Arthritis in a young woman after Latarjet - challenges in management

 A woman in her mid thirties developed painful arthritis of the right shoulder after prior arthroscopic Bankart with remplissage and a subsequent Latarjet procedure for glenohumeral instability. On exam her shoulder was very stiff and felt unstable with "clunking" on movement.

X-rays at presentation showed glenhumeral arthritis, posterior decentering on a biconcave glenoid, and fixation of the coracoid on the anteroinferior glenoid by two large screws.

After discussion regarding the pros and cons of the alternatives, the patient elected an anatomic total shoulder arthroplasty.

No preoperative CT scan or 3D planning was used. The procedure was performed under general anesthesia without a brachial plexus block. 

The arthritic humeral head showed a large posterior Hill-Sachs defect.

The long head tendon of the biceps was preserved. 

After concentric reaming with a nubbed (non-cannulated) reamer, one of the pegs on the glenoid component could not be fully seated because of interference with one of the screws. A pine-cone bur was used to remove part of the screw to allow for full, secure seating of the glenoid component.   A posteriorly eccentric humeral head was used to control excess anterior translation. 

After careful mobilization of the subscapularis, a robust repair was achieved with 6 fiber wire sutures and two additional reinforcement sutures placed in the lateral rotator interval.

In the post anesthesia care unit, the patient demonstrated near full assisted flexion without the preoperative "clunking" and without feelings of instability.

Comment: In this case it was elected not to attempt removal of the screws to avoid the risk of damage to the musculocutaneous nerve, axillary nerve, and axillary artery that may be scarred in non-anatomical positions. 

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Nerve injuries and the Latarjet procedure

A reduction in the rate of nerve injury after Latarjet: a before-after study after neuromonitoring

These authors reviewed the Latarjet practice of a highly experienced shoulder surgeon, including 38 patients (group 1) who underwent surgery before neuromonitoring study and 48 patients (group 2) who underwent surgery with neuromonitoring. 

In group 1, there were 7 nerve injuries, of which all but 2 recovered. In group 2, there were 3 nerve injuries, of which all but 1 recovered. The overall incidence of nerve injury was 18.4% (group 1) vs. 6.3% (group 2); however, the incidence of permanent motor dysfunction was 5.3% (group 1) vs. 2.1% (group 2).

Thus overall 12% of patients experienced nerve injuries and 3.5% of these did not recover. 

The supra scapular nerve was injured in 2, the axillary in 6, the musculocutaneous (MCN) in 3 and the radial in one. For the nerve injuries that were not permanent, recovery took from 2 to 9 months.

In one patient the EMG demonstrated severe axillary nerve dysfunction and MCN dysfunction. Required open nerve release of his axillary and MCNs MCN resolved, axillary permanent (mild deltoid weakness at 11 months).

In another with EMG confirmation, resection of axillary nerve neuroma was performed with end-to-end motor nerve transfer of radial nerve medial triceps to axillary motor nerve (12.6 months post-op). Moderate recovery with mild deltoid weakness at 12 months after nerve transfer.

In another with EMG confirmation, revision reconstruction was performed with iliac crest bone graft and suprascapular nerve decompression (28 months).

In another with EMG confirmation, there was mild permanent deltoid weakness and numbness (lost to follow-up at 15 months).

The authors identified certain risk factors for nerve injury:

Comment: This report clearly documents the risk of serious nerve injury with the Latarjet procedure, even when it is performed by expert hands. Recovery, if it occurred, required many months. When recovery did not occur,  major reconstructive procedures were considered.

This information is useful in surgical decision making and in preoperative discussions with patients considering this procedure.

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The Latarjet procedure - how safe is it?

Ninety-day complications following the Latarjet procedure

These authors sought to describe the rate and type of complications occurring within 90 days following the Latarjet procedure for anterior glenohumeral instability. They reviewed consecutive patients undergoing the Latarjet procedure by fellowship-trained surgeons from a single institution between 2007 and 2016 were included for analysis. Their indications for the Latarjet procedure included primary or recurrent anterior instability with clinically significant anterior glenoid bone loss and/or failed prior arthroscopic stabilization. Patients undergoing the Latarjet procedure after prior glenoid bone grafting were excluded.

