Abstract
BACKGROUND: The prevalence of hyperlaxity in patients with shoulder instability is high, and its management is challenging. Shoulder hyperlaxity denotes a redundant anterior capsule with an elongated or weak glenohumeral ligament that may be associated with worse functional outcomes after procedures for instability. The functional outcomes and postoperative recurrence after a Latarjet procedure for recurrent instability in shoulders with hyperlaxity versus those without hyperlaxity has not been studied. QUESTIONS/PURPOSES: (1) What are the differences in functional outcomes (Rowe score and shoulder subjective value [SSV]) after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity, and what proportion of shoulders achieve the patient acceptable symptom state (PASS) in both groups? (2) What is the difference in the proportion of patients who experienced a recurrence after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity? (3) What are the differences in radiologic outcomes after a Latarjet procedure for unidirectional anterior instability in shoulder hyperlaxity versus no hyperlaxity? METHODS: Between January 2014 and January 2022, one surgeon performed the Latarjet procedure for anterior shoulder instability in 155 patients. During that time, he performed the Latarjet for all patients with recurrent instability, with or without bone loss and with or without shoulder hyperlaxity. Of those who fit the prespecified inclusion criteria, 37% (48 of 131) had shoulder hyperlaxity (defined as external rotation [elbow adducted] ≥ 85° in the opposite normal shoulder) and 63% (83 of 131) had no hyperlaxity. A total of 90% (43 of 48) of the patients with shoulder hyperlaxity and 87% (72 of 83) of patients without hyperlaxity had a minimum follow-up time of 2 years and were evaluated for the first two study questions by comparing functional outcomes (SSV, Rowe scores, ROM) and the proportion of patients who experienced recurrent instability after a Latarjet procedure. We also compared the hyperlaxity group with a subgroup of 32 patients with no hyperlaxity who had ≥ 15% glenoid loss (defined as the "critical defect, no hyperlaxity" group). In addition, 84% (36 of 43) of patients in the hyperlaxity group and 81% (58 of 72) in the no hyperlaxity group had CT scans at a median (range) 3 years (1 to 7) after surgery, and this subset of patients was analyzed for radiologic outcomes. The PASS was defined as an SSV of 82.5%, per an earlier study. Recurrent instability after the procedure was defined as any overt instability (dislocation, subluxation) or anterior apprehension noted in the postoperative period . Subluxation was evaluated clinically based on the patient's history of a subjective instability event or a dislocation of the glenohumeral joint that could be self-reduced. The patients in the hyperlaxity group were younger (mean ± SD age 23 ± 4 years) and had a smaller preoperative glenoid defect (4% ± 7%) than those in the no hyperlaxity group (age 28 ± 7 years, p < 0.001; glenoid defect 11% ± 9%, p < 0.001) and those in the critical defect, no hyperlaxity group (age 27 ± 8 years, p = 0.01; glenoid defect 19% ± 6%, p < 0.001). A priori sample size calculation showed that at a power of 90% and an alpha value of 0.05, a total of 18 patients were needed in each group to detect a difference in SSV of 12 ± 11 points. RESULTS: The hyperlaxity group did not differ from the no hyperlaxity group in terms of SSV (median [IQR] 85 [80 to 95] versus 90 [80 to 95], difference of medians -5; p = 0.17), Rowe score (median [IQR] 95 [90 to 100] versus 98 [88 to 100], difference of medians -3; p = 0.61), or Duplay-Walch score (median [IQR] 90 [86 to 100] versus 90 [80 to 100], difference of medians 0; p = 0.73). We found no difference between the hyperlaxity and the no hyperlaxity group in terms of the proportion of patients who achieved the PASS (56% [24 of 43] versus 71% [51 of 72], OR 0.5 [95% CI 0.23 to 1.14]; p = 0.10). The hyperlaxity group did not differ from the no hyperlaxity group in the proportion of patients who experienced postoperative instability (12% [5 of 43] versus 11% [8 of 72], OR 1.1 [95% CI 0.32 to 3.45]; p = 0.93). We found no difference between the hyperlaxity and the no hyperlaxity group in terms of bony healing (97% [35 of 36] versus 98% [57 of 58], OR 0.6 [95% CI 0.04 to 10.13]; p > 0.99). We found no difference between the hyperlaxity and the no hyperlaxity group in the proportion of patients who had major graft resorption at the superior screw level in the sagittal section (86% [31 of 36] versus 90% [52 of 58], OR 0.7 [95% CI 0.20 to 2.54]; p = 0.74), minor graft resorption at the inferior screw level in the sagittal section (100% [36 of 36] versus 97% [56 of 58], OR 3.2 [95% CI 0.15 to 69.2]; p = 0.45), and acceptable mediolateral graft positioning at the superior screw level (75% [27 of 36] versus 79% [46 of 58], OR 0.8 [95% CI 0.29 to 2.10]; p = 0.62) and the inferior screw level (75% [27 of 36] versus 86% [50 of 58], OR 0.5 [95% CI 0.17 to 1.39]; p = 0.18). CONCLUSION: The Latarjet procedure for unidirectional shoulder instability does not result in inferior functional outcomes or higher postoperative recurrence in patients with preexisting shoulder hyperlaxity compared with patients without hyperlaxity. Therefore, our findings suggest that shoulder hyperlaxity may not necessarily be an exclusion criterion for performing the Latarjet procedure. Future studies may need to compare the functional outcomes and complications after the Latarjet procedure with those of capsular plication procedures in patients with hyperlaxity and shoulder instability. LEVEL OF EVIDENCE: Level III, therapeutic study.