Management of Posttraumatic Posterior Shoulder Instability Following a Latarjet: A Case Report

A common complication of shoulder dislocations is recurrent instability, as the soft tissue restraint providing stability is commonly damaged. Recurrent instability is especially high in younger contact athletes and in patients with some degree of either glenoid (i.e. bony Bankart) or humeral (i.e. Hill-Sachs) bone loss (21Olds M. Ellis R. Donaldson K. Parmar P. Kersten P. Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis.Br J Sports Med. 2015 Jul; 49: 913-922https://doi.org/10.1136/bjsports-2014-094342Crossref PubMed Scopus (163) Google Scholar,22Owens B.D. Agel J. Mountcastle S.B. Cameron K.L. Nelson B.J. Incidence of glenohumeral instability in collegiate athletics.Am J Sports Med. 2009; 37: 1750-1754https://doi.org/10.1177/0363546509334591Crossref PubMed Scopus (264) Google Scholar). Surgical treatment for anterior instability commonly includes soft tissue procedures to reattach a torn anterior inferior glenohumeral ligament or Latarjet-Bristow procedures, a technique that involves transferring the patient's coracoid process to augment a bony-deficient glenoid and thus increase stability (12Hurley E.T. Matache B.A. Wong I. Itoi E. Strauss E. Delaney R. et al.Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement.Arthroscopy. 2022; 38: 214-223.e7https://doi.org/10.1016/j.arthro.2021.07.022Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar,16Longo U.G. Loppini M. Rizzello G. Ciuffreda M. Maffulli N. Denaro V. 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Maffulli N. et al.Posterior shoulder instability: a systematic review.Br Med Bull. 2020; 134: 34-53https://doi.org/10.1093/bmb/ldaa009Crossref Scopus (12) Google Scholar,28Tannenbaum E. Sekiya J.K. Evaluation and Management of Posterior Shoulder Instability.Sports Health: A Multidisciplinary Approach. 2011; 3: 253-263https://doi.org/10.1177/1941738111400562Crossref PubMed Scopus (61) Google Scholar). The purpose of this case report is to describe the treatment and outcome of a 17-year-old male who had a posterior shoulder bony reconstruction for posttraumatic posterior shoulder instability three years after a Latarjet. A 17-year-old right hand dominant male presented for left posterior shoulder instability following a reported posterior dislocation with spontaneous reduction caused by an axial load injury from falling on an outstretched hand. Three years prior, he suffered an anterior left shoulder dislocation with axillary nerve palsy during competitive wrestling and subsequently underwent a closed reduction. Due to a large bony Bankart lesion (Image 1, Image 2, Image 3), he underwent a primary Latarjet with neurolysis of the medial, lateral, and posterior cords of brachial plexus as well as the axillary and musculocutaneous nerve (Image 4, Image 5). The patient regained his preinjury level of axillary nerve function and deltoid contraction with normal findings on EMG by 24 months postinjury. He lost approximately 10 degrees of internal rotation but regained full ROM otherwise and reached preinjury strength of the left shoulder by 24 months postinjury. He was able to return to his preinjury level of athletic participation without pain, recurrent instability, motor, and sensory deficits.Image 2Sagittal CT image taken after anterior dislocation revealing bony Bankart lesionView Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 3Axial CT image taken after anterior dislocation revealing bony Bankart lesionView Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 4Axial X-ray from 4.5 weeks after LatarjetView Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 5AP X-ray from 4.5 weeks after LatarjetView Large Image Figure ViewerDownload Hi-res image Download (PPT) Upon orthopedic evaluation, the patient's shoulder demonstrated full ROM and good strength of the supraspinatus, infraspinatus, teres minor, subscapularis, as well as the anterior, middle, and posterior deltoid. However, he had evidence of posterior-inferior instability demonstrated by positive posterior apprehension, load-and-shift, and O'Brien's tests. Three-dimensional CT scan revealed a reverse Hill-Sachs lesion and bony deficiency of the posterior inferior glenoid (Image 6, Image 7, Image 8, Image 9). Treatment options were discussed, including an arthroscopic capsular shift with labral repair, but the patient desired to return to contact sports and weightlifting. Thus, the decision was made to undergo a posterior glenoid reconstruction with bone graft, capsular shift, and labral repair with possible removal of the Latarjet screws to make room for the posterior glenoid bony reconstruction.Image 7Three-dimensional CT scan image taken after posterior dislocation of lateral scapula and glenoidView Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 8Three-dimensional CT scan image taken after posterior dislocation of anterior scapula and glenoidView Large Image Figure ViewerDownload Hi-res image Download (PPT)Image 9Axial CT image taken after posterior dislocation revealing reverse Hill-Sachs lesionView Large Image Figure ViewerDownload Hi-res image Download (PPT) Examination under anesthesia prior to surgery confirmed the shoulder was unstable in the posterior-inferior direction. The patient was placed in the lateral position and an