Among 133 patients (average age, 28.5 ± 11.8 years; 75% male patients), 10 total complications occurred within 90 days of surgery, for an overall short-term complication rate of 7.5%. Of these 10 complications, 6 required subsequent surgery, with recurrent instability in 2 cases (overall rate, 1.50%), infection in 2 (overall rate, 1.50%), musculocutaneous nerve palsy in 1 (overall rate, 0.75%), and postoperative pain in 1 (overall rate, 0.75%).

Each of the 2 patients who experienced recurrent subluxation events ultimately required conversion to arthroplasty. The 2 patients with infections underwent subsequent irrigation and débridement, as well as antibiotic therapy. The patient with the musculocutaneous nerve injury ultimately required further surgery in the form of a musculocutaneous nerve decompression and subsequent nerve transfer procedure. The remaining 4 complications were transient and resolved with nonoperative treatment, including wound dehiscence, hematoma, complex regional pain syndrome, and ulnar neuritis.

Comment: An increasing number of surgeons are being attracted to the Latarjet procedure for patients both without and with glenoid bone deficiencies. This article concerns the Latarjet complications in a single institution with highly trained shoulder surgeons - their report is likely to underrepresent the nature and frequency of Latarjet complications in the hands of community surgeons. 

It is to be noted that this study of 90 day complications would not capture the longer term complications of this procedure, such as screw loosening, coracoid non-union, and capsulorrhaphy arthropathy. Their article did show one case of arthritis related to contact of the fixation screw with the humeral head.

In our practice we have been referred a number of patients with hardware problems after the Latarjet procedure; some performed on shoulders without glenoid bone deficiency.

Here are some examples:

Patients and surgeons considering the Latarjet procedure should be aware of these potential complications as well as the difficulties associated with revision surgery in patients with a failed Latarjet (subscapularis scarring/deficiency, altered surgical anatomy, glenoid bone deficiency, nerve entrapment).

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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Total shoulder arthroplasty for arthritis after coracoid transfer for instability

In a prior post (see this link) we reviewed the problem of arthritis after a Bristow or Latarjet procedure. Because of the increasing utilization of these coracoid transfer surgeries, there is an increasing number of shoulders requiring revision because of complications or because of capsulorrhaphy arthropathy. 

We had such a case recently, in which the dissection was difficult, the subscapularis was scarred and the screw and bone block were approximated to the axillary nerve.

 In spite of his B2 glenoid, this shoulder was managed with a standard (non-augmented) all polyethylene glenoid component. The screw and most of the bone block was removed by careful dissection. The subscapularis was securely reconstructed.

 The patient sent us this photo of his motion at his home on the second day after surgery.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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

Arthroplasty for glenohumeral arthritis in shoulders with a previous Bristow or Latarjet procedure

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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Latarjet - a cautionary tale

A coracoid transfer (Latarjet) is preferred by some surgeons to manage recurrent anterior instability. This procedure is not without its risks as demonstrated by the x-rays below taken of the right shoulder of a young man who presented with pain and crepitant after his coracoid transfer. They show loosening and an intrarticular location of two cannulated screws associated with erosion of the inferior humeral head and loss of glenoid bone stock.

Comment: As pointed out in a prior post (see this link), the Latarjet procedure for shoulder instability carries some risk to the  axillary and musculocutaneous nerves, has had a 16% incidence of complications needing reoperation, has had a recurrence rate of 6%, and has had a 20% rate of subsequent arthritis.

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Is there anything new in shoulder surgery? - the Cliff Notes

What’s New in Shoulder and Elbow Surgery?

