TREATMENT OF ANTERIOR SHOULDER INSTABILITY BY LATARJET CORACOID BONE BLOCK: PRELIMINARY FUNCTIONAL RESULTS IN A SUB-SAHARAN HOSPITAL

Hermann Victoire Feigoudozoui^1*, Dogossou Parteina^1,2,3, Théodore Mempanou⁴, Wilfried Donald Ta Bi¹, Pierre Alfred Issa-Mapouka⁵

¹Félix Houphouët-Boigny University of Cocody, TRU/MSA, Abidjan, Ivory Coast

²Farah Polyclinic, Abidjan, Ivory Coast

³Sainte Anne-Marie Polyclinic, Abidjan, Ivory Coast

⁴University of Maryland School of Medicine, Department of Epidemiology, USA

⁵Communautary University Hospital of Bangui, Central African Republic

*Correspondence: Hermann Victoire Feigoudozoui; +2250779473608; hfeigoudozoui@gmail.com ; https ://orcid.org/0000-0001-6972-5024.

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Abstract

Background: The Latarjet technique aims to stabilize the shoulder by reconstructing the glenoid rim using a bone fragment taken from the coracoid bone and generally fixed to the anteroinferior part of the glenoid. The aim of this study was to assess the functional outcome of this type of treatment.

Methods: This retrospective study was conducted in several health institutions in Ivory Coast from January 2008 to December 2013. Folders of 15 patients whose shoulders were treated by the Latarjet coracoid bone block procedure for anterior shoulder instability and were followed-up for a minimum of 10 years were retrieved and data collected. Functional outcomes were assessed by the Rowe score. The data were evaluated and analysed using Epi Info and Excel statistical software.

Results: The functional assessment according to the Rowe score revealed three excellent results, nine good results, two average results and one poor result. One case of recurrence was observed in the postoperative period and required a revision.

Conclusion: This study suggests that the Latarjet preglenoid bone block procedure is an effective surgical procedure for treating anterior shoulder instability. It allows for a significant improvement in functional outcomes as well as a satisfactory return to sporting activity.

Keywords: Instability, Latarjet, Result, Shoulder, Sub-saharan, Treatment.

Cite this article: Feigoudozoui HV, Parteina D, Mempanou T, Ta Bi WD, Issa-Mapouka PA. Treatment of anterior shoulder instability by Latarjet coracoid bone block: Preliminary functional results in a Sub-Saharan hospital. Yen Med J. 2023;5(1):23–29.

INTRODUCTION

Anterior shoulder instability is a common condition.^1,2 It is characterised by abnormal displacement of the humeral head relative to the glenoid cavity, which can lead to recurrent shoulder dislocation or subluxation.³ This condition can lead to serve pain, loss of strength and mobility, and limitation.^4,5 Several surgical techniques are available to treat anterior shoulder instability including arthroscopic ligament repair, biceps tendon repair or shortening, Latarjet coracoid bone block and Bristow coracoid bone block.^6,7 The Latarjet coracoid bone block is the most commonly used technique.^8,9,10 It is a surgical intervention that stabilises the shoulder by reconstructing the glenoid rim using a bone fragment taken from the coracoid bone and generally fixed to the anteroinferior part of the glenoid. The Latarjet-type pre-glenoid coracoid bone block technique is increasingly used in patients because of its satisfactory functional outcome.¹¹ The aim of this study was to assess the functional outcome of the Latarjet technique in Abidjan (Ivory Coast).

MATERIALS AND METHOD

Study Design and Setting

This retrospective study was conducted in four health establishments (Farah Polyclinic, Sainte Anne Marie Polyclinic and the Orthopedic surgery departments of the university hospitals of Yopougon and Cocody) in Abidjan (Ivory Coast) from January 2008 to December 2013.

Study Population

Data were collected from the records of 15 patients whose shoulders were treated by Latarjet pre-glenoid coracoid bone block for anterior shoulder instability.

Inclusion Criteria

Inclusion criteria were age greater than 15 years, at least two anterior dislocations of the same shoulder, surgery using the Latarjet technique, regular monthly clinical examination, and a minimum follow-up of 10 years.

