent study of failed Latarjet procedures reported that use of a single screw for graft fixation was associated with clinical failure. 71 Careful preparation of the coracoid graft and the anterior glenoid is therefore paramount, along with careful placement of two screws parallel to the glenoid face to mini- mize the risk of graft nonunion.