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Editorial Commentary: Arthroscopic Latarjet Procedure—Time Will Tell
Editorial Commentary: Arthroscopic Latarjet ProceduredTime Will Tell Paul Favorito, M.D., Editorial Board
Abstract: The arthroscopic Latarjet procedure is gaining acceptance as a procedure to treat anterior glenohumeral instability. Although complications occur, it is possible to obtain clinically meaningful results. Acquiring the skills and mastering the procedure are challenging even for expert surgeons.
See related article on page 2304
M
y senior partner, a shoulder specialist, approached me one afternoon: “I understand you’re performing this procedure arthroscopically?” “Yes,” I replied. “You’re wasting your time,” he said. “Just make an incision and do it open. It’s much easier.” I nodded and thanked him for his advice. The year was 2000; I had just finished a fellowship, and “this procedure” was arthroscopic rotator cuff repair. We all know how “this procedure” has evolved and is now considered the standard of care. The question is whether the same will hold true for the arthroscopic Latarjet procedure. Some would say that this operation is a victory of technology and ego over reason and prudence. The arthroscopic procedure allows surgeons to visualize structures that we commonly avoid, minimize retraction of neurovascular structures, and accurately position and secure the graft. I thought it should be possible to perform an arthroscopic Latarjet procedure. In 2011, 2 other surgeons and I traveled to Annecy to visit Laurent Lafosse, the pioneer of the procedure and a master shoulder surgeon. After spending 2 days with him, I was convinced that this procedure could be performed arthroscopically both safely and effectively.
The author reports the following potential conflicts of interest or sources of funding: P.F. is a consultant for DePuy Synthes Mitek Sports Medicine, Smith & Nephew, Conventus, and Arthrosurface. He receives payments for product development, professional education, and advisory board participation for shoulder products. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/19630/$36.00 https://doi.org/10.1016/j.arthro.2019.05.032
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But mastery is challenging. In general, the Latarjet procedure is more frequently chosen as a first-line procedure by European surgeons to manage glenohumeral instability. During an instructional course lecture at the 2019 Arthroscopy Association of North America annual meeting, I heard a European surgeon state that he performs more than 100 open Latarjet procedures yearly. I suspect that there are few or no surgeons in North America performing that many cases. Leuzinger, Brzoska, Métais, Clavert, Nourissat, Walch, Smolen, and Lafosse,1 authors of “Learning Curves in the Arthroscopic Latarjet Procedure: A Multicenter Analysis of the First 25 Cases of 5 International Surgeons,” have extensive experience with both open Latarjet and arthroscopic procedures. They are the ideal surgeons to attempt and then transition to the allarthroscopic approach. It may not be possible for all surgeons to make the same claim. Despite having a subspecialty shoulder practice, I perform approximately 12 arthroscopic Latarjet procedures per year, or 1 each month. Some would say that number is insufficient to become an expert. There are several studies that have evaluated the learning curve associated with the arthroscopic Latarjet procedure. Castricini et al.2 reported a longer operative time for the first 15 patients and opined that it is a reproducible technique but only suitable for experienced arthroscopic shoulder surgeons. Cunningham et al.3 reported that it took 10 cases to avoid conversion to an open procedure and it took 20 procedures to achieve an equal operative time. Kany et al.4 recognized that this is a complex and demanding technique and recommended cadaveric training with an experienced surgeon.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 8 (August), 2019: pp 2312-2313
2313
EDITORIAL COMMENTARY
The Latarjet procedure, performed either open or arthroscopically, is a nonanatomic procedure that substitutes for, but does not re-create, the normal anatomy. Despite the skill set and experience of the surgeon, complications occur. In a meta-analysis of open Bristow-Latarjet procedure results, Griesser et al.5 reported a 30% complication rate and a 7% unplanned reoperation rate. The proximity of the neurovascular structures during graft harvest and transfer, the achievement of graft healing, and the location of hardware adjacent to the articular surfaces pose substantial risks. Frequently, this procedure is performed as a revision procedure for patients in whom soft-tissue repairs have failed. Consistent with that which has been described in almost every orthopaedic procedure, revision surgery is usually less successful than primary surgery. As well, the patient population is often younger, athletic, and expecting to return to collision activities. As a result, the likelihood of reinjury is high. It remains to be seen whether the arthroscopic version of the Latarjet procedure gains global acceptance. As results are disseminated and younger surgeons are taught more advanced arthroscopic techniques, it is likely that more surgeons will attempt the
procedure. However, an honest evaluation of an individual’s skill set and steadfast commitment to master a very challenging procedure are critical prerequisites.
References 1. Leuzinger J, Brzoska R, Métais P, et al. Learning curves in the arthroscopic Latarjet procedure: A multicenter analysis of the learning curves for the first 25 cases of 5 international surgeons. Arthroscopy 2019;35:2304-2311. 2. Castricini R, De Benedetto M, Orlando N, Rocchi M, Zini R, Pirani P. Arthroscopic Latarjet procedure: Analysis of the learning curve. Musculoskelet Surg 2013;97:93-98 (suppl 1). 3. Cunningham G, Benchouk S, Kherad O, Lädermann A. Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc 2016;24:540-545. 4. Kany J, Flamand O, Grimberg J, et al. Arthroscopic Latarjet procedure: Is optimal positioning of the bone block and screws possible? A prospective computed tomography scan analysis. J Shoulder Elbow Surg 2016;25:69-77. 5. Griesser MJ, Harris JD, McCoy BW, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review. J Shoulder Elbow Surg 2016;22: 286-292.