Exclusion Criteria

Patient’s suffering from rotator cuff injury, shoulder fracture, multidirectional shoulder instability or recent dislocation were excluded from this study.

Data Collection

The data collected included demographic characteristics, medical history, characteristics of anterior shoulder instability, functional outcomes assessed by the Rowe score,¹² radiological outcomes, recurrence rate of anterior shoulder instability and patients’ occupational prognosis after surgery.

Data Analysis

The data were evaluated and analysed using Epi Info and Excel statistical software.

RESULTS

The characteristics of the patients are shown in Table 1. The average age was 27.8 ± 3.53 years, there were more males and they all did one sports activity or the other. One case of recurrence was observed in the post-operative period. There were no complications such as haematoma, local infection, omarthrosis, pseudarthrosis or migration of the bone block. Antepulsion and abduction of the operated shoulders were close to normal but external rotation remained around 45° (Table II). Periodic global evaluation by the ROWE score was used to assess functional improvement of the operated shoulders (Table III). Table IV showed that one patient was not satisfied with his clinical condition after surgery. Twelve patients had resumed with the same sports activities while three others had changed their sports activities altogether.

Table I: Characteristics of the series.

Characteristics

Values

Age (years)

Average

Extremes

27.8 ± 3.53

19 and 42

Gender

Male

Female

Sport practiced

Rugby

Handball

Box

Judo

Others

Table II: The averages of the scapular amplitudes.

Amplitude	Preoperative	Postoperative	Normal value	p-value
Antepulsion	132.3°	155.6°	180°	0.0041
Abduction	170.8°	180°	180°	0.0456
External rotation	58.9°	45.0°	90°	0.0039

Table III: The periodic assessment outcomes according to the Rowe score.

Score	At 2 years	Between 5 – 9 years	At 10 years
Excellent	1	2	4
Good	3	7	9
Average	11	6	2
Bad	1	0	0
Total	15	15	15

Table IV: Occupational prognosis of patients at follow-up.

Items

Numbers

Patient satisfaction

Very satisfied

Satisfied

Disappointed

Total

Patient decision on sport

Return to same sport

Change sport

Give-up sport

Total

Figure 1: Postoperative range of motion in retrograde position, here anteflexion of the limb.

Figure 2: Postoperative range of motion in retrograde position, here abduction/external rotation of the arm.

Figure 3: Postoperative range of motion, here internal rotation of the arm.

Figure 4: Postoperative control X-ray.

DISCUSSION

Characteristics of the series

Many studies agree on the average age of patients suffering from anterior shoulder instability. Toffoli et al found 27.7 years,¹³ Thon et al 29.2 years,¹⁴ Schmidt et al 25 years,¹⁵ and Gerber et al 25.5 years.¹⁶ In this study, the average age of the patients was 27.8 years. Therefore, the typical patient suffering from anterior shoulder instability is a young person under 30 years of age. In this age group, the patients are very active in sporting activities during which the pathology can reveal itself.

The second characteristics common to all studies is the predominance of male patients. This is a consistent finding in many other series.^{3,4,6,8,15-19} Men are majorly involved in sporting activities. As they strive for performance, they are increasingly exposed to scapular trauma that can trigger anterior shoulder instability. It can also be stated therefore that anterior shoulder instability is commoner in young men under 30 years of age.

Active scapular amplitudes

The clinical examination carried out during the follow-ups focused on measuring the patients’ scapular amplitudes. In addition to the Rowe score, these parameters made it possible to assess the effectiveness of the treatment and the quality of the outcomes. Mean scapular amplitudes in the perioperative periods were close to normal thresholds after surgery and rehabilitation. Schmidt et al found the same outcomes as ours.¹⁵ They also found that external rotation values were decreasing in retrospect. The latter finding was due to the fact that external rotation of the arm is a procedure that can cause anterior glenohumeral dislocation, making patients not to perform it completely. In addition, postoperatively, the presence of pain also increased the limitation of external rotation of the arm. Dossim et al had obtained postoperative values similar to ours for antepulsion and external rotation.⁸ They found 170° of antepulsion and 50° of external rotation of the arm.⁸

