Single-screw Fixation During Latarjet Procedure Increases Risk of Complications

Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.

Graft- and nerve-related complications are relatively common following the Latarjet procedure. Fixation with only one screw was a significant predictor of graft failure, according to a study that Benjamin A. Hendy, MD, of the Rothman Orthopaedic Institute at Thomas Jefferson University Hospitals in Philadelphia, presented as part of the Annual Meeting Virtual Experience.

“Although the Latarjet procedure is known to reliably restore shoulder stability, the complications can be disastrous,” Dr. Hendy told AAOS Now. “The literature is varied with regard to the reported complication rates. As a result, we sought to report our institution’s 10-year experience with the procedure, highlighting complications within the first 90 days after surgery.”

The study retrospectively reviewed Latarjet procedures performed in 190 shoulders (182 open, eight arthroscopically assisted) in 185 patients by fellowship-trained surgeons at a single institution from August 2008 to July 2018. The indication for Latarjet procedure was recurrent glenohumeral instability following a failed soft-tissue procedure or a primary stability procedure for patients with significant anterior glenoid bone loss. Patients were excluded if they underwent a Bristow procedure or had a chronic locked anterior shoulder dislocation or concomitant hemiarthroplasty.

Researchers conducted a chart review to assess demographics, postoperative radiographs for screw angle divergence from the glenoid, number of previous operations, complications, and return to the OR for all patients within 90 days from the index Latarjet procedure. Mean patient age was 28.7 years, and most patients were male (84.2 percent) and had undergone a revision of a prior stabilization procedure (62.6 percent).

Seventeen complications occurred, for a 90-day complication rate of 9 percent. Eight patients (4.2 percent) underwent reoperation. Nine patients (4.7 percent) had graft failure with loosened or broken screws, and six required reoperation (revision Latarjet [n = 4], distal tibia allograft [n = 1], and iliac crest autograft [n = 1]). See Table 1 for demographics related to 90-day complications.

Among the cases, 60 percent (n = 114) were treated with cannulated screws versus 40 percent (n = 76) treated with solid screws. Seven of nine (77.8 percent) graft failures involved the use of cannulated screws. Four of the nine (44.4 percent) graft failures utilized only one screw. Fixation with only one screw was associated with graft failure (P < 0.001), but use of cannulated screws was not (P = 0.49).

Two patients (1.1 percent) had postoperative dislocations, and both underwent reoperation; one patient dislocated following a seizure and underwent revision stabilization with iliac crest autograft; the other patient had Ehlers-Danlos syndrome and underwent a Nicola procedure, which failed, then ultimately underwent arthrodesis.

Six nerve injuries (3.2 percent) occurred: two axillary and suprascapular, one musculocutaneous, one brachial plexopathy, one peripheral sensory nerve deficit (likely axillary), and one sensory plexopathy. Both cases of suprascapular nerve injury predominantly affected the infraspinatus muscle and preserved the supraspinatus muscle on electromyography. Suprascapular nerve injury at the spinoglenoid notch was associated with longer superior screw length (mean, 41.0 mm versus 33.5 mm; P = 0.035) and increased screw angle divergence (mean, 40 versus 24 degrees; P = 0.0197). Of the six nerve injuries, three had complete resolution; the other three improved but had residual weakness and numbness at last follow-up. No infections occurred.

“Surgeons should try to obtain fixation with a minimum of two screws and avoid single-screw fixation when possible. Furthermore, surgeons should avoid high degrees of screw angle divergence from the glenoid and cautious of longer screw lengths, especially the superior screw, to avoid suprascapular nerve injury,” Dr. Hendy. “Strategies to reduce the risk of nerve injury during Latarjet should be a focus of technical innovation.”

The study is limited by its heterogenous patient population and surgical techniques. In addition, preoperative CT evaluation was not available for a sufficient number of patients, which would have allowed for a meaningful analysis of preoperative bone loss as a risk factor for complications.

Dr. Hendy’s coauthors of “Early Postoperative Complications after Latarjet: A Single Institution Experience over 10 Years” are Eric M. Padegimas, MD; Liam Thomas Kane, BS; Thomas Harper, BA; Joseph A. Abboud, MD; Mark D. Lazarus, MD; Anthony A. Romeo, MD; and Surena Namdari, MD, MSc.

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.