Outcomes of the Latarjet Procedure Versus Free Bone Block Procedures for Anterior Shoulder Instability

Clinical Sports Medicine Update

A Systematic Review and Meta-analysis

Ron Gilat,*y MD,EricD.Haunschild,* BS, Ophelie Z. Lavoie-Gagne,* BS, Tracy M. Tauro,* BS, BA, Derrick M. Knapik,z MD, Michael C. Fu,* MD, MHS, and Brian J. Cole,*§ MD, MBA Investigation performed at Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA

Background: Free bone block (FBB) procedures for anterior shoulder instability have been proposed as an alternative to or bail- out for the Latarjet procedure. However, studies comparing the outcomes of these treatment modalities are limited. Purpose: To systematically review and perform a meta-analysis comparing the clinical outcomes of patients undergoing anterior shoulder stabilization with a Latarjet or FBB procedure. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, Embase, and the Cochrane Library databases were systematically searched from inception to 2019 for human-participants studies published in the English language. The search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement including studies reporting clinical outcomes of patients undergoing Latarjet or FBB procedures for anterior shoulder instability with minimum 2-year follow-up. Case reports and technique articles were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine the proportions of recurrent instability, other complications, progression of osteoarthritis, return to sports, and patient-reported outcome (PRO) improvement. Results: A total of 2007 studies were screened; of these, 70 studies met the inclusion criteria and were included in the meta- analysis. These studies reported outcomes on a total of 4540 shoulders, of which 3917 were treated with a Latarjet procedure and 623 were treated with an FBB stabilization procedure. Weighted mean follow-up was 75.8 months (range, 24-420 months) for the Latarjet group and 92.3 months (range, 24-444 months) for the FBB group. No significant differences were found between the Latarjet and the FBB groups in the overall random pooled summary estimate of the rate of recurrent instability (5% vs 3%, respectively; P = .09), other complications (4% vs 5%, respectively; P = .892), progression of osteoarthritis (12% vs 4%, respectively; P = .077), and return to sports (73% vs 88%; respectively, P = .066). American Shoulder and Elbow Surgeons scores improved after both Latarjet and FBB, with a significantly greater increase after FBB procedures (10.44 for Latarjet vs 32.86 for FBB; P = .006). Other recorded PRO scores improved in all studies, with no significant difference between groups. Conclusion: Current evidence supports the safety and efficacy of both the Latarjet and FBB procedures for anterior shoulder stabilization in the presence of glenoid bone loss. We found no significant differences between the procedures in rates of recurrent instability, other complications, osteoarthritis progression, and return to sports. Significant improvement in PROs was demonstrated for both groups. Significant heterogeneity existed between studies on outcomes of the Latarjet and FBB procedures, warranting future high-quality, comparative studies. Keywords: shoulder instability; bone block; glenoid reconstruction; glenoid augmentation; iliac crest bone graft; distal tibial allograft; Latarjet

The management of anterior glenohumeral instability in the setting of glenoid bone loss remains challenging.74 Soft tissue procedures have shown inferior results in cases The American Journal of Sports Medicine of anterior shoulder instability associated with as little as 1–12 13.5% of glenoid bone loss,31 requiring bone grafting tech- DOI: 10.1177/0363546520925833 17,19,66 Ó 2020 The Author(s) niques in such cases to restore stability. Commonly

