Monday, May 14, 2018

Total shoulder for post-Latarjet/Bristow arthritis - high complication rate

These authors point out that coracoid transfer (Latarjet or Bristow) has become increasingly popular as a surgical treatment for recurrent anterior shoulder instability, but that glenohumeral arthropathy develops in some patients. They point out that arthroplasty in this population is complicated by altered anatomy, scarring, and retained hardware. 

They evaluated 33 patients having shoulder arthroplasty after coracoid transfer at a minimum of 2 years or until reoperation. Arthroplasty procedures included hemiarthroplasty (HA) in 5, total shoulder arthroplasty (TSA) in 14, and reverse shoulder arthroplasty (RTSA) in 11. 

9 shoulders (30%) underwent revision for instability (1 TSA and 1 HA), glenoid loosening (1 TSA), instability and glenoid loosening (3 TSA), late cuff failure (1 TSA), and painful glenoid erosion (2 HA).

Radiographically, 2 additional anatomic glenoid components were considered loose, progressive medial erosion was seen in 1 HA, and grade 1 to 2 notching was observed in 2 RTSAs.

Neurologic complications developed in 2 shoulders in the RTSA group: a transient axillary nerve palsy developed in 1 patient and neuropathic pain developed in the other patient.

The overall rate of complications in the whole cohort was 43.3%.  Complications included instability in 6 (4 TSA and 2 HA), neurologic complications in 2 (RTSA), glenoid loosening in 2 (TSA), glenoid erosion in 2 (HA), and cuff tearing in 1 shoulder (TSA).

Survival free of revision was 56.8% at 5 years for the entire cohort.

Comment: Glenohumeral arthritis is a known consequence of a Latarjet procedure (see Glenohumeral arthritis after Latarjet procedure: Progression and it's clinical significance). 

If a shoulder arthroplasty is needed, a prior coracoid transfer can compromise the function of the subscapularis, challenge the stability of the arthroplasty, put the musculocutaneous and axillary nerve at risk, and complicate the stability of the glenoid component in shoulder arthroplasty, even in the hands of these experienced surgeons. 

These risks should be considered in the selection of the surgical procedure for glenohumeral instability.

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