Allain et al only specified the values of external rotation observed postoperatively. They found 63°±14° (30° – 95°) on the healthy side and 42°±17° (10° – 80°) on the treated side.³ These outcomes were similar to those in this study. The outcome in this work revealed a significant improvement in activity and muscle strength, assessed by the Rowe score. The decrease in mobility was in external rotation, which is related to the operative approach towards the subscapulari muscle. Other studies had also obtained satisfactory outcomes similar to those of this study.⁵ The surgical technique opted for transectioning half of the subscapular muscle, resulted in a decrease in external rotation. The outcome was similar with previous studies that had shown the coracoid bone block technique is more effective in treating anterior shoulder instability.²⁰ Subjectively, 10 patients were very satisfied, four were satisfied and one was disappointed. The disappointed patient was the one in whom there was a recurrence that required revision surgery. In terms of return to sport, twelve returned to the same sport, three changed their sport and no-one gave-up their sport activities. These outcomes suggested that coracoid bone block technique may allow satisfactory return to activity in patients treated for anterior shoulder instability.¹⁷

Assessment according to the Rowe score

The functional aspect of the score assesses the various ranges of motion of the shoulder. Pain is subjectively approved in the immediate post-operative period and in the long-run after the operation to residual defect. Stability and mobility are assessed in relation to possible recurrence of dislocation after surgery. Recurrence of dislocation after the Latarjet technique is not rare.¹⁹ A study conducted in Dakar concluded that the Latarjet technique offered patients stabilisation of the shoulder, almost normal mobility, and the possibility of resuming professional and sporting activities under good conditions.⁴ Under similar conditions and with almost the same sample size, Gueye et al used the Rowe score to assess their patients.⁴ These were similar outcomes to those observed in this study. The difference was that the authors obtained average and poor outcomes, unlike Gueye’s team where there were no average or poor outcomes. In addition, in Morocco, with the same score and out of a total of 77 patients collected, Jamal’s team obtained 28 excellent outcomes, 45 good outcomes, 4 average outcomes and 4 poor outcomes.¹⁹ These results demonstrated the good stability of using the Latarjet technique. Other studies have also shown similar satisfactory outcomes.⁵ Some studies have shown a significant improvement in the Rowe score in patients treated with the Latarjet strut, with a recurrence rate of 4.2% – 9.43%.^8,13,17 Several studies have assessed the outcomes of the Latarjet-type coracoid bone block for the treatment of anterior shoulder instability in professional athletes, with satisfactory results.^21,22

In this study, there were no major complications. Complications are usually few in the Latarjet technique.^23,24 However, some studies have highlighted the shortcomings of the Latarjet coracoid bone block technique, including surgery complications such as coracoid bone block fractures, infections and chronic pain.¹⁹ It is important to note that the result of surgery may vary depending on the technique used, the severity of the shoulder instability and the individual characteristics of the patient. Overall, the literature suggests that Latarjet pre-glenoid bone block technique is an effective surgical procedure for treating anterior shoulder instability, with satisfactory functional and radiological outcomes.¹⁹ However, it is necessary to consider the limitations and possible complications of the procedure, as well as the individual characteristics of the patients, when choosing the surgical technique.²⁵

This study suggests that the Latarjet pre-glenoid bone block technique is an effective surgical procedure for treating anterior shoulder instability. It provides a significant improvement in functional outcome and a satisfactory return to sport. Patients should be informed of the outcomes and risks of this surgery in order to make an informed decision regarding their treatment.

Limitations of the study

The small sample size did not allow for significant statistical testing. There were not many patients and women who suffer anterior instability, as some of them could have consulted elsewhere. Some patients were excluded from the study because their anterior scapular instabilities were associated with other lesions such as rotator cuff tears or glenoid rim fractures which are contraindications to the Latarjet technique. Another weakness of this study was the difficulty in following up some fussy patients who did not comply with the surgery instructions or follow-up appointment dates.