1 2 Gilat et al The American Journal of Sports Medicine used bone block procedures include the Latarjet procedure METHODS and the modern Eden-Hybinette procedure.8,106 The Latar- jet procedure achieves stability with the bone block effect Data Sources and Searches of the coracoid process and the sling effect created by the conjoint tendon.41,106 However, the Latarjet procedure This systematic review was performed in line with the has been criticized for possible postoperative limited range PRISMA (Preferred Reporting Items for Systematic of motion,66 shoulder dyskinesia,20 potential neurovascu- Reviews and Meta-Analyses) guidelines. PubMed, Embase, lar injury, and a more difficult revision surgery.99 Also, and the Cochrane Library were systematically searched for concerns regarding the development of glenohumeral relevant articles from inception to December 19, 2019. The arthritis after the Latarjet procedure have been raised.79 reference lists of original and review articles were also Glenoid reconstruction using a free bone block (FBB) has screened. The search was limited to English-language been proposed as an alternative for the Latarjet procedure articles or articles with English translation. The search or as a bail-out after failed Latarjet, with equivalent clini- strategy combined the following search terms: ((‘‘glenoid’’ cal and radiographic outcomes.66 However, to our knowl- OR ‘‘glenohumeral’’ OR ‘‘shoulder instability’’) AND edge, no systematic review and meta-analysis has (‘‘*graft*’’ OR ‘‘bone block’’ OR reconstruct* OR augment* compared the outcomes of the Latarjet and FBB proce- OR ‘‘Latarjet’’)). dures in terms of recurrent instability, other complications, progression of osteoarthritis, and patient-reported Selection Criteria outcomes (PROs). Several open and arthroscopic techniques, using differ- Predefined eligibility criteria were clinical trials and obser- ent bone block types, including both autograft and allograft vational studies (cohort studies and case series) that || bone blocks, have been described. Sources of autograft reported clinical outcomes after anterior shoulder stabili- { 92 include iliac crest bone graft (ICBG), distal clavicle, and zation using the Latarjet procedure or an FBB procedure. free partial-thickness coracoid (leaving the conjoint tendon We included studies with a sample size of at least 5 attached to the remaining anatomic coracoid and not trans- patients and a minimum 2-year follow-up. We excluded ferred with the graft as performed during a Latarjet/Bris- (1) studies not providing PROs or recurrence rate, (2) stud- 7,95 tow procedure). Sources of allograft include the distal ies reporting the use of bone blocks in the setting of shoul- 40,73,75 87 87 tibia, proximal tibia, distal femur, iliac der arthroplasty, (3) case reports and technique articles 2,90,108 98 crest, and femoral head. The use of autografts reporting the outcomes of fewer than 5 patients, and (4) may be associated with donor site morbidity, including medical conference abstracts. Investigations from the risk for infection, hematoma, sensory disturbances, and an same institutions were separately reviewed to identify 67 additional scar. Disadvantages related to the use of studies likely reporting on the same cohort of patients. allografts include issues related to allograft availability When these were identified, the most comprehensive study and costs, graft incorporation, and the minimal risk for dis- was included, while the rest were omitted after mutual dis- ease transmission. cussion and consensus agreement. In 2014, Sayegh et al82 published a systematic review on allograft reconstruction for glenoid bone loss in glenohumeral instability. That early review included 4 case series Data Extraction and Quality Assessment and 4 case reports. Since then, a number of studies have been published investigating the use of FBB for the treat- The initial screening of records was performed based on ment of anterior shoulder instability. The aim of the cur- titles and abstracts. Three reviewers (R.G., E.D.H., rent review was to assess the clinical outcomes of D.M.K.) reviewed the articles and extracted manuscripts anterior shoulder stabilization using FBBs and perform independently. Discrepancies were resolved by mutual dis- a meta-analysis comparing the outcomes of FBB proce- cussions. The following information was extracted: publi- dures to those of the Latarjet procedure. cation year, study design, level of evidence, mean patient age, sample size, surgical approach, graft type (autograft/ allograft), graft origin (eg, iliac crest, distal tibia), follow- ||References 4, 5, 8, 14, 37, 39, 54, 55, 61, 63, 69, 73, 74, 91, 92, 100. up (minimum, mean, and range), previous surgeries, radio- {References 6, 8, 27, 59, 66, 83, 89, 96. graphic and clinical outcomes, complications, and specific

§Address correspondence to Brian J. Cole, MD, MBA, Midwest Orthopaedics at Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA (email: [email protected]) (Twitter: @BrianColeMD; @SportsMedicineWeekly). *Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA. yDepartment of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel. zUniversity Hospitals Cleveland Medical Center, Department of Orthopaedic Surgery, Cleveland, Ohio, USA. Submitted September 30, 2019; accepted March 13, 2020. One or more of the authors has declared the following potential conflict of interest or source of funding: B.J.C. has received grants, personal fees, and nonfinancial support from Arthrex during the conduct of the study; other from Aesculap, Athletico, JRF Ortho, and NIH; personal fees and other from Elsev- ier Publishing; personal fees and other from OTSM; personal fees from Ossio; personal fees and other from Regentis; other from Smith and Nephew outside the submitted work; and consulting fees from AcuMed, Geistlich Pharma North America, and Vericel outside the submitted work. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. AJSM Vol. XX, No. X, XXXX Outcomes of Latarjet vs Free Bone Blocks 3 n o

i Records idenﬁed through Addional records idenﬁed t

a database searching through other sources c i f i (n = 3113) (n = 1) t n e d I

Records after duplicates removed (n = 2007)

Screening Records screened Records excluded (n = 2007) (n = 1826)

Full-text arcles excluded, Full-text arcles assessed with reasons for eligibility (n = 105) (n = 181) Absence of outcomes (58) Less than 2 year follow up (40) Abstract only (6) Eligibility Less than 5 paents (1)

Studies included in Free- Studies included in Bone Blocks qualitave Latarjet qualitave synthesis synthesis (n = 18) (n = 58)

Included Studies included in Free- Studies included in Bone Blocks quantave Latarjet quantave synthesis (meta-analysis) synthesis (meta-analysis) (n = 18) (n = 54)

