1 Introduction

The progression of recurrent instability can occur from a subluxation event or initial dislocation. The occurrence of subluxation events is more frequent and causes significant pain in the shoulder and leads to dysfunctionality.¹ The primary and recurrent instability in the shoulder causes short-term physical discomfort, loss of activity duration, and potentially invasive surgical procedures. In addition, it also elevates the risk of joint degeneration for a long duration with glenoid bone loss, posttraumatic osteoarthritis (PTOA), and labral injuries.² However, recurrence of instability can be observed among patients above the age of 40-year poses a therapeutic challenge due to declining tissue quality and rising concurrent structural lesions.³ In younger patients, the causes of ignored recurrent shoulder dislocations are nearly drinking, convulsions, or numerous traumas.⁴ It can be challenging for magnetic resonance imaging (MRI) and even computed tomography (CT) scans to detect and describe the extent of glenoid bone loss accurately.⁵ However, irrespective of the defect and size of the glenoid bone, the Latarjet surgical procedure has provided satisfactory results⁶ A Hill-Sachs lesion is another humeral head bone defect that is associated with recurrent instability in the anterior shoulder.^7,8 Hill-Sachs lesion is based on the combined glenoid defect.⁹ In young active patients, anterior glenohumeral dislocation is a frequently encountered injury that is commonly accompanied by Bankart lesions, which are often associated with glenoid rim abnormalities.¹⁰ The patients with bone abnormalities and recurring anterior shoulder instability were treated using various glenoid-restoring methods.¹¹ For shoulder surgeons, choosing the best course of action to treat shoulder instability can be particularly difficult in cases where patients have experienced multiple recurrent dislocations without significant bone loss. Chronic instability arises as a result of recurrent dislocation, as the anatomical glenohumeral constraints gradually wear out, posing a persistent problem.⁸ Glenohumeral joint stabilization surgery is recommended when the recurrent stability in the shoulder leads to discomfort.¹² The Latarjet procedure is a preferred choice of the surgical operation in cases of the loss of glenoid bone loss. Firstly, the progression of recurrent instability often stemming from subluxation events, leads to significant pain and dysfunctionality. In older patients above the age of 40, the therapeutic challenge arises due to declining tissue quality and concurrent structural lesions.¹³ Even visualization during arthroscopic procedure may not exactly predicate the extent of the loss of anterior glenoid bone. Recent studies suggest that critical bone loss in recurrent instability may be as low as 10 %–13.5 %.^14–16 MRI and CT scans may struggle to accurately detect and describe the extent of the loss of glenoid bone. Significant loss of the bone is the absence or reduction of bone tissue in the glenoid region exceeding 20 %. This threshold is crucial in determining the choice of surgical intervention for recurrent shoulder dislocation. Despite glenoid bone defects, the Latarjet surgical procedure consistently provided satisfactory results, even in cases with a Hill-Sachs lesion.¹⁷ Chronic instability resulting from recurrent dislocations presents a persistent problem, and glenohumeral joint stabilization surgery becomes recommended. The Latarjet procedure, involving the coracoid process transfer is frequently and effectively utilized for the treatment of instability in younger populations.^18,19 The procedure which secures the coracoid, with a preglenoid screw through the subscapularis muscle, has demonstrated its effectiveness in treating recurrent dislocations with glenoid bone defects.²⁰ The instability severity index (ISI) helps to evaluate the severity of shoulder instability and directs the surgical intervention decision-making action.²¹ In comparison, the arthroscopic bankart repair procedure is linked to a higher rate of re-dislocation, has a steep learning curve, is costlier, and is influenced by the condition of the glenoid labrum. The Latarjet procedure, on the other hand, is considered safe and provides a stable shoulder for recurrent dislocation patients without significant bone loss (>20 %), showcasing highly satisfactory results regardless of glenoid bone loss.²² There have been multiple studies that suggest that chances of re-dislocation are much lesser in the patients operated with the Latarjet technique in comparison with the procedure of arthroscopic Bankart repair.^22–24 This surgical method involves the transfer of coracoid process and its conjoint tendon from their original location and then reattaching them to anterior-inferior part of glenoidal rim, which helps to stabilize the joint and prevent further dislocations, making the Latarjet procedure a preferred choice for patients with intact glenoid experiencing recurrent shoulder dislocations.²⁵ Under the surface of the coracoid process, it is decorticated and secured with screws.²⁶ This study sought to assess the rate with which athletes returned to sports after having their recurrent shoulder dislocation stabilised using the minimally invasive Latarjet method with recurrent dislocations in the anterior shoulder without remarkable glenoid bone loss.

