Sahu Dipit, Shah Darshil
Sir H. N. Reliance Foundation Hospital, Mumbai, India.
Mumbai Shoulder Institute, Mumbai, India.
Clin Orthop Relat Res. 2025 May 6. doi: 10.1097/CORR.0000000000003485.
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?
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.
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).
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 III, therapeutic study.
肩关节不稳定患者中关节过度松弛的发生率较高，其治疗具有挑战性。肩关节过度松弛表现为前侧关节囊冗余，肱盂韧带拉长或薄弱，这可能与不稳定手术后更差的功能结果相关。对于存在或不存在关节过度松弛的复发性肩关节不稳定患者，行Latarjet手术后的功能结果和术后复发情况尚未得到研究。
问题/目的：（1）对于单向性前侧肩关节不稳定，行Latarjet手术的关节过度松弛患者与无关节过度松弛患者的功能结果（Rowe评分和肩关节主观评分[SSV]）有何差异，两组中达到患者可接受症状状态（PASS）的肩关节比例是多少？（2）对于单向性前侧肩关节不稳定，行Latarjet手术的关节过度松弛患者与无关节过度松弛患者术后复发的患者比例有何差异？（3）对于单向性前侧肩关节不稳定，行Latarjet手术的关节过度松弛患者与无关节过度松弛患者的影像学结果有何差异？
2014年1月至2022年1月期间，一名外科医生为155例肩关节前侧不稳定患者实施了Latarjet手术。在此期间，他为所有复发性不稳定患者实施了Latarjet手术，无论有无骨质丢失以及有无肩关节过度松弛。符合预先设定纳入标准的患者中，37%（131例中的48例）存在肩关节过度松弛（定义为对侧正常肩关节的外旋[肘部内收]≥85°），63%（131例中的83例）无关节过度松弛。肩关节过度松弛组中90%（48例中的43例）的患者和无关节过度松弛组中87%（83例中的72例）的患者的最短随访时间为2年，并通过比较功能结果（SSV、Rowe评分、活动度）和Latarjet手术后复发性不稳定患者的比例，对前两个研究问题进行评估。我们还将关节过度松弛组与32例无关节过度松弛且关节盂缺损≥15%的亚组患者（定义为“临界缺损，无关节过度松弛”组）进行了比较。此外，关节过度松弛组中84%（43例中的36例）的患者和无关节过度松弛组中81%（72例中的58例）的患者在术后中位（范围）3年（1至7年）时进行了CT扫描，并对该亚组患者的影像学结果进行了分析。根据早期研究，PASS定义为SSV为82.5%。手术后的复发性不稳定定义为术后出现的任何明显不稳定（脱位、半脱位）或前侧恐惧。半脱位根据患者主观不稳定事件或可自行复位的肱盂关节脱位病史进行临床评估。关节过度松弛组患者比无关节过度松弛组患者更年轻（平均±标准差年龄为23±4岁），术前关节盂缺损更小（4%±7%），与“临界缺损，无关节过度松弛”组患者相比也更年轻（年龄27±8岁，p = 0.01；关节盂缺损19%±6%，p < 0.001），术前关节盂缺损也更小（年龄28±7岁，p < 0.001；关节盂缺损11%±9%，p < 0.001）。预先的样本量计算表明，在检验效能为90%且α值为0.05时，每组共需要18例患者来检测SSV中12±11分的差异。
关节过度松弛组与无关节过度松弛组在SSV方面无差异（中位数[四分位间距]85[80至95]对90[80至95]，中位数差异为-5；p = 0.17）、Rowe评分方面无差异（中位数[四分位间距]95[90至100]对98[88至100]，中位数差异为-3；p = 从0.61）或Duplay-Walch评分方面无差异（中位数[四分位间距]90[86至100]对90[80至100]，中位数差异为0；p = 0.73）。我们发现关节过度松弛组与无关节过度松弛组在达到PASS的患者比例方面无差异（56%[43例中的24例]对71%[72例中的51例]，OR 0.5[95%CI 0.23至1.14]；p = 0.10）。关节过度松弛组与无关节过度松弛组在术后不稳定患者的比例方面无差异（12%[43例中的5例]对11%[72例中的8例]，OR 1.1[95%CI 0.32至3.45]；p = 0.93）。我们发现关节过度松弛组与无关节过度松弛组在骨愈合方面无差异（97%[36例中的35例]对98%[58例中的57例]，OR 0.6[95%CI 0.04至10.13]；p > 0.99）。我们发现关节过度松弛组与无关节过度松弛组在矢状面上级螺钉水平出现主要移植物吸收的患者比例方面无差异（86%[36例中的31例]对90%[58例中的52例]，OR 0.7[95%CI 0.20至2.54]；p = 将0.74），在矢状面下级螺钉水平出现轻微移植物吸收的患者比例方面无差异（1(100%[36例中的36例]对97%[58例中的56例]，OR 3.2[95%CI 0.15至69.2]；p = 0.45），在矢状面上级螺钉水平移植物内外侧位置可接受的患者比例方面无差异（75%[36例中的27例]对79%[58例中的从46例]，OR 0.8[95%CI 0.29至2.10]；p = 0.62）以及在矢状面下级螺钉水平移植物内外侧位置可接受的患者比例方面无差异（75%[36例中的27例]对86%[58例中的50例]，OR 0.5[95%CI 0.17至1.39]；p = 0.18）。
对于单向性肩关节不稳定，与无关节过度松弛的患者相比，预先存在肩关节过度松弛的患者行Latarjet手术后的功能结果不会更差，术后复发率也不会更高。因此，我们的研究结果表明，肩关节过度松弛不一定是行Latarjet手术的排除标准。未来的研究可能需要比较关节过度松弛和肩关节不稳定患者行Latarjet手术后的功能结果和并发症与关节囊折叠手术的情况。
III级，治疗性研究。