Figure 1. Flowchart using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Includes 2 studies directly comparing Latarjet and a free bone block procedure and therefore included in the quantitative analysis of both groups. remarks. We corresponded with study authors to provide Simple Shoulder Test, Oxford Shoulder Instability Score, additional information when necessary. Disabilities of the Arm, Shoulder and Hand score, Oxford Quality assessment was performed through use of the Shoulder Score, and Single Assessment Numeric Evaluation Methodological Index for Non-randomized Studies (SANE). Only PROs with a minimum of 2 studies in each (MINORS) checklist45 and the Newcastle-Ottawa Quality treatment group reporting on change from preoperative to Assessment Scale (NOS).88 Baseline comparisons of patient postoperative scores were analyzed in the meta-analysis. characteristics between groups were evaluated by weighted Outliers were defined as studies with effects that had an means, independent t tests, and 2-proportion z tests. Studies upper bound of the 95% CI that was lower than the minimum were expected to have high levels of heterogeneity due to pooled effect or studies with effects that had a lower bound of nonidentical patient populations, varying indications for sur- the 95% CI that was higher than the maximum pooled effect. gery, variable surgical techniques, and inconsistent defini- Outliers were then removed from the pooled analysis to min- tions of outcomes. Therefore, we used the DerSimonian- imize distortion of results. Forest plots were used to present Laird method28-30,44 to calculate pooled effect sizes. Heteroge- summarized results of the meta-analyses. Statistical signifi- neity was evaluated using the I2 value,44 and the 95% CI was cance was determined as P \ .05. All statistical analyses used to report all pooled statistics. Binomial data were were performed by use of R software (version 3.6.2). assessed using a random effects meta-analysis of proportions to synthesize rates of recurrent instability, other complications, progression of osteoarthritis, and return to sports. Con- RESULTS tinuous data were analyzed via random effects meta-analysis of pooled means to report differences in PROs including the Literature Selection visual analog scale for pain (VAS) score, Rowe score, Ameri- can Shoulder and Elbow Surgeons (ASES) score, Western A literature search of the PubMed, Embase, and Cochrane Ontario Shoulder Instability Index (WOSI), Subjective Shoul- Library databases was performed, yielding a total of 3113 der Value for Sports (SSVS), Constant score, University of studies. After removal of duplicates, a total of 2007 California, Los Angeles, shoulder score, Walch-Duplay, abstracts were identified. After evaluation of the title, 4 Gilat et al The American Journal of Sports Medicine

AB Author ES 95% CI Weight

Abdelhady 2015 0.07 [0.00; 0.34] 1.2% Allain 1998 0.12 [0.05; 0.23] 3.5% Balestro 2015 0.33 [0.10; 0.65] 0.0% Baverel 2018 0.03 [0.01; 0.08] 4.8% Bessiere 2013 0.12 [0.04; 0.24] 3.3% Blonna 2016 0.00 [0.00; 0.12] 0.0% Boileau 2019 0.03 [0.01; 0.07] 5.3% Bouju 2014 0.01 [0.00; 0.07] 4.2% Burkhart 2007 0.05 [0.02; 0.11] 4.7% Castricini 2019 0.02 [0.00; 0.12] 3.0% Cautiero 2017 0.00 [0.00; 0.07] 0.0% Chaudhary 2016 0.03 [0.00; 0.17] 2.3% De Carli 2019 0.20 [0.09; 0.36] 0.0% Dos Santos 2015 0.11 [0.03; 0.25] 2.7% Dossim 2008 0.17 [0.10; 0.26] 0.0% Dumont 2014 0.02 [0.00; 0.08] 3.7% Emami 2011 0.00 [0.00; 0.12] 0.0% Author ES 95% CI Weight Erntsbrummer 2019 0.20 [0.09; 0.36] 0.0% Flinkkilä 2015 0.13 [0.06; 0.26] 3.3% Abdelshahed 2018 0.20 [0.01; 0.72] 2.2% Frank 2018 0.00 [0.00; 0.07] 0.0% Anderl 2016 0.00 [0.00; 0.22] 4.8% Gordins 2015 0.26 [0.12; 0.45] 0.0% Arianjam 2015 0.12 [0.03; 0.27] 7.2% Hardy 2020 0.04 [0.02; 0.07] 6.7% Deml 2016 0.00 [0.00; 0.23] 4.6% Hovelius 2012 0.18 [0.14; 0.23] 0.0% Frank 2018 0.02 [0.00; 0.11] 8.3% Jeon 2018 0.06 [0.01; 0.21] 2.3% Lunn 2008 0.09 [0.02; 0.21] 8.1% Kawasaki 2018 0.03 [0.01; 0.07] 5.8% Moroder AJSM 2018 0.00 [0.00; 0.10] 7.3% Kee 2017 0.05 [0.02; 0.11] 4.9% Moroder 2019 0.07 [0.01; 0.23] 6.8% Lateur 2018 0.00 [0.00; 0.09] 0.0% Provencher 2019 0.00 [0.00; 0.11] 7.0% Li 2016 0.48 [0.28; 0.69] 0.0% Rahme 2003 0.23 [0.14; 0.34] 0.0% Marion 2017 0.02 [0.00; 0.09] 3.5% Scheibel 2008 0.00 [0.00; 0.31] 3.7% Maynou 2005 0.14 [0.08; 0.22] 0.0% Steffen 2013 0.08 [0.02; 0.20] 8.2% Mizuno 2014 0.06 [0.02; 0.14] 3.9% Taverna 2018 0.00 [0.00; 0.13] 6.5% Mook 2016 0.21 [0.10; 0.37] 0.0% Venkatachalam 2016 0.01 [0.00; 0.06] 9.4% Moroder JSES 2018 0.04 [0.00; 0.20] 2.0% Warner 2006 0.00 [0.00; 0.28] 4.0% Moroder 2019 0.04 [0.00; 0.20] 2.0% Weng 2009 0.22 [0.03; 0.60] 3.5% Neyton 2012 0.14 [0.05; 0.29] 2.6% Zhao 2014 0.06 [0.01; 0.16] 8.4% Privitera 2018 0.22 [0.13; 0.33] 0.0% Rossi 2018 0.00 [0.00; 0.04] 0.0% Random effects model 0.03 [0.01; 0.05] 100.0% Schroder 2006 0.27 [0.15; 0.41] 0.0% Heterogeneity: I 2 = 58%; τ2 = 0.0114; P < .01 Shih 2012 0.00 [0.00; 0.12] 0.0% 0 0.05 0.15 0.25 Singer 1995 0.07 [0.00; 0.34] 1.2% Vadalà 2017 0.00 [0.00; 0.14] 1.9% Valencia 2020 0.10 [0.03; 0.24] 2.8% Weaver 1994 0.19 [0.09; 0.33] 0.0% Wredmark 1992 0.05 [0.01; 0.15] 3.0% Xu 2020 0.01 [0.00; 0.05] 0.0% Xu 2019 0.00 [0.00; 0.13] 0.0% Yang 2016 0.15 [0.07; 0.28] 3.3% Yang 2018 0.05 [0.02; 0.12] 4.5% Zhang 2017 0.05 [0.01; 0.15] 3.0% Zhu 2015 0.00 [0.00; 0.06] 0.0% Zhu Arthroscopy 2017 0.00 [0.00; 0.04] 0.0% Zhu AJSM 2017 0.00 [0.00; 0.07] 0.0% Zimmermann 2016 0.12 [0.06; 0.20] 4.5%