2 Methods

The research was conducted as a retrospective study at a single center. The inclusion criteria of this research involved patients with recurrent dislocation at the anterior shoulder and bone loss <20 % who underwent the Bristow-Latarjet procedure. The patients with other associated pathology such as rotator cuff tear and biceps tendinosis were not included in the study. For the study, a total of 164 patients were considered, and their medical records were retrospectively reviewed. The follow-up of the patients was taken at the time points of 3-month, 12-month, and 24-month postoperatively. The outcomes of the investigation were assessed by utilizing the Rowe score to evaluate the stability of the shoulder, range of motion, and functionality.

2.1

2.1 Surgical procedure

The procedure was performed under a superficial cervical plexus nerve block associated with a supraclavicular block with the patient in supine position. First, an incision was made along the deltopectoral groove from the coracoid process to the deltoid insertion (Fig. 1 Incision and superficial dissection for Bristow-Latarjet procedure). The identification of the deltopectoral groove was performed by following the path of the cephalic vein. To prevent postoperative edema, the cephalic vein was protected at the time of dissection. The cephalic vein was retracted laterally or medially, although in a few patients the cephalic vein was ligated for better exposure. An opening was made following the path of the groove. The deltoid was pulled back laterally, whereas the pectoralis major was retracted medially. The coracoid process and its conjoined muscle attachments were then revealed (Fig. 2 Deep dissection and the tip of coracoid). The detachment of insertions of the coracoacromial ligament and the pectoralis minor was carried out. The coracoid process was then osteotomized with a bigger size osteotome of 20 % so that the chances of going deep were less and the brachial plexus was kept safe from injury (Fig. 3 Osteotomy of the coracoid process). Approximately, 2cm of coracoid was taken off along with the muscles that were attached. The under surface of the coracoid process was decorticated for better union. The coracoid with its associated short head of the biceps and coracobrachialis, was repositioned distally. The subscapularis was then divided along its fibers from lateral to medial at the middle to lower part of the muscle fibres, starting from the outer side towards the inner side at the middle to lower region. A periosteal elevator was employed at this position to reflect the subscapularis from the outer side of the shoulder capsule. The division of the anterior capsule was then carried out. Proper placement of the transplanted coracoid required a medial exposure of the anterior scapular neck. Subperiosteal dissection aids in the exposure of the scapular neck. The scapular neck was roughened, and every effort was made to eliminate any soft tissues. The transplanted coracoid with its muscular attachments was positioned onto the glenoid margin via the horizontal opening in the subscapularis. K-wire was inserted to hold the coracoid against the anterior glenoid margin, which was then replaced by the guidewires. Two parallel holes were drilled through the coracoid into the scapular neck near the anteroinferior region of the scapular neck with a drill bit of 2.7mm (Fig. 4 Osteotomised coracoid process). To secure the coracoid to the scapular neck, two cancellous bone screws (Biotek- Chetan Meditech Pvt. Ltd., Ahmedabad, India), partially threaded, flat head and self-tapping screw with the diameter of 3.5 mm and with adequate length of 34mm or 36mm were employed (Fig. 5 Screw fixation over guidewire compressing coracoid process over the anterior rim of the glenoid). A washer was not required due to the big and flat head of the screws. The appropriate placement of the bone block and screw was ensured carefully to prevent any protrusion towards the medial side beyond the glenoid's anterior rim. Finally, the subcutaneous tissue, deltopectoral fascia, and skin were approximated. The shoulder was immobilized for 6-week with the help of a shoulder immobilizer.

