Salvage Iliac Crest Bone Grafting for a Failed Latarjet Procedure: Analysis of Failed and Successful Procedures
Lukas Ernstbrunner1, Torsten Pastor1, Manuel Waltenspül1
1Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
Background:
The Latarjet is a successful procedure but can be associated with significant complications, including failure. Iliac crest bone grafting (ICBG) is one of the salvage options for such failure.
Purpose:
To analyze factors associated with failure or success to restore shoulder stability with ICBG after Latarjet failure.
Study Design:
Case series; Level of evidence, 4.
Methods:
Twenty consecutive patients with recurrence of instability after a Latarjet procedure underwent revision using ICBG. Sixteen patients (80%) with a mean age of 35.0 years (range, 25-55) could be personally reexamined clinically and radiographically (including computed tomography scan) after a mean follow-up of 4.5 years (range, 2-8). Twelve patients had redislocation and 4 had recurrent subluxation after the Latarjet.
Results:
Salvage ICBG failed in 7 patients because of recurrent dislocations, with 5 necessitating reoperations: 2 arthrodeses, 1 reverse total shoulder arthroplasty, 1 repeat ICBG, and 1 Hill-Sachs allograft reconstruction and Bankart repair. Factors associated with ICBG failure were multidirectional instability (n = 2), subscapularis insufficiency (n = 1), uncontrolled seizures (n = 1), static inferior glenohumeral subluxation (n = 1), total graft resorption (n = 1), and voluntary dislocation attributed to schizoaffective disorder (n = 1). The initial Latarjet graft was malpositioned (too medial) in 3 of these patients. In patients without recurrent instability (n = 9), reasons for Latarjet failure were graft related: 6 graft avulsions, 2 graft resorptions, and 1 medial graft malpositioning. The mean absolute Constant score (62 to 87 points, P = .012) and relative Constant score (66% to 91%, P = .012), pain (10 to 15 points, P < .001), and Subjective Shoulder Value (31% to 85%, P = .011) in the group with a successful procedure were significantly improved over the preoperative state, and the total Western Ontario Shoulder Instability Index averaged 64% at final follow-up. Except in 1 case of major resorption, mild graft resorption or none was observed in successful procedures. Axial and sagittal graft positioning was good in all 9 patients.
Conclusions:
Salvage ICBG for failed Latarjet procedures failed in 7 of 16 patients. It was successful in patients with clearly graft-related factors of the initial Latarjet procedure. However, patients with unclear instability symptoms, subscapularis insufficiency, inferior subluxation, uncontrolled seizures, or psychological disorders were poor candidates for salvage ICBG, underlining the importance of careful patient selection for the initial Latarjet procedure and for salvage ICBG.