Random effects model 0.05 [0.04; 0.07] 100.0% Heterogeneity: I 2 = 45%; τ2 = 0.0030; P < .01 0 0.05 0.15 0.25

Figure 2. Random effects model for proportion of patients undergoing (A) a Latarjet procedure or (B) a free bone block procedure who had experienced recurrent instability. ES, effect size. abstract, and, if necessary, full manuscript, a total of 76 directly comparing Latarjet and FBB procedures.40,67 One studies meeting inclusion criteria were selected for further study was supplied to us by the authors,75 as our search evaluation. Of these studies, 6 were removed from the produced only a presentation abstract of the study. The quantitative analysis due to the high likelihood of PRISMA flow diagram is presented in Figure 1. reporting on the same cohort of patients as other Free Bone Blocks. There were 16 case series, level 4 studies.47,48,53,75,77,78 There were 52 studies reporting on studies (n = 544 shoulders)**; 1 cohort, level 3 study (n = outcomes of the Latarjet procedure,# 16 studies reporting 50 shoulders)40; and 1 randomized controlled, level 1 study on the outcomes of FBB procedures,** and 2 studies (n = 29 shoulders).66 There were 6 studies reporting on the use of allografts (2 distal tibial,40,75 3 iliac crest,2,90,108 and #References 1, 3, 9-11, 13, 15, 16, 18, 21, 22, 24, 26, 32-36, 38, 42, 43, 46, 50-52, 56, 57, 60, 62, 64, 65, 68, 70-72, 80, 84-86, 93, 95, 97, 101-105, 107, 109-112. **References 2, 6-8, 27, 59, 66, 73, 76, 83, 89, 90, 95, 96, 98, 108. AJSM Vol. XX, No. X, XXXX Outcomes of Latarjet vs Free Bone Blocks 5

Author MD 95% CI Mean Difference Weight

Zhu 2017 (Arthroscopy) 8.00 [−0.62; 16.62] 56.2% Author MD 95% CI Mean Difference Weight Zhu 2017 (AJSM) 9.10 [−5.60; 23.80] 19.3% Xu 2020 15.00 [−12.93; 42.93] 5.4% Warner 2006 29.00 [1.36; 56.64] 38.6% Zhu 2015 15.00 [−4.60; 34.60] 10.9% Frank 2018 34.94 [12.79; 57.09] 60.1% Li 2016 17.00 [−35.63; 69.63] 1.5% Provencher 2019 52.00 [−102.84; 206.84] 1.2% Mook 2016 19.00 [−16.13; 54.13] 3.4% Frank 2018 25.56 [−10.07; 61.19] 3.3% Random effects model 32.86 [ 15.68; 50.03] 100.0% Heterogeneity: I 2 = 0%; τ2 = 0; P = .92 Random effects model 10.44 [ 3.97; 16.90] 100.0% −40−20 0 20 40 60 Heterogeneity: I 2 = 0%; τ2 = 0; P = .95 −40−20 0 20 40 60

Figure 3. Forest plots presenting the change in the American Shoulder and Elbow Surgeons scores in (A) patients who underwent a Latarjet procedure and (B) patients who underwent a free bone block procedure. MD, mean difference.