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Fig. 1 Incision and superficial dissection for Bristow-Latarjet procedure.

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Fig. 2 Deep dissection and the tip of the coracoid.

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Fig. 3 Osteotomy of the coracoid process.

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Fig. 4 Osteotomised coracoid process.

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Fig. 5 Screw fixation over guidewire compressing coracoid process over the anterior rim of the glenoid.

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3 Results

A total of 164 patients aging 28.04 ± 7.08 years were included in the study. Dislocation happened on the dominant arm, with a mean 17.32 ± 17.26 dislocation episode (Table 1). The mean bone loss was found to be 9.48 ± 5.21. Hill-Sachs lesion was reported in 26 patients where the mean length of the lesion was 15.85. At the follow-up, there was a rise in mean Rowe score from 38.20 ± 9.18 pre-operatively to 87.47 ± 5.21 at 3-month followed by 91.55 ± 3.35 at 12-month and 93.66 ± 2.60 at 24-month (Fig. 6 Mean Rowe score). There was statistical significance in Rowe's score from baseline to the 24-month follow-up period (P < 0.0001) (Table 2).

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Fig. 6 Mean Rowe score.

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The study observed 7 patients (4.26 %) who experienced neuropraxia due to mild traction injuries at the C8-T1 nerve roots, but they recovered within 4–6 week. A total of 15 patients (9.15 %) reported experiencing mild pain at night while at rest after the operation, but this symptom resolved within 2–3 week. Moreover, 16 patients (9.76 %) reported a snapping noise during a throwing movement or outstretched hand, however, there was no requirement for revision surgery (Table 3). These results indicate that the observed complications were generally mild and self-limiting, with no need for additional surgical intervention.

4 Discussion

The Latarjet surgical technique appears as a safe alternative for the surgical intervention having a lower incidence of complications even in patients having minimum glenoid bone loss.²⁷ The Latarjet technique shows to be the better surgical option for recurrent antero-inferior dislocation of the glenohumeral joint.¹² The clinical outcomes of the Bristow-Latarjet method for the recurrent instability of the anterior shoulder without remarkable loss of glenoid bone were evaluated in this study. The study included 24-month follow-up period and the patient conditions were assessed using the Rowe score at the time point of 3-month, 12-month, and 24-month. The results demonstrated significant improvement in the condition of patients, indicating the effectiveness of the Bristow-Latarjet surgical method for cases of recurrent instability of the anterior shoulder. However, the study also observed some complications, including neuropraxia, mild pain at rest, and snapping noise during throwing movements or outstretched hands. Nevertheless, these complications were generally mild and self-limiting, with no need for additional surgical intervention.

Patients exhibiting substantial defects depict elevated susceptibility to recurrent instability following isolated capsulolabral repair. The labral tissue undergoes repetitive instances of detachment and subsequent repair, potentially compromising its ability to resist translational forces. As a consequence, there is an observed reduction in the average peak force, which is correlated with the increasing severity of glenoid bone defects.²⁸ The combined glenoid retroversion and posterior glenoid bone loss (pGBL) emerge as a pivotal risk factor for contributing to the ineffectiveness of arthroscopic capsulolabral repairs among individuals undergoing posterior shoulder stabilization.²⁹ The procedure of modified Latarjet technique yields favorable results in patients exhibiting combined bone loss, a condition associated with elevated recurrence rates in conventional arthroscopic stabilization approaches.³⁰ Individuals with glenoid bone loss exhibit labral tears that are more extensive, an increased prevalence of glenolabral articular disruption lesions, and larger Hill-Sachs lesions.³¹ In cases involving recurrent instability of the anterior shoulder and substantial glenoid bone loss, the modified Latarjet procedure without capsulolabral repair yields the improved functional results.³² The Latarjet technique improves the glenoid track within the glenohumeral joint, transforming pre-existing off-track lesions into on-track lesions. This technique imparts macro stability, thereby mitigating the risk of dislocation, and the repositioning of the conjoint tendon is likely a contributing factor to the changes in throwing mechanics observed in the shoulder joint.³³

