Recurrent Instability after the Latarjet Procedure

Abstract

The Latarjet procedure is a favored approach for managing chronic and recurrent dislocation, especially in the presence of bone loss. Although generally yielding excellent results, the procedure carries a 15 to 30% complication rate. Although recurrent instability is a major concern, various complications such as infection, nerve injuries, and hardware impingement can also necessitate revision after a Latarjet procedure. Strategies for addressing this issue include glenoid bone grafting, using autogenous bone grafts from the iliac crest or distal clavicle, and allografts, with fresh lateral distal tibial allografts offering advantages because of their osteochondral nature. In addition, soft-tissue procedures offer another solution for recurrent instability, suitable for patients lacking substantial bone loss or those experiencing multidirectional instability. This review aims to provide a comprehensive overview of the causes and management strategies for recurrent instability following a failed Latarjet procedure.

Shoulder instability is the most frequent complication after traumatic anterior shoulder dislocation, particularly in young men and athletes.^1,2 Although various soft-tissue and bony procedures have been described for the treatment of anterior shoulder instability, the arthroscopic Bankart repair and the Latarjet procedure are the most commonly performed ones. However, recurrent instability remains a notable concern, particularly in patients who have substantial glenoid bone loss. This issue has been reported in up to 67% of cases, frequently attributed to soft-tissue procedures rather than bone augmentation, including the Latarjet procedure.³ Critical glenoid bone loss refers to the amount of bone loss in the glenoid fossa that is considered critical for predicting failure after an isolated soft-tissue repair.³ Clinical and biomechanical studies have defined critical glenoid bone loss as defects comprising 21% to 30% of the glenoid fossa.⁴ Moreover, recent research has shown that even subcritical bone loss of 13.5% or more notably decreases the functional outcome.³ Therefore, in patients with critical bone loss, the Latarjet procedure is often recommended because it provides more stability and reduces the risk of recurrent instability.⁵

Latarjet described the original coracoid process transfer in 1954 to restore the anatomical shape of the glenoid and reinforce the weak and stretched anterior-inferior capsule.¹ This procedure involves transferring the coracoid process to reconstruct the anterior-posterior glenoid diameter, reinforce the anterior capsule with coracoacromial ligament remnant, and provide additional sling effect of the conjoined tendon on the subscapularis.^5,6 It is important to note that the Latarjet⁶ procedure also involves nonanatomical repair and fixing the coracoid through the subscapularis muscle, converting off-track Hill-Sachs lesions to on-track lesions. However, when a sizable Hill-Sachs lesion pairs with a pronounced glenoid defect, the risk of the coracoid graft failing to transition off-track Hill-Sachs lesions to on-track increases. If the gap between the Hill-Sachs interval and the glenoid track exceeds the graft size, the coracoid graft might fall short of achieving this conversion. Although the Latarjet procedure generally has a low recurrence rate and favorable clinical outcomes, it is not without potential complications.⁷ The overall complication rates have been reported between 15 and 30%,^5,7,8 with specific complications including graft-related issues (11.7%),⁵ hardware-related complications (6.5%),⁵ nerve injuries (0.7% to 4%),^5,9 recurrent instability (8%),² and revision (5%).⁷

The causes of failure after a primary Latarjet procedure can be multifactorial, and defining failure based on the frequency of recurrent instability after the index procedure is still debatable. Some authors consider a single episode of subluxation or dislocation as a failure,¹⁰ whereas others require two or more dislocation events to define a failure.¹¹ Notably, long-term follow-up studies have shown that most patients with a single instability episode are satisfied after 15 years of follow-up, whereas recurrent instability is described when referring to two or more dislocation events.^2,11 Therefore, it should be emphasized that not every recurrence necessitates a revision surgery. Subluxation was used to describe a suspected dislocation, followed by immediate spontaneous reduction.²

Although the reported rates of recurrent shoulder instability after the Latarjet procedure vary between 0% and 8%, it remains a notable concern.^2,12 Recurrent instability typically manifests within the first few years after surgery.⁷ Moreover, although recurrent anterior instability is the main reason for revision surgery, it is encountered in fewer than 2% of patients, highlighting a relatively low revision rate.^2,6 Therefore, addressing the issue of recurrent instability after a Latarjet procedure is crucial to improve patient outcomes and reduce the need for revision surgery.

This review aimed to analyze the factors associated with recurrent instability after the Latarjet procedure and proposes potential strategies to mitigate this complication by addressing knowledge gaps and critically assessing the available literature.

Etiology

Identifying the causes of recurrent instability is crucial for determining appropriate treatment options. Surgical technical factors, patient-related risk factors, and postoperative trauma can contribute to the failure of the procedure and the development of recurrent instability. A thorough evaluation of each patient's specific situation is necessary to determine the optimal treatment plan.