AB Author ES 95% CI Weight

Allain 1998 0.51 [0.40; 0.63] 0.0% Baverel 2018 0.62 [0.52; 0.71] 8.0% Bessiere 2013 0.63 [0.48; 0.76] 6.9% Boileau 2019 0.70 [0.61; 0.77] 8.2% Bouju 2014 0.62 [0.50; 0.72] 7.6% Burkhart 2007 0.96 [0.87; 1.00] 0.0% Author ES 95% CI Weight Castricini 2019 0.00 [0.00; 0.08] 0.0% Cautiero 2017 1.00 [0.93; 1.00] 0.0% Anderl 2016 1.00 [0.75; 1.00] 12.0% De Carli 2019 0.72 [0.56; 0.85] 6.5% Arianjam 2015 0.76 [0.59; 0.89] 16.1% Dossim 2008 0.57 [0.46; 0.67] 7.8% Auffarth 2008 0.94 [0.79; 0.99] 15.9% Ernstbrunner 2019 0.72 [0.56; 0.85] 6.5% Lunn 2008 0.72 [0.57; 0.84] 17.0% Jeon 2018 0.97 [0.83; 1.00] 0.0% Taverna 2018 0.67 [0.35; 0.90] 11.6% Kawasaki 2018 0.81 [0.74; 0.86] 8.5% Venkatachalam 2016 0.85 [0.74; 0.92] 17.9% Mizuno 2014 0.93 [0.84; 0.98] 0.0% Warner 2006 1.00 [0.63; 1.00] 9.6% Mook 2016 0.81 [0.61; 0.93] 5.6% Neyton 2012 0.65 [0.46; 0.80] 6.2% Random effects model 0.88 [0.76; 0.96] 100.0% Privitera 2018 0.49 [0.37; 0.61] 0.0% Heterogeneity: I 2 = 76%; τ2 = 0.0278; P < .01 Rossi 2018 0.91 [0.84; 0.96] 7.9% 0.4 0.5 0.6 0.7 0.8 0.9 1 Schroder 2006 0.90 [0.79; 0.97] 7.0% Shih 2012 1.00 [0.88; 1.00] 0.0% Vadalà 2017 0.67 [0.45; 0.84] 5.4% Zimmermann 2016 0.78 [0.69; 0.86] 7.8%

Random effects model 0.73 [0.66; 0.79] 100.0% Heterogeneity: I 2 = 81%; τ2 = 0.0145; P < .01 0.4 0.5 0.6 0.7 0.8 0.9 1

Figure 4. Random effects model for proportion of patients undergoing (A) a Latarjet procedure or (B) a free bone block procedure who returned to sports after the procedure. ES, effect size.

1 femoral head allograft)98, and 12 studies reporting on the Patient Demographics use of autografts (10 iliac crestyy and 2 free partial-thickness coracoid autograft7,95). Studies are presented in detail Free Bone Blocks. There were 623 shoulders treated with MINORS and NOS scores in the Appendix (available with an FBB stabilization procedure for anterior shoulder in the online version of this article). instability. Weighted mean age at the time of the proce- Latarjet. There were 29 case series, level 4 studies (n = dure was 27.8 years (range, 15-63 years). At least 56% 1620 shoulders)zz; 22 level 3 studies (n = 2193 shoulders)§§; (n = 349/623) of shoulders had a previous stabilization pro- 2 level 2 studies (n = 82 shoulders)60,93; and 1 level 1 stud- cedure; of these, 77 had a failed Latarjet. Weighted mean ies (n = 25 shoulders).67 Studies are presented in detail follow-up for FBB patients was 92.3 months (range, 24- with MINORS and NOS scores in the Appendix (available 444 months). online). Latarjet. There were 3917 shoulders treated with a Latarjet procedure for anterior shoulder instability. Weighted mean age at the time of the procedure was 27.6 yyReferences 6, 8, 27, 59, 66, 67, 76, 83, 89, 96. zz years (range, 14-85 years). At least 15% (n = 575/3917) References 1, 3, 9, 11, 15, 16, 18, 22, 24, 33-36, 38, 42, 51, 56, 57, had a documented previous stabilization procedure, which 65, 68, 70, 72, 84, 86, 101, 102, 107, 109, 110. §§References 10, 13, 21, 26, 32, 40, 43, 46, 50, 52, 62, 64, 71, 80, 85, was significantly lower than that of the FBB group (P \ 95, 97, 103-105, 111, 112. .001). Weighted mean follow-up for patients undergoing 6 Gilat et al The American Journal of Sports Medicine

TABLE 1 TABLE 2 Recurrent Instability Complications (Not Related to Recurrent Anterior Instability)a n (%) n (%) Free bone block procedures Dislocation 20 (3.2) Free bone block procedures Subluxation 5 (0.8) Persistent pain 19 (3) Apprehensiona 5 (0.8) Donor site hypoesthesia (autograft) 10 (1.6) Latarjet procedure Donor site pain (autograft) 3 (0.5) Dislocation 92 (2.2) Hardware failure 3 (0.5) Subluxation 105 (2.7) Graft fracture 3 (0.5) Apprehensiona 84 (2.1) Postoperative hematoma 2 (0.3) Instability not defined 19 (0.5) Subscapularis failure 2 (0.3) Donor site superficial infection 2 (0.3) aIn some studies, it was unclear whether patients with apprehension Surgical site infection 2 (0.3) included all or some of the patients who had subluxation or dislocation. SLAP lesion indicating repair 1 (0.2) Posterior dislocation 1 (0.2) Unknown revision procedure 1 (0.2) a Latarjet procedure was 75.8 months (range, 24-420 Latarjet procedure months). No statistically significant differences between Hardware failure/removal 56 (1.4) groups were reported in regard to age and mean follow- Surgical site infection 26 (0.7) up (P = .811 and P = .761, respectively). Graft fracture/dislocation 22 (0.6) Postoperative hematoma 19 (0.5) Persistent pain 12 (0.3) Surgical Characteristics Frozen shoulder/adhesive capsulitis 9 (0.2) Total shoulder arthroplasty due to arthritis 7 (0.2) Free Bone Blocks. Of patients undergoing stabilization Musculocutaneous nerve neuropathy 4 (0.1) with FBB, 452 patients underwent an open procedure, Unknown revision procedure 3 (0.1) and 157 patients underwent an arthroscopic procedure; Humeral fracture during manipulation 1 (0.03) the surgical approach was not reported in a single study Complex regional pain syndrome 1 (0.03) Axillary nerve palsy 1 (0.03) consisting of 14 patients.27 A total of 173 patients under- Clavicle fracture 1 (0.03) went stabilization with an allograft (distal tibia, n = 81; Other neuropathy 1 (0.03) iliac crest, n = 83; femoral head, n = 9), whereas 450 patients were treated with an autograft (ICBG, n = 332; aSLAP, superior labral anterior and posterior. free coracoid, n = 118). Latarjet. A total of 3543 patients underwent an open Latarjet procedure compared with 374 patients treated PROs including VAS, Rowe, WOSI, SSVS, and SANE showed using an arthroscopic Latarjet procedure. improvement after both Latarjet and FBB procedures, with no significant difference between the groups in terms of the magnitude of score increases (P = .625, P = .401, P = .143, Outcomes P = .366, and P = .776, respectively). Forest plots presenting changes in PRO scores for the VAS, Rowe, WOSI, SSVS, and Recurrent Instability. The overall random pooled sum- SANE are available in the online Appendix. mary estimate of the proportion of patients who underwent Athletes and Return to Sports. A total of 23 studies (9 an FBB procedure with recurrent postoperative instability FBB studies6-8,59,66,67,90,95,96 and 14 Latarjet studieskk) 2 was 3% (95% CI, 1%-5%; I = 58%), whereas that of reported return to sports rates. Return to sports rates patients who underwent a Latarjet procedure was 5% were 73% for Latarjet (95% CI, 66%-79%; I2 = 81%) and 2 (95% CI, 4%-7%; I = 45%) (Figure 2). No statistically sig- 88% for FBB (95% CI, 76%-96%; I2 = 76%) (Figure 4). No nificant difference was found in terms of recurrent insta- significant difference was found between groups in pooled bility between the 2 groups (P = .09). Of note, the return to sports rates (P = .066). definition of recurrent instability varied across studies; Other Complications (Not Instability-Related). There 2,60,94 some studies did not define recurrent instability, were 49 complications reported after FBB procedures.{{ whereas others defined recurrent instability as disloca- Persistent pain and donor site morbidity were the most 95 7,27,40,83,89,90 tion ; dislocation and subluxation ; or disloca- common complications of the FBB procedure. We noted 6,8,59,73,96,98,108 tion, subluxation, and apprehension. More that 3 of the 8 studies reporting on the use of ICBG auto- details can be found in Table 1 and in the online Appendix. grafts reported variable rates of donor site discomfort, Patient-Reported Outcomes. Improvement in PROs was hypoesthesia, or superficial donor site infection.59,66,96 observed across all studies reporting on Latarjet and FBB A total of 163 complications were reported after the procedures. ASES scores significantly improved after both Latarjet procedure. Hardware failure/removal, surgical Latarjet and FBB procedures, with a significantly greater increase in patients undergoing FBB procedures (10.44 for kkReferences 3, 18, 36, 50, 51, 64, 65, 70, 72, 80, 84, 85, 93, 112. Latarjet vs 32.86 for FBB; P = .006) (Figure 3). Other {{References 2, 6, 8, 40, 59, 66, 67, 89, 90, 95, 96, 108. AJSM Vol. XX, No. X, XXXX Outcomes of Latarjet vs Free Bone Blocks 7