Tanaka et al. conducted a study among rugby players comparing clinical outcomes, rate of bone repair, and resorption rates of bone in the coracoid process after open Bristow and open Latarjet procedures. The Bristow group in the study included 66 patients and 35 shoulders were included in the Latarjet group. The researchers found that 72.7 % of cases of the Bristow procedure showed bone union at 6-month post-operation, while the resorption of bone occurred in 6.1 % of shoulders post Bristow procedure. On the other hand, 100 % of bone resorption was observed after the Latarjet procedure.²⁶ In the present study, it was evident that bone resorption was not frequent with the Latarjet procedure and the results are satisfactory even if there was mild resorption of bone. Ruci et al. carried out a study to assess the functional outcomes of the Bristow-Latarjet procedure among individuals with recurrent instability in the anterior glenohumeral joint. They found that the overall functional results were favorable, with an average Rowe score of 88 points.¹² Ferreira Filho et al. proposed a study describing the radiographic and clinical outcomes among the patients who underwent the Bristow-Latarjet technique for recurring traumatic dislocation in the anterior shoulder. The study showed that 96 % of patients had good outcomes, with two cases of subluxation recurrence. The graft healing rate was 62 % in the patient population.³⁴ Moroder et al. assessed the radiological and clinical outcomes of the Bristow-latarjet procedure for recurring instability in the anterior shoulder among patients aged over 40-year. The study had a follow-up period of 9-year, during which nine patients (36 %) required revisions. The mean Rowe score of 77 was recorded among the patients.¹⁸ Shao et al. carried out a clinical investigation to assess the positioning of the coracoid graft, rate of bone union, and clinical results of the arthroscopic Bristow procedure with fixation by using a suture button. The study reported that the Rowe score improved remarkably from 33.5 ± 12.1 to 96.0 ± 4.9 at the last follow-up.³⁵ Similarly, the present study showed a significant improvement in Rowe score from 38.20 ± 9.18 at the pre-operative time to 93.66 ± 2.60 at the 24-month follow-up. Thus, it demonstrated that the outcomes of the study were consistent with other research investigations that have reported the effectiveness of the Bristow-Latarjet surgical method in treating the instability of the anterior shoulder. However, a lower incidence of complications such as neuropraxia, mild pain at rest, and snapping noise during throwing movements or outstretched hands. These complications were generally mild, self-limiting, and did not require additional surgical intervention that distinguishes them in comparison to other studies that have reported more severe complications, such as recurrent instability, infection, and nerve injuries.

There are some limitations of the present study such as single-centre retrospective clinical study, which may potentially introduce selection bias and constrain the applicability of our results, the results may not apply to patients in different geographical locations or healthcare settings. An additional constraint in our study pertained to the comparatively brief duration of the follow-up period. While our study showed significant improvement in patient outcomes at the 24-month follow-up, longer follow-up may be required to assess the durability of the results and to detect any potential late complications. More complications may occur in a larger population, which were not accounted for in our study.

5 Conclusion

The outcomes of the clinical investigation showed a noteworthy improvement in patient condition with a low incidence of complications and recurrence. Our study suggests that the Latarjet surgical technique can be a safe, and durable treatment option for recurrent instability of the anterior shoulder without significant loss of glenoid bone.

Funding statement

There were no funding sources or scholarships granted for the conduct of the study.

Ethical approval and informed consent statements

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all individual participants included in the study.

CRediT authorship contribution statement

Naveen Sharma: Conceptualization. Varun Singh: Critical revision, Methodology, First draft and Formal analysis. Abha Sharma: Review & editing.