These authors reviewed what they felt to be the most impactful studies related to advances in shoulder and elbow surgery from March 2014 to March 2015. They placed specific emphasis on higher-quality research (Level-I and II studies) and particularly relevant Level-III and IV studies.


Here is a Cliff Note summary of 18 articles from this report:


Rotator Cuff:
*A longer duration of symptoms did not correlate with more severe rotator cuff disease, and symptom duration was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures.

*An analysis of 434 patients with an atraumatic rotator cuff tears found that shoulder activity was not associated with the severity of the rotator cuff tear.

*In asymptomatic degenerative cuff tears, progression was seen in 49% and the development of shoulder pain was seen in 46% of the cohort.

*The operative treatment of nontraumatic supraspinatus tears is no better than conservative treatment; conservative treatment should be considered as the primary method of treatment for this condition.

*The short-term outcomes of arthroscopic rotator cuff repair performed with and without acromioplasty showed no differences in clinical outcome scores.

*A combined systematic review and meta-analysis of 108 articles from 1980 to 2012, with data for 8011 shoulders showed that the rate of tendon healing and clinical results were not improving with the advent of newer surgical techniques. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, advanced age, and double-row repairs. Clinical improvement averaged 72% of the maximum possible improvement. Patient-reported outcomes generally improved regardless of the integrity of the repair.

*The treatment effect of surgery for degenerative cuff tears was thought not to be profound enough to justify surgical management of painful degenerative cuff tears on initial presentation.

*Concurrent distal clavicle resection does not improve the results of cuff repair.

*Platelet rich plasma did not improve clinical outcomes or tendon healing in cuff repair.

The Latarjet procedure for shoulder instability
*The axillary and musculocutaneous nerves are at risk

*16% of patients had complications needing reoperation

*Recurrence rate 6%

*20% developed arthritis


Arthroplasty
*The overall readmission rate was 7.3%, with the highest rate found in the reverse shoulder arthroplasty group. Medical complications contributed to 82% of the readmissions. Infection and dislocation were the most common surgical complications resulting in readmission. Patients with Medicaid insurance had more than a 50% greater risk of readmission compared with patients with Medicare. Procedures performed in medium and high volume hospitals were associated with a lower risk of readmission compared with those in low-volume centers

*Higher surgeon and hospital case volumes led to improved perioperative metrics with all shoulder arthroplasty procedures.

*The rate of revision of metal-backed glenoids was much higher than that of polyethylene glenoids (14.0% versus 3.8%; p < 0.0001).

*The clinical benefit of 3D planning patient specific instrumentation has not been demonstrated.

*The clinical benefit of augmented glenoid components has not been demonstrated.

Comment: Taken as a group, the articles selected for this "what's new" review seem to indicate that the "new" developments have not led to improvements over the time-tested standard approaches to cuff disease, instability or glenohumeral arthritis.

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Arthritis after a Bristow-Latarjet procedure

Risk of arthropathy after the Bristow-Latarjet repair: a radiologic and clinical thirty-three to thirty-five years of follow-up of thirty-one shoulders.

These authors report long term followup on 31patients (mean age, 26.7 years) who had a Bristow-Larjet repair from 1977 to 1979.

One patient required revision surgery because of recurrence and another because of repeat dislocation. Six patients reported subluxations. Eighteen patients (58%) were very satisfied, and 13 (42%) were satisfied. The mean Western Ontario Shoulder Instability Index score was 85/100, and the median score was 93/100. According to Samilson-Prieto classification of arthropathy of the shoulder, 39% were classified as normal, 27% as mild, 23% as moderate, and 11% as severe. The classification of arthropathy varied with observers and radiologic views. Age younger than 22 years at the primary dislocation was associated with less arthropathy at follow-up.

Comment: The Latarjet procedure has become a popular method for stabilizing shoulders with recurrent instability. Some surgeons reserve it for failed anatomic repairs or for cases with substantial anterior glenoid bone loss while others use it routinely for the surgical repair of instability.  The cases reported here were done quite a long time ago and it is likely that the surgical techniques have changed substantially since that time. In these cases it is not clear how much of the arthropathy is due to the episodes of instability and how much to the surgical procedure. We have previously posted regarding capsulorrhaphy arthropathy, including arthropathy after a Latarjet as shown here.