Author ES 95% CI Weight

Allain 1998 0.09 [0.03; 0.19] 3.6% Baverel 2018 0.03 [0.01; 0.08] 4.7% Blonna 2016 0.07 [0.01; 0.22] 2.4% Boileau 2019 0.06 [0.03; 0.11] 5.1% Bouju 2014 0.01 [0.00; 0.07] 4.1% Burkhart 2007 0.05 [0.02; 0.11] 4.6% Castricini 2019 0.14 [0.05; 0.27] 3.0% Cautiero 2017 0.00 [0.00; 0.07] 0.0% Chaudhary 2016 0.20 [0.08; 0.39] 0.0% De Carli 2019 0.00 [0.00; 0.09] 0.0% Dos Santos 2015 0.00 [0.00; 0.09] 0.0% Dossim 2008 0.00 [0.00; 0.04] 0.0% Dumont 2014 0.20 [0.11; 0.32] 0.0% Author ES 95% CI Weight Emami 2011 0.00 [0.00; 0.12] 2.4% Erntsbrummer 2019 0.18 [0.07; 0.33] 0.0% Abdelshahed 2018 0.20 [0.01; 0.72] 2.7% Frank 2018 0.10 [0.03; 0.22] 3.3% Anderl 2016 0.07 [0.00; 0.32] 5.4% Hardy 2020 0.05 [0.03; 0.08] 6.3% Arianjam 2015 0.00 [0.00; 0.10] 7.4% Hovelius 2012 0.03 [0.01; 0.05] 6.3% Auffarth 2008 0.02 [0.00; 0.11] 8.0% Jeon 2018 0.00 [0.00; 0.11] 2.4% Deml 2016 0.00 [0.00; 0.23] 5.2% Kawasaki 2018 0.15 [0.10; 0.22] 0.0% Frank 2018 0.10 [0.03; 0.22] 8.1% Kee 2017 0.07 [0.03; 0.14] 4.8% Lunn 2008 0.15 [0.06; 0.29] 8.0% Lateur 2018 0.10 [0.03; 0.24] 2.9% Moroder AJSM 2018 0.03 [0.00; 0.15] 7.4% Marion 2017 0.05 [0.01; 0.14] 3.6% Moroder 2019 0.38 [0.21; 0.58] 0.0% Mizuno 2014 0.04 [0.01; 0.12] 3.9% Provencher 2019 0.00 [0.00; 0.11] 7.2% Mook 2016 0.05 [0.01; 0.18] 2.8% Scheibel 2008 0.00 [0.00; 0.31] 4.3% Moroder JSES 2018 0.52 [0.31; 0.72] 0.0% Steffen 2013 0.21 [0.10; 0.35] 8.1% Moroder 2019 0.12 [0.03; 0.31] 2.1% Taverna 2018 0.12 [0.02; 0.30] 6.8% Neyton 2012 0.11 [0.03; 0.25] 2.7% Venkatachalam 2016 0.04 [0.01; 0.10] 8.9% Privitera 2018 0.01 [0.00; 0.07] 4.0% Weng 2009 0.00 [0.00; 0.34] 4.1% Rossi 2018 0.13 [0.07; 0.21] 0.0% Zhao 2014 0.12 [0.04; 0.23] 8.2% Schroder 2006 0.04 [0.00; 0.14] 3.2% Vadalà 2017 0.21 [0.07; 0.42] 0.0% Random effects model 0.05 [0.02; 0.09] 100.0% Valencia 2020 0.02 [0.00; 0.13] 2.9% Heterogeneity: I 2 = 70%; τ2 = 0.0179; P < .01 Weaver 1994 0.04 [0.01; 0.15] 3.2% 0 0.05 0.1 0.15 0.2 Wredmark 1992 0.00 [0.00; 0.08] 0.0% Xu 2020 0.01 [0.00; 0.05] 4.6% Xu 2019 0.00 [0.00; 0.13] 2.2% Yang 2016 0.21 [0.11; 0.35] 0.0% Yang 2018 0.12 [0.06; 0.21] 4.4% Zhang 2017 0.00 [0.00; 0.08] 0.0% Zhu 2015 0.00 [0.00; 0.06] 0.0% Zhu Arthroscopy 2017 0.00 [0.00; 0.04] 0.0% Zhu AJSM 2017 0.00 [0.00; 0.07] 0.0% Zimmermann 2016 0.03 [0.01; 0.09] 4.5%

Random effects model 0.04 [0.03; 0.06] 100.0% Heterogeneity: I 2 = 54%; τ2 = 0.0038; P < .01 0 0.05 0.1 0.15 0.2

Figure 5. Random effects model for proportion of patients undergoing (A) a Latarjet procedure or (B) a free bone block procedure who experienced a postoperative complication not instability related. ES, effect size. site infection, graft fracture/dislocation, and postoperative reported to experience moderate to severe arthritis.66,89,108 hematoma were the most common complications after the Although progression of glenohumeral arthritis was Latarjet procedure. Complications are described in detail reported in several studies,8,59,96 other studies did not in Table 2 and the online Appendix. find progression of glenohumeral arthritis.6,108 Pooled complication rates were 4% for the Latarjet We found that 19 Latarjet studies reported progression group (95% CI, 3%-6%; I2 = 54%) and 5% for the FBB group of osteoarthritis in a total of 197 patients. Only 16 (95% CI, 2%-9%; I2 = 70%), with no significant difference patients were reported to progress to grade 3 instability between groups (P = .892) (Figure 5). arthropathy according to the Samilson and Prieto Glenohumeral Arthritis. We identified 8 FBB studies classification.3,81 that reported on the development of glenohumeral arthri- Pooled osteoarthritis rates were 12% for the Latarjet tis in a fraction of their patients.6,8,59,66,83,89,90,108 Most of group (95% CI, 8%-16%; I2 = 71%) and 4% for the FBB these studies reported progression of different rates to group (95% CI, 0%-12%; I2 = 80%) (Figure 6), with no sig- mild grade 1 arthritis; however, several patients were nificant difference between the groups (P = .077). 8 Gilat et al The American Journal of Sports Medicine