Surgical Technical Factors Influencing Recurrent Anterior Instability

Position of the Graft

The accurate placement of the coracoid bone graft is critical for the success of the Latarjet procedure.¹³ The optimal position is below the glenoid equator in the vertical plane and flushed to the glenoid rim in the horizontal plane. Malpositioning, such as placing the graft too medial or too superior, can lead to recurrent anterior instability, necessitating revision surgery in up to 18.9% of cases.^11,14 Studies have shown that placing the bone block >1 cm medial to the glenoid rim results in a recurrence rate of 83%.¹¹ Alternative techniques, such as the congruent arc coracoid modification, may offer similar stability results to the classic technique.¹⁵ The arthroscopic approach allows for better visualization but presents technical challenges and requires a steep learning curve.¹⁶

Types of the Screws

The choice of screw type and fixation method in the Latarjet procedure varies based on surgeon preference and experience. The literature indicates that screw type or fixation method does not notable affect the biomechanical performance or coracoid graft osseous union.¹³ However, monocortical screws are weaker than bicortical fixation and may result in nonunion or breakage. Bicortical drilling or long screws can pose risks to the suprascapular nerve.¹⁷ Some studies have postulated that cannulated screws might offer weaker purchase in the native scapula compared with noncannulated screws.¹³ This potential disadvantage arises because of partially threaded cannulated screws, which can lead to suboptimal graft compression. Despite these considerations, further research is still essential to definitively determine the optimal screw type, the best fixation method, and to gauge the long-term outcomes and associated complications.

Soft-Tissue Stabilizers

Although the Latarjet procedure effectively stabilizes the shoulder joint by reattaching the labrum and the anterior capsule with the glenoid rim and the stump of the coracoacromial ligament, residual instability can still occur because of factors such as soft-tissue laxity and extensive damage to the capsule and labrum.¹⁶ The arthroscopic Latarjet approach has, in some instances, left the anterior-inferior capsule defect unaddressed, posing a challenge in fully rectifying the insufficiency.

Capsular reconstruction techniques address these concerns and reinforce the anterior-inferior capsule, reducing the risk of recurrent instability. These techniques include combining the Latarjet procedure with a Bankart repair,¹⁸ capsular shift, coracohumeral ligament reconstruction, and rotator interval closure. In the combined Latarjet procedure with a Bankart repair, suture anchors are placed on the anterior-inferior aspect of the glenoid rim to reinforce the capsule before the final fixation of the bone block.¹⁸ After fixation, the sutures are tied to the capsule to recreate the anterior labral bumper effect and to protect the humeral head from direct contact with the coracoid bone graft.¹⁸ However, Hovelius et al¹¹ suggested that the latter technique did not markedly improve recurrent instability rates or functional outcomes. On the other hand, capsular shift and coracohumeral ligament reconstruction have demonstrated effectiveness in reducing recurrent instability rates, particularly in patients with ligamentous laxity. The traditional inferior capsular shift (often termed ‘south to north’) is typically chosen for its potential stability advantages. In contrast, although horizontal capsular shifts have been reported to notably reduce recurrence rates from 18% to 4%,¹¹ they come with inherent limitations. Specifically, these horizontal shifts might limit external rotation, which could be less ideal for certain patient groups or specific activity demands. Furthermore, a rotator interval closure, whether performed open or arthroscopically, has proven effective in reducing recurrent instability when complemented with a previous Latarjet procedure.¹⁹ It should be noted that the choice between open and arthroscopic methods depends on the surgeon's expertise and the specific clinical scenario.

Patient-Related Risk Factors

Recurrent instability after the Latarjet procedure can be influenced by patient-related risk factors. Giacomo et al²⁰ have shown that patients with atraumatic instability are more likely to experience recurrent instability after the Latarjet procedure compared with those with a traumatic mechanism of injury. Similarly, patients with bilateral shoulder instability have a higher risk of recurrent instability. Addressing initial incomplete diagnoses, such as those of posterior instability or associated lesions including superior labrum from anterior to posterior tear or posterior labral tears, is essential in preventing recurrent instability.

Overall, a comprehensive understanding of the factors contributing to recurrent instability after the Latarjet procedure is necessary to optimize treatment outcomes and reduce the risk of complications.

Diagnoses

Patient Evaluation

In diagnosing a failed Latarjet procedure, the root cause must be identified. Determining whether the patient suffers from instability or other complications such as pain, weakness, a subjective sense of failure, or stiffness aids in distinguishing genuine instability failure from other conditions. A detailed patient assessment should begin with a comprehensive history and physical examination. Inquiries about symptoms and previous treatments are crucial. Further investigation using imaging studies such as X-rays, CT scans, and MRI might be needed. Potential reasons for the procedure's failure often stem from incomplete diagnoses, which can include posterior instability that might emerge from factors such as bidirectional instability or incidental posterior labral tears. Furthermore, considerations such as multidirectional instability, global labral pathologies, or inadequately managed off-track Hill Sachs lesion should be thoroughly evaluated. Using the Latarjet procedure to address anterior instability events with bone loss can sometimes exacerbate posterior symptoms, underscoring the need for comprehensive preoperative assessment to preempt and manage potential complications.²⁰

Detailed History and Physical Examination

Understanding the nature of the instability episode is vital, whether it results from a minor event during daily activities or a notable event requiring reduction. The arm's position during the episode and motions avoided to prevent apprehension should also be explored. These details provide critical insights into the type and direction of instability. The reason for the primary bony block procedure, either as the initial procedure or secondary to a failed soft-tissue Bankart repair, is essential.