CONCLUSION

This retrospective study of 15 patients treated for anterior shoulder instability using the Latarjet pre-glenoid bone block technique showed satisfactory outcomes. This surgical procedure resulted in a significant improvement in functional outcomes and a satisfactory return to activity in the majority of patients.

ACKNOWLEDGEMENTS

To all the staff who contributed to the management and follow-up of the patients.

AUTHOR CONTRIBUTIONS

Author HVF designed the study and wrote the protocol which was reviewed by all authors; led data collection and analysis along with Author DP and WDTB. Author TM conceptualized the study Author PA supervised the manuscript. All authors read and approved the final draft.

CONFLICT OF INTEREST

The authors declare they have no conflicts of interest that are directly or indirectly related to the research.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

ETHICAL APPROVAL

Ethical approval was obtained from the Félix Houphouët-Boigny University of Cocody, TRU/MSA, Abidjan, Ivory Coast.

DISCUSSION

DVT is one of the important causes of maternal deaths.⁸ Pregnancy is classically thought to be a hypercoagulable state. Fibrin generation is increased, fibrinolytic activity is decreased, levels of coagulation factors II, VII, VIII, and X are all increased, free protein S levels are decreased, and acquired resistance to activated protein C is common.⁹During the third trimester and during the first 2 weeks following delivery, women have a relatively high risk of VTE, which is the leading cause of maternal death in Western countries.¹⁰ The most important risk factors are multiparity, puerperium, post-operative periods, infections, neoplasm, systemic lupus erythematosus and hypercoagulability states.¹¹ In our case Caesarean section was one of the major risk factors involved. Also, reduction in venous flow velocity of approximately 50% occurs in the legs by third trimester and lasts until approximately 6 weeks after delivery, at which time it returns to normal nonpregnancy flow-velocity rates.¹²There is a striking predisposition for deep-vein thrombosis to occur in the left leg (approximately 70 to 90% of cases), possibly because of exacerbation of the compressive effects on the left iliac vein due to its being crossed by the right iliac artery.¹³ Another probable explanation is that the left venous system follows a more tortuous course leading to increased incidence of left iliofemoral DVT. The approach to making a diagnosis currently involves an algorithm combining pretest probability, D-dimer testing, and compression ultrasonography. This will guide further investigations if necessary.¹ In our patient diagnosis was made by Doppler USG of the left lower limb and pelvis and a high D-dimer level. A study showed that by 4-6 weeks postpartum, D-dimer had returned to non-pregnant normal levels in 70 % of women. There was a high variability in D-dimer levels in the early postpartum period; level ranged between 550-5700 ng/ml. In later postpartum period D-dimer level had decreased between 100- 900 ng/ml. D-dimers levels were significantly elevated among women who had caesarean section when compared to women who had normal vaginal delivery (2500 ng/ml -1350 ng/ml).¹⁴In a study, a D-dimer value > 500 ng/ml was considered abnormal.¹⁵ Patients with extensive DVT usually presents with PE. Fiengo et al reported a case of a 33-year-old woman with extensive DVT and PE.¹⁶ Similarly, Nartey et al reported similar case in patient with bleeding uterine fibroid.¹⁷ In another different case, a 24-year-old lady presented with PE from extensive DVT following prolonged sitting of approximately 80 hours of continuous game play.¹⁸ Despite having extensive DVT, our patient has no clinical features of PE. Studies have found that increased age, D-dimer level, proximal DVT, right side DVT, and unprovoked DVT, were associated with a higher incidence of silent PE.¹⁹Currently anticoagulants specifically targeting components of the common pathway have been recommended for prophylaxis. These include fondaparinux, a selective indirect factor Xa inhibitor and the new oral selective direct thrombin inhibitors (dabigatran) and selective factor Xa inhibitors (rivaroxaban and apixaban). Others are currently undergoing trials. Thrombolytics and vena caval filters are very rarely indicated in special circumstances.¹ Following confirmation of diagnosis of DVT, our patient was immediately commenced on subcutaneous LMWH and compression stockings to which initial clinical response noted. Follow up scan however was not done because patient was transferred to another tertiary hospital on request.

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