Introduction
Bone block surgeries for the treatment of recurrent shoulder dislocation are widely
used and established. Among several techniques, the Bristow-Latarjet procedure stands
out. It is a surgery that fixates the coracoid process graft and the conjoint tendon
to the anterior glenoid region to promote joint stability.[1 ]
[2 ]
[3 ]
Throughout the years, these surgeries have undergone modifications, and now it is
possible to perform the Bristow-Latarjet procedure using an open or arthroscopic approach.
The development of specific materials, including guides and cutting saws, facilitated
the surgical steps.[4 ]
Even though Bristow-Latarjet surgery has been performed globally for years by orthopedists,
it demands high technical ability from the surgeon. The literature describes many
complications from these procedures, with rates ranging from 0% to 30%.[5 ]
[6 ] In recent years, there has been an exponential increase in the number of Bristow-Latarjet
procedures performed.[7 ]
[8 ]
[9 ]
[10 ]
[11 ] The present study aims to provide a current overview of Bristow-Latarjet surgery
in Brazil.
Materials and Methods
We sent an electronic questionnaire by e-mail to all orthopedists who are active members
of the Brazilian Society of Shoulder and Elbow Surgery (Sociedade Brasileira de Cirurgia
do Ombro e Cotovelo, SBCOC, in Portuguese). The questionnaire consisted of 26 questions
with multiple-choice answers that covered specialist training, surgical techniques,
complications, and postoperative management.
From April 20 to May 12, 2021, we sent the questionnaire to 845 active SBCOC members,
and we received 310 questionnaires answered in full. The insitutional Ethics in Research
Committee approved the present study.
Statistical Analysis
The platform used to obtain data was Google Forms. The statistical analysis included
the test of equality of two proportions, the Chi-squared, Kruskal-Wallis, and Mann-Whitney
tests, confidence intervals for the mean values, and p -values. The statistical analysis was performed using the following software: IBM
SPSS Statistics for Windows (IBM Corp., Armonk, NY, United States), version 20.0,
Minitab 16 (Minitab, LLC, State College, PA, United States) and Excel Office 2010
(Microsoft Corp., Redmond, WA, United States). The significance level adopted was
of 0.05 (5%).
Results
The year 2021 was the base to calculate the time since graduation from medical school,
the year of completion of the medical residency in orthopedics and traumatology, and
the date of obtainment of the specialist title from SBCOC ([Table 1 ]).
Table 1
Mean
Median
Standard deviation
CV
Q1
Q3
Mode
Min
Max
N
CI
Time (in years)
Medical school graduation
19.3
17
9.6
50%
12
24
12
1
50
309
1.1
Residency graduation
15.6
14
9.9
63%
8
21
4
3
48
310
1.1
Specialization title
13.0
12
8.7
67%
6
18
3
1
44
303
1.0
The state of São Paulo was the largest producer of specialists, followed by Minas
Gerais, Rio de Janeiro, and Rio Grande do Sul ([Fig. 1 ]). The largest concentration of shoulder and elbow surgery specialists is in São
Paulo, Minas Gerais, Rio de Janeiro, and Rio Grande do Sul as well.
Fig. 1 State of Brazil where the specialization in shoulder and elbow surgery was obtained.
We asked about the number of Bristow-Latarjet procedures performed by orthopedists
during their internship. Most specialists performed one to ten surgeries ([Fig. 2 ]). We also asked them about the most frequent complications according to the literature.
The most prevalent answers included graft fracture, graft failure, graft resorption,
screw loosening, and postoperative hematoma ([Fig. 3 ]).
Fig. 2 Number of procedures during training.
Fig. 3 Most frequent complications.
The leading technical difficulties mentioned by the specialists were screw positioning,
glenoid exposure, subscapularis opening, and osteotomy of the coracoid process ([Table 2 ]).
Table 2
Major difficulties
N
%
p -value
Screw/fixation device positioning
137
54.6%
Ref.
Glenoid exposure
102
40.6%
0.002
Subscapularis and joint capsule opening
48
19.1%
< 0.001
Coracoid process osteotomy
36
14.3%
< 0.001
Other
11
4.4%
< 0.001
Most specialists (287; 92.6%) preferred the open approach; only 4 (1.3%) favored the
arthroscopic route, and 19 (6.1%) used both approaches. Most participants indicated
a sling for postoperative immobilization, often for 4 weeks ([Fig. 4 ]).
Fig. 4 Postoperative immobilization time.
Most specialists only allow the return to sports that require the use of the upper
limbs after the fourth month of surgery. Graft consolidation is a determining factor
for resuming physical activities for most participants ([Fig. 5 ]).
Fig. 5 Time to return to sports after surgery.
[Fig. 6 ] shows the answers regarding the use of special devices/instruments during surgery,
use of anchors for anterior labial repair, postoperative use of drains, intra- and
postoperative complications, subscapularis suture, postoperative immobilization, the
significance of graft consolidation to resume physical activities, and the use of
computed tomography to assess graft consolidation.
Fig. 6 Distribution of YES/NO questions.
When assessing the time since the obtainment the specialist title and the most prevalent
complications, the highest number of complications occurred in the group of surgeons
who specialized 11 to 15 years ago. This finding was statistically significant compared
with all other groups ([Table 3 ]).
Table 3
Complications: mean
Median
Standard deviation
Q1
Q3
N
CI
p -value
Specialization time in years
1–5
1.83
1
1.80
0.5
3
71
0.42
0.005
6–10
2.19
2
1.67
1
3
64
0.41
11–15
2.93
3
1.69
2
4
55
0.45
16–20
2.26
2
1.81
1
3
57
0.47
> 21
2.27
2
1.98
1
3
56
0.52
Discussion
The widely performed Bristow-Latarjet surgery for shoulder stabilization is a technically
challenging procedure. For Castricini et al.,[12 ] the following five stages of the Latarjet procedure are the most critical: joint
assessment, subscapularis division, coracoid graft removal, graft transfer, and graft
fixation.
An overview of the Bristow-Latarjet surgery yields fundamental tools to improve the
training of Brazilian orthopedists. The learning curve for any surgical procedure
has a direct implication on determinant health factors; moreover, higher training
and experience on the part of the the surgeon are associated with higher patient safety.[13 ]
[14 ] Ethkiari et al.[15 ] described that after 22 Latarjet procedures surgeons reach a level of proficiency
that is reflected in a shorter intraoperative time. In the present study, we found
that 23.5% of orthopedists participated in 21 to 30 Bristow-Latarjet procedures during
their shoulder and elbow surgery internship. Most (39.4%) reported performing up to
10 procedures. It is noteworthy that 13.5% of the specialists reported they did not
perform any Bristow-Latarjet surgery during their specialization.[15 ]
We asked the participants about the number of procedures they had performed in the
previous year. In total, 207 specialists (66.8%) performed up to 10 surgeries, 62
(20%), 11 to 20 surgeries, 8 (2.6%), 21 to 30 surgeries, and 6 (1.9%) participants
performed more than 30 procedures. It is worth mentioning that the study was conducted
during the coronavirus disease 2019 (COVID-19) pandemic, in which there was a decrease
in the volume of elective surgeries in Brazil and worldwide. In a systematic review,
Hope et al.[16 ] described the negative impact of the pandemic in the training of new surgeons due
to the reduced number of procedures.[16 ]
[17 ]
Despite the increase in the number of arthroscopic procedures performed worldwide,
in the present study we observed that our specialists still prefer the open approach.[18 ]
[19 ] Although technological advances introduced specific instruments, such as cutting
and drilling guides, to help with the surgical steps of the Bristow-Latarjet procedure,
most participants do not use them.[4 ]
[20 ]
[21 ]
When asked about their preferred method for graft fixation, the rates for the exclusive
use of cannulated screws (38.4%), cannulated screws with another fixation device (35.2%),
and the lack of use of cannulated screws (26.5%) were similar. In our study, most
orthopedists performed graft fixation with 2 screws (82.9%), which has been consistent
with the literature[22 ]
[23 ]
[24 ]
[25 ]
[26 ] since its description by Patte et al.[23 ]
Graft fracture was the most frequent complication in the present study, with 145 (46.8%)
answers. Griesser et al.[5 ] stated that this complication often results from excessive screw tightening, advanced
patient age, and excessive graft decortication during its preparation. As for screw-related
issues in graft fixation, 65 (21%) and 58 (18.7%) participants mentioned loosening
and breakage/deformation respectively.[6 ]
[27 ]
Neurological injury was reported by 61 participants (19.7%). For Cohen et al.,[6 ] the rates of neurological injury ranged from 1% to 20%, and the musculocutaneous
and axillary nerves were the most frequently injured. Watchful waiting is usually
enough for complete resolution of the complication.[5 ]
[6 ]
[28 ]
Postoperative hematoma was mentioned by 61 participants (19.7%). For Metais et al.,[19 ] hematoma is a rare complication, with an incidence ranging from 1% to 2%.
Hovelius and Saeboe[29 ] stated that glenohumeral arthrosis is often associated with a lateralized graft
positioning or intra-articular screw placement of screws. In the present study, 56
(18.1%) participants reported this complication.
For Walch and Boileau,[30 ] the incidence of dislocation recurrence after the Bristow-Latarjet procedure is
low, ranging from 1% to 3%. In the present study, 40 (12.9%) participants reported
this complication.
Less than 10% of the participants in the present study reported infection, suture
dehiscence or necrosis, joint tendon rupture, and vascular injury. This finding is
consistent with the literature, which states that these complications are rare.[5 ]
[6 ]
[28 ]
[29 ]
[31 ]
[32 ]
Screw positioning was the technical aspect most mentioned as the major difficulty
(by 137 participants; 44.2%). Correct screw positioning has a direct influence on
graft positioning and fixation. Latarjet[1 ] recommended the best screw position as parallel to the articular surface. Hovelius
and Saeboe[29 ] stated that, in addition to the correct graft positioning, it is critical to comply
with the maximum screw inclination of 15 degrees to the articular surface. Kawakami[33 ] recommended screw parallelism; however, this is not the single and mandatory condition
to avoid complications.
Glenoid exposure was the second major technical difficulty reported by participants,
with 102 mentions (32.9%). In total, 48 specialists (15.5%) reported having difficulty
opening the subscapularis and joint capsule, while 35 (11.6%) reported difficulty
in coracoid process osteotomy. Walch and Boileau[30 ] recommended the horizontal opening of the subscapularis, keeping two-thirds superior
and one-third inferior. The capsulotomy should be vertical and measure about 1.5 cm
at the anteroinferior margin of the glenoid. The osteotomy must use a curved osteotome
or an angled saw only after careful dissection of the pectoralis minor tendon and
the coracoacromial ligament.[30 ]
Mobilization was indicated by 309 out of 310 specialists (99.7%). The optimal immobilization
time ranged widely, and 117 (37.7%) participants preferred 4 weeks. Walch and Boileau[30 ] recommended a sling for 2 weeks, followed by physical therapy. In his original work
published in 1958, Helfet[2 ] recommended postoperative immobilization for 6 weeks.
Most specialists (197; 63.5%) recommended returning to sports that require the use
of the upper limbs only in the fourth month after surgery. Most participants also
mentioned graft consolidation as a determining factor to resume physical activities,
which is in line with the literature.[27 ]
According to Scheffer et al.,[34 ] the number of physicians in Brazil increased exponentially in recent decades. In
the present study, we observed a greater participation of physicians graduating from
1999 onwards. The Brazilian states where most specialists work were São Paulo, Minas
Gerais, and Rio de Janeiro. Our sample consisted entirely of specialists in Orthopedics
and Traumatology (Brazilian Society of Orthopedics and Traumatology, Sociedade Brasileira
de Ortopedia e Traumatologia, SBOT, in Portuguese) and Shoulder and Elbow Surgery
(SBCOC). The states in which the internship in Shoulder and Elbow Surgery mostly occurred
were São Paulo (51% of the participants), Minas Gerais (24.2%), Rio de Janeiro (10.3%),
and Rio Grande do Sul (6.8%). Following the national scenario, the order of the states
that produce the most specialists is the same. In the present study, consistent with
the Brazilian scenario presented by Scheffer et al.,[34 ] the Northeast, North, and Midwest regions have few specialist training centers.
Study Limitation
Even though we sent the questionnaire to all active SBCOC members and followed it
up with an active search, not all specialists answered it. Using the questionnaire
as a tool created a memory bias, and specialists with the greatest number of years
since the obtainment of the titles had more difficulty in answering precisely. Many
orthopedists who are not SBCOC members perform shoulder surgeries, but they were not
included in the present study, which sought to obtain data from active specialists
from SBCOC.
Conclusion
Most specialists participated in one to ten Bristow-Latarjet procedures during their
specialization. A total of 13.5% of specialists graduated without participating in
any surgery. The most frequent complication was graft fracture. The most prevalent
technical difficulty was screw positioning. Most participants preferred postoperative
immobilization since they considered graft consolidation essential to resume physical
activities. The highest number of complications occurred with specialists who had
obtained their titles 11 to 15 years ago. The Southeast region is the largest producer
of specialists and where most of them have their practices in Brazil.