inverted L incision was made just distal to the level of the spine of the scapula that extended towards the posterior acromion and from there, distally to the posterior axillary floor. Skin flaps were raised, and the posterior deltoid was retracted laterally so that the infraspinatus and teres minor were exposed. The interval between the teres minor and infraspinatus was developed such that the capsule was exposed. With elevation of the capsule, most of the posterior, inferior, and superior labrum appeared to be detached and there was an area of bony defect involving the posterior-inferior aspect of the glenoid measuring approximately 11 mm in length and 10 mm in width. This area was débrided, but it appeared that the screws from the anterior Latarjet procedure were prominent, and the decision was made to remove them. Débridement of the glenoid was performed at this time and the wound irrigated as attention was moved anteriorly for screw removal. The scar from his previous Latarjet was partially reopened and the deltopectoral interval developed. Deep dissection was performed until the level of the coracoid was reached. The inferior Latarjet screw was more posteriorly prominent and removed with its washer through an anterior approach. The proximal screw was well-seated in the bone and broke after partially disengaging the screw head from the bone such that most of the length of the screw remained inside the bone. Irrigation of the anterior wound was performed, and the rotator interval was closed with interrupted UHMW polyethylene suture in layered subcuticular fashion. Attention was again directed posteriorly, and the capsule was opened longitudinally. The joint was exposed. The detached labrum was further separated to expose the undersurface, which was débrided with a burr. Three size 2.9 double-loaded suture anchors were placed with equal spacing superior, middle, and inferior to the posterior glenoid. The shoulder was then placed in 20 degrees of external rotation and the sutures from the anchor were used to repair the labrum and imbricate the redundant capsule. Attention was then directed toward bony reconstruction. Through the same exposure, the lower trapezius insertion over the medial spine of the scapula was elevated and approximately 15 mm by 12 mm of bone from the medial spine of the scapula was harvested to be used as a bone graft. After thorough irrigation of the site of the harvest, drill holes were placed medially, and the lower trapezius was reattached back to its anatomic location. The bone was contoured to fit the site of the bony defect and a cannulated 3.5 mm stainless steel screw and washer were placed (image 10). Excellent compression was achieved at this level and the shoulder was stable to posterior and anterior stress testing. Prior to surgery, the shoulder easily subluxated posteriorly and inferiorly. Drill holes were placed in the spine of the scapula and used to repair the deltoid back to its anatomic location. Antibiotic powder was placed in the wound and the wound layers were closed in subcuticular fashion. Dressing and an external rotation brace was applied. The patient was awakened and transferred to recovery without complication. Postoperative course was uneventful. After remaining in the external rotation brace for eight weeks, the patient quickly regained full ROM compared contralaterally (except for the internal rotation lost after the Latarjet) and gained approximately 5 degrees of external rotation compared contralaterally before beginning rotator cuff strengthening. By seven months postop, he had achieved preinjury strength. Upon last follow-up, which was approximately ten years after surgery, he has been able to do all desired physical activity without pain or instability. His American Shoulder and Elbow Surgeons (ASES) score is 95, marking substantial improvement from his preoperative baseline of 75, his subjective shoulder value (SSV) is 100, and his SSV-Sport is 97. Treatment for recurrent shoulder instability is guided by a variety of factors. The ideal plan correctly pairs surgical technique with the underlying pathology in order to restore anatomical function. Determining the extent of soft tissue and bony involvement is crucial to creating a successful treatment plan, as these have widely differing contributions to instability due to their differing anatomical defects. Arthroscopic Bankart repairs are generally considered first line surgical management for recurrent anterior instability with soft tissue damage to the labrum and minimal (<20%) glenoid bone loss (1Ahmed I. Ashton F. Robinson C.M. Arthroscopic Bankart Repair and Capsular Shift for Recurrent Anterior Shoulder Instability.Journal of Bone and Joint Surgery. 2012; 94: 1308-1315https://doi.org/10.2106/jbjs.j.01983Crossref Google Scholar). Similarly, surgical management of tears in the glenohumeral ligament target the soft tissue defects within the joint. Soft tissue procedures are often preferred because complications are frequently less severe and more easily corrected than complications of bone augmentation procedures. However, the Bankart repair and similar soft tissue techniques are inferior to bone augmentation when there is significant bony involvement, as they do not address the bony anatomic defects. 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