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Editorial Commentary: Lower Return to Play After Failed Prior Instability Surgery: Should the Open Latarjet Be the Gold Standard for Anterior Shoulder Instability?

      Abstract

      Anterior shoulder instability is common in contact athletes. Arthroscopic Bankart repair can result in good clinical outcomes, but high recurrence rates have been reported. The open Latarjet procedure can result in excellent functional outcomes with low rates of recurrent instability. Despite these encouraging results, there may be a lower return to play rate in athletes undergoing this procedure for a prior failed instability surgery. Due to the complexity of the procedure and high complication rate, the open Latarjet should continue to be reserved for cases of significant glenoid bone loss or revision settings.
      Anterior shoulder instability is a common problem, especially in contact athletes. The challenge shoulder surgeons continue to face is twofold. First, is surgery indicated for the first-time dislocator, or should it be reserved for patients with recurrent instability? And secondly, what is the best surgical option for athletes? Arthroscopic Bankart repair has become the gold standard for management of glenohumeral instability. Several studies have shown good functional outcomes following this procedure at 10-year follow-up.
      • Murphy A.I.
      • Hurley E.T.
      • Hurley D.J.
      • Pauzenberger L.
      • Mullett H.
      Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up.
      ,
      • Flinkkilä T.
      • Knape R.
      • Sirniö K.
      • Ohtonen P.
      • Leppilahti J.
      Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up.
      However, recurrent instability rates have been reported as high as 30%.
      • Murphy A.I.
      • Hurley E.T.
      • Hurley D.J.
      • Pauzenberger L.
      • Mullett H.
      Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up.
      ,
      • Flinkkilä T.
      • Knape R.
      • Sirniö K.
      • Ohtonen P.
      • Leppilahti J.
      Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up.
      Additionally, recurrence rates may be significantly higher after arthroscopic repair compared to open Latarjet in contact athletes, even in the setting of subcritical glenoid bone loss.
      • Rossi L.A.
      • Tanoira I.
      • Gorodischer T.
      • Pasqualini I.
      • Ranalletta M.
      Recurrence and revision rates with arthroscopic Bankart repair compared with the Latarjet procedure in competitive rugby players with glenohumeral instability and a glenoid bone loss <20%.
      In addition to recurrence rates, return to play is an important benchmark when discussing outcomes following operative management of shoulder instability. The goal of nearly all competitive athletes after a shoulder instability event is return to play, ideally at the same level as pre-injury. It is for this reason we read with great interest the article entitled “Open Latarjet Procedure in Competitive Athletes Following Failed Prior Instability Surgery Results in Lower Rates of Return to Play,” by Davey, Hurley, O’Doherty, Stafford, Delahunt, Gaafar, Pauzenberger, and Mullett.
      • Davey M.S.
      • Hurley E.T.
      • O’Doherty R.
      • Stafford P.
      • Delahunt E.
      • Gaafar M.
      • et al.
      Open Latarjet procedure in competitive athletes following failed prior instability surgery results in lower rates of return to play.
      In this retrospective review of 200 patients, the authors report on outcomes following open Latarjet in athletes with primary instability and recurrent instability and patients who had failed prior instability surgery. At a mean of 38 months’ follow-up, there were no significant differences in any of the clinical outcome scores between the groups. However, only 64% of patients who had prior instability surgery were able to return to play, and only 56% were able to return to the same or higher level of play. Of note, there was a 4% to 6% complication rate, none of which were nerve injuries.
      Given the higher rates of recurrent instability after arthroscopic Bankart repair, some surgeons advocate for open Latarjet as the initial surgery for shoulder instability in the contact athlete regardless of indication. Studies have shown that the open Latarjet can result in excellent clinical outcomes and low recurrence rates.
      • Privitera D.M.
      • Sinz N.J.
      • Miller L.R.
      • Siegel E.J.
      • Solberg J.
      • Daniels S.D.
      • et al.
      Clinical outcomes following the Latarjet procedure in contact and collision athletes.
      • Hurley E.T.
      • Jamal M.S.
      • Ali Z.S.
      • Montgomery C.
      • Pauzenberger L.
      • Mullet H.
      Long-term outcomes of the Latarjet procedure for anterior shoulder instability: A systematic review of studies at 10-year follow-up.
      • Bessiere C.
      • Trojani C.
      • Carles M.
      • Mehta S.S.
      • Boileau P.
      The open Latarjet procedure is more reliable in terms of shoulder stability than arthroscopic Bankart repair.
      • Ali Z.S.
      • Hurley E.T.
      • Jamal M.S.
      • Horan M.P.
      • Montgomery C.
      • Pauzenberger L.
      • et al.
      Low rate of recurrent instability following the open Latarjet procedure as a revision procedure for failed prior stabilization surgery.
      On the other hand, some argue that because of the complexity of the surgery and higher complication rates, an open Latarjet should only be undertaken in the setting of significant bone loss or in the revision situation.
      So the question becomes, should we be performing the open Latarjet as the index procedure for shoulder instability in competitive athletes, regardless of indication? There is validity and clear support for both viewpoints. In our opinion, however, we do not feel that the Latarjet should become the gold standard for the initial treatment of shoulder instability in the contact athlete. There may certainly be exceptions to this, and we have performed the Latarjet as the first stabilization procedure in this patient population, but we truly feel these decisions are best made on a case-by-case basis. Although the authors of this study report a low complication rate, this may not be the case for lower-volume surgeons. The complication rate after this procedure has been reported as high as 30% in some studies.
      • Griesser M.J.
      • Harris J.D.
      • McCoy B.W.
      • Hussain W.M.
      • Jones M.H.
      • Bishop J.Y.
      • et al.
      Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review.
      The Latarjet is a technically demanding surgery, and the reported complications are often not easy to manage. Although the return-to-play rate is lower in the revision setting, this is likely a multifactorial problem. Therefore, we feel it is crucial to appropriately counsel patients regarding expectations for return to play in the revision surgery setting.

      Supplementary Data

      References

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        • Gorodischer T.
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