Abstract: The arthroscopic Latarjet procedure is gaining acceptance as a procedure to treat anterior glenohumeral instability. Although complications occur, it is possible to obtain clinically meaningful results. Acquiring the skills and mastering the procedure are challenging even for expert surgeons.
See related article on page 2304
M
y senior partner, a shoulder specialist, approached me one afternoon: “I understand you’re performing this procedure arthroscopically?” “Yes,” I replied. “You’re wasting your time,” he said. “Just make an incision and do it open. It’s much easier.” I nodded and thanked him for his advice. The year was 2000; I had just finished a fellowship, and “this procedure” was arthroscopic rotator cuff repair. We all know how “this procedure” has evolved and is now considered the standard of care. The question is whether the same will hold true for the arthroscopic Latarjet procedure. Some would say that this operation is a victory of technology and ego over reason and prudence. The arthroscopic procedure allows surgeons to visualize structures that we commonly avoid, minimize retraction of neurovascular structures, and accurately position and secure the graft. I thought it should be possible to perform an arthroscopic Latarjet procedure. In 2011, 2 other surgeons and I traveled to Annecy to visit Laurent Lafosse, the pioneer of the procedure and a master shoulder surgeon. After spending 2 days with him, I was convinced that this procedure could be performed arthroscopically both safely and effectively.
The author reports the following potential conflicts of interest or sources of funding: P.F. is a consultant for DePuy Synthes Mitek Sports Medicine, Smith & Nephew, Conventus, and Arthrosurface. He receives payments for product development, professional education, and advisory board participation for shoulder products. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/19630/$36.00 https://doi.org/10.1016/j.arthro.2019.05.032
2312
But mastery is challenging. In general, the Latarjet procedure is more frequently chosen as a first-line procedure by European surgeons to manage glenohumeral instability. During an instructional course lecture at the 2019 Arthroscopy Association of North America annual meeting, I heard a European surgeon state that he performs more than 100 open Latarjet procedures yearly. I suspect that there are few or no surgeons in North America performing that many cases. Leuzinger, Brzoska, Métais, Clavert, Nourissat, Walch, Smolen, and Lafosse,1 authors of “Learning Curves in the Arthroscopic Latarjet Procedure: A Multicenter Analysis of the First 25 Cases of 5 International Surgeons,” have extensive experience with both open Latarjet and arthroscopic procedures. They are the ideal surgeons to attempt and then transition to the allarthroscopic approach. It may not be possible for all surgeons to make the same claim. Despite having a subspecialty shoulder practice, I perform approximately 12 arthroscopic Latarjet procedures per year, or 1 each month. Some would say that number is insufficient to become an expert. There are several studies that have evaluated the learning curve associated with the arthroscopic Latarjet procedure. Castricini et al.2 reported a longer operative time for the first 15 patients and opined that it is a reproducible technique but only suitable for experienced arthroscopic shoulder surgeons. Cunningham et al.3 reported that it took 10 cases to avoid conversion to an open procedure and it took 20 procedures to achieve an equal operative time. Kany et al.4 recognized that this is a complex and demanding technique and recommended cadaveric training with an experienced surgeon.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 8 (August), 2019: pp 2312-2313
2313
EDITORIAL COMMENTARY
The Latarjet procedure, performed either open or arthroscopically, is a nonanatomic procedure that substitutes for, but does not re-create, the normal anatomy. Despite the skill set and experience of the surgeon, complications occur. In a meta-analysis of open Bristow-Latarjet procedure results, Griesser et al.5 reported a 30% complication rate and a 7% unplanned reoperation rate. The proximity of the neurovascular structures during graft harvest and transfer, the achievement of graft healing, and the location of hardware adjacent to the articular surfaces pose substantial risks. Frequently, this procedure is performed as a revision procedure for patients in whom soft-tissue repairs have failed. Consistent with that which has been described in almost every orthopaedic procedure, revision surgery is usually less successful than primary surgery. As well, the patient population is often younger, athletic, and expecting to return to collision activities. As a result, the likelihood of reinjury is high. It remains to be seen whether the arthroscopic version of the Latarjet procedure gains global acceptance. As results are disseminated and younger surgeons are taught more advanced arthroscopic techniques, it is likely that more surgeons will attempt the
procedure. However, an honest evaluation of an individual’s skill set and steadfast commitment to master a very challenging procedure are critical prerequisites.
References 1. Leuzinger J, Brzoska R, Métais P, et al. Learning curves in the arthroscopic Latarjet procedure: A multicenter analysis of the learning curves for the first 25 cases of 5 international surgeons. Arthroscopy 2019;35:2304-2311. 2. Castricini R, De Benedetto M, Orlando N, Rocchi M, Zini R, Pirani P. Arthroscopic Latarjet procedure: Analysis of the learning curve. Musculoskelet Surg 2013;97:93-98 (suppl 1). 3. Cunningham G, Benchouk S, Kherad O, Lädermann A. Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc 2016;24:540-545. 4. Kany J, Flamand O, Grimberg J, et al. Arthroscopic Latarjet procedure: Is optimal positioning of the bone block and screws possible? A prospective computed tomography scan analysis. J Shoulder Elbow Surg 2016;25:69-77. 5. Griesser MJ, Harris JD, McCoy BW, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review. J Shoulder Elbow Surg 2016;22: 286-292.