Author ES 95% CI Weight

Allain 1998 0.43 [0.30; 0.57] 0.0% Bouju 2014 0.09 [0.04; 0.18] 7.1% Cautiero 2017 0.00 [0.00; 0.07] 0.0% Dossim 2008 0.10 [0.05; 0.18] 7.4% Emami 2011 0.30 [0.15; 0.49] 5.3% Emstbrunner 2019 0.35 [0.21; 0.52] 5.9% Gordins 2015 0.61 [0.42; 0.78] 0.0% Author ES 95% CI Weight Kee 2017 0.08 [0.04; 0.15] 7.6% Lateur 2018 0.05 [0.01; 0.17] 5.9% Anderl 2016 0.00 [0.00; 0.22] 11.9% Li 2016 0.60 [0.39; 0.79] 0.0% Auffarth 2008 0.15 [0.06; 0.28] 15.8% Mizuno 2014 0.24 [0.14; 0.35] 6.9% Lunn 2008 0.13 [0.05; 0.26] 15.7% Mook 2016 0.03 [0.00; 0.14] 5.8% Steffen 2013 0.15 [0.06; 0.28] 15.8% Moroder 2018 0.84 [0.64; 0.95] 0.0% Taverna 2018 0.04 [0.00; 0.20] 14.1% Neyton 2012 0.22 [0.10; 0.38] 5.8% Warner 2006 0.00 [0.00; 0.28] 10.6% Schroder 2006 0.10 [0.03; 0.22] 6.3% Zhao 2014 0.00 [0.00; 0.07] 16.0% Shih 2012 0.11 [0.02; 0.28] 5.2% Singer 1995 0.71 [0.42; 0.92] 0.0% Random effects model 0.04 [0.00; 0.12] 100.0% Valencia 2020 0.05 [0.01; 0.17] 5.9% Heterogeneity: I 2 = 80%; 2 = 0.0299; P < .01 Weaver 1994 0.04 [0.01; 0.15] 6.2% 0 0.05 0.15 0.25 Wredmark 1992 0.05 [0.01; 0.15] 6.1% Xu 2020 0.00 [0.00; 0.04] 0.0% Yang 2016 0.21 [0.11; 0.35] 6.4% Zhang 2017 0.14 [0.05; 0.27] 6.1% Zhu AJSM 2017 0.02 [0.00; 0.10] 0.0%

Random effects model 0.12 [0.08; 0.16] 100.0% Heterogeneity: I 2 = 71%; 2 = 0.0119; P < .01 0 0.05 0.15 0.25

Figure 6. Random effects model for proportion of patients undergoing (A) a Latarjet procedure or (B) a free bone block procedure who were found to have progression of glenohumeral arthritis after the procedure. ES, effect size.

DISCUSSION Only 2 studies in this systematic review directly compared the outcomes of an FBB procedure versus the Latar- The findings of this systematic review and meta-analysis jet procedure. Frank et al40 compared the outcomes of support the safety and efficacy of both the Latarjet and distal tibial allograft with the Latarjet procedure and FBB augmentation procedures in the setting of anterior reported no significant difference in outcomes or postoper- shoulder instability associated with glenoid bone loss. ative range of motion, even though the distal tibial allo- This meta-analysis did not find significant differences graft group had a significantly greater preoperative bone between the Latarjet and FBB procedures in postoperative loss compared with the Latarjet group. Moroder et al66 per- rates of recurrent instability, other complications, osteoar- formed a randomized, controlled, prospective study com- thritis progression, most PROs, and return to sports. paring the J-shaped ICBG to the Latarjet procedure. The In this meta-analysis, we reported outcomes of 4540 authors also reported no significant difference in PROs; shoulders after anterior shoulder stabilization using the however, postoperative internal rotation was found to be Latarjet or FBB procedures, with a 3% to 5% rate of postop- decreased in the Latarjet group, whereas donor site mor- erative instability. Moreover, at minimum 2-year follow-up, bidity was an issue in the ICBG group. postoperative PROs were significantly improved compared In the current study, the differences between the 2 with preoperative scores. Complication rates and progres- types of procedures in terms of recurrent instability sion of glenohumeral arthritis were relatively low, although rates, osteoarthritis progression, and return to sports donor site morbidity is a concern with the use of ICBG. may be interpreted as borderline significant (P \ .1). Although several systematic reviews and meta-analyses However, the studies included in the analysis had mod- have been reported on the Latarjet procedure,23,49,58 sys- erate to high heterogeneity. Although the increase in tematic reviews reporting on the outcomes of FBB proce- ASES scores was significantly greater with the FBB pro- dures have been limited. A previous systematic review on cedures, all other improvements in PROs were not signif- FBB procedures published in 2014 by Sayegh et al82 icantly different between the 2 types of procedures. As focused on the use of allografts only, describing only 4 previously mentioned, both studies directly comparing case series and 4 case reports. Of these, only 4 studies, Latarjet and bone block procedures did not find a signifi- reporting on a total of 64 patients, had a minimum 2- cant difference in instability rates and PROs between year follow-up. Since 2014, a number of new studies have surgical groups. As such, further investigations are nec- provided additional details on the outcomes of FBB proce- essary to determine whether aclinicallyimportantdif- dures for the treatment of recurrent shoulder instability in ference in PRO improvement exists between the the presence of glenoid bone deficiency. Latarjet and FBB procedures. AJSM Vol. XX, No. X, XXXX Outcomes of Latarjet vs Free Bone Blocks 9

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