For comparison, a recent review found a 30% complication rate with this type of procedure.

While their method of single screw fixation of the coracoid in the 'standing' position led to 25% failure of bony union, the authors opine that fixation of the transferred coracoid in the 'lying' position with two screws may increase the risk of hardware complications.

In our practice, we reserve bony transfer procedures for shoulders in which an anatomic repair has failed or for those with major glenoid bone defects.

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Propionibacterium in a primary arthroplasty after a Latarjet procdure, seeing what you look for

A man is his early twenties presented with pain and stiffness in the shoulder after two prior instability procedures, the last being a Latarjet in 2012.

He had a primary hemiarthroplasty with removal of the screw, the head of which was rubbing on his humeral head. Because of the global loss of cartilage seen on his preoperative films, we obtained cultures before administering antibiotics.

At surgery there was no obvious evidence of infection. The humeral head showed global loss of cartilage as shown here.

His postoperative films are shown here.

After surgery he was started on the 'yellow' antibiotic protocol. Range of motion exercises were started on day one and he had 150 degrees of motion on discharge two days later.

Five days after surgery, the cultures grew out coagulase negative staph in one specimen and Propionibacterium in three (capsule, humeral head #1 and humeral head #2). At that time a PICC line was plaeced and he was converted to the 'red' antibiotic protocol.

Comment: It would have been easy to miss this infection. Our index of suspicion was heightened by the generalized destruction of the joint surface in contrast to the local destruction that would be expected from contact of the humeral head with the screw.

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Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Shoulder arthritis from suture anchors and screws; Latarjet

One of our first articles about the shoulder, published in 1984 concerned complications of hardware around the shoulder.  We observed that "Screws and staples are used frequently in the surgical treatment of glenohumeral joint problems. We analyzed a series of thirty-seven patients with complications related to the use of these implants. Twenty-one patients had problems related to the use of screws for affixing a transferred coracoid process to the glenoid. Sixteen patients had problems related to the use of staples: ten had undergone capsulorrhaphy, four had had advancement of the subscapularis, and two had had repair of a rotator cuff tear. The complaints at examination were shoulder pain (thirty-six patients), decreased glenohumeral motion (nineteen patients), crepitus with glenohumeral motion (sixteen patients), and radiating paresthesias (four patients). The time between placement of the implant and the onset of symptoms ranged from four weeks to ten years. The screws or staples had been incorrectly placed in ten patients, had migrated or loosened in twenty-four, and had fractured in three. Thirty-four patients required a second surgical procedure specifically for removal of the implant. At operation fourteen patients (41 per cent) were noted to have sustained a significant injury to the articular surface of the glenoid or humerus. The results in this group of patients indicated that screws and staples can produce complications that require reoperation and are capable of causing a permanent loss of joint function. Adequate surgical exposure and careful placement of the implant appear to be essential when these devices are used about the glenohumeral joint."

Here's yet another example of 'anchor arthropathy', which is the modern version of what we discussed 30 years ago. These films are of the right shoulder of a young person having had surgery for shoulder instability. After surgery the shoulder became stiff and painful and did not respond to exercises.

The severe anchor arthritis is apparent.

The individual is scheduled for a ream and run.

Here's another: two days ago we did a ream and run on a young active person with pain and stiffness after a Latarjet. The x-rays show where the screw and bone had been rubbing on the humerus.

At surgery the prominent screw head was seen to be rubbing on the humeral head 

and the bone graft rubbing on the medial humeral cortex.

"Adequate surgical exposure and careful placement of the implant appear to be essential when these devices are used about the glenohumeral joint."

More here.

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Consultation for those who live a distance away from Seattle.

**Check out the new Shoulder Arthritis Book - click here.**

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.