Reviewing previous surgical reports and arthroscopic images may help understand the techniques used, fixation construct, and any accompanying osseous or chondral damage during the initial procedure. Comparing the affected shoulder to the contralateral shoulder in resting position, range of motion, and strength is an important part of the physical examination. Deficits in motion may indicate chondrolysis, hardware impingement, or capsulolabral complex overtightening. In addition, the engagement of a notable Hill-Sachs lesion with the anterior glenoid rim could lead to persistent pain, limited range of motion, and a heightened risk of recurrent instability. Strength loss, on the other hand, might signal concurrent rotator cuff pathology or neurapraxia.

Patients older than 40 should be assessed for rotator cuff function and strength because of the higher incidence of rotator cuff tears linked with traumatic anterior instability events. It is essential to rule out multidirectional instability. The sulcus test, apprehension/relocation tests,²¹ and the load and shift test can be used to understand and quantify the instability.²² Hyperextension of the elbows, knees, and metacarpophalangeal joints, the ability to approximate the thumbs to the forearm, and hyperflexion of the lumbosacral spine can be checked using the Beighton hypermobility score.²³

Imaging

Proper use of imaging is necessary to understand the nature of the failed instability surgery and detect other possible pathologies. Standard imaging includes three views shoulder series with a Grashey true AP, lateral scapular, and axillary views. Additional views such as West Point, Bernageau, and Stryker notch or internal rotation AP are valuable in assessing glenoid and humeral bone loss.²⁴

Advanced imaging using CT scans can precisely define humeral and glenoid lesions, graft position, and the extent of bone loss.²⁴ In cases of failed Latarjet procedures, CT images can reveal graft size, location, union of the graft, hardware used, and the presence of previous anchors with or without secondary fracture lines.²⁵ Three-dimensional CT imaging with humeral head subtraction is recommended to study and quantify glenoid bone loss potential for engagement²⁶ (Figure 1).

Figure 1.

Imaging of a 28-year-old man with recurrent instability treated with the Latarjet procedure. A and (B), CT cuts illustrating screw migration, loosening, breakage, and joint penetration. C, 3D CT displaying severe degenerative changes.

Magnetic resonance arthrogram is critical for evaluating missed or accompanying soft-tissue pathology that may have led to the procedure's failure. It is primarily used to identify extensive labral lesions, humeral avulsion of the glenohumeral ligament lesion, capsular laxity or tears, and rotator cuff tears, particularly in older patients. Recognizing and diagnosing these pathologies using magnetic resonance arthrogram can assist in improved surgical planning and outcomes. A summary of clinical and radiological findings after a failed Latarjet procedure is provided in Table 1.

Table 1.

Summary of Key History, Physical Examination, and Imaging Findings in Patients With Failed Bony Block Surgery

Category	Summary of Key History, Physical Examination, and Imaging Findings in Patients With Failed Bony block Surgery
History	Assess for the type of failure (subluxation versus dislocation)
	Assess for frequency of instability events
	Assess for the number and nature of previous surgeries
	Analyze previous surgical reports, arthroscopic photos, or imaging
	Hand dominance
	Level of activity
	Type of sport (contact versus noncontact)
	Occupation
	Symptoms of instability during sleep, activities of daily living, and during mid-range of motion (indicates bone loss)
Physical examination	Assess instability at mid-range of motion (bone loss)
	Sulcus sign (multidirectional instability)
	Generalized ligamentous hyperlaxity using beighton score
	Associated pathologies (rotator cuff injury, biceps tendon etc.)
	Neurovascular status (musculocutaneous, axillary, suprascapular nerves)
Imaging	Previous imaging
	Plain radiographs: •Understand the type of failure, graft nonunion, hardware failure, technical failure etc. •Subtle bone loss •Presence of arthritis
	CT scan with 3D reconstruction with humeral head subtraction to assess: •Location and union of the graft •Quantify glenoid and humeral bone loss •Calculate off-track lesions
	MRI can be helpful in assessing associated soft-tissue pathology: •Extension of labral lesion posteriorly or pan-labral pathology •Presence of HAGL lesion •Capsular tears or laxity •Rotator cuff tears •Biceps tendon •Chondral damage

Revision Complexities of a Failed Latarjet Procedure

The management of recurrent instability after a failed Latarjet procedure can be challenging and requires a technically demanding salvage procedure. The indication for the primary procedure should be evaluated, and the scar tissue from previous surgery, previous hardware, and changes in neurovascular anatomy to prevent complications during revision. Recent literature highlighted the importance of understanding changes in the neurovascular anatomy when performing a second procedure.^27,28 The musculocutaneous and axillary nerves can move inferior and medial to the anterior glenoid rim, which can make dissection and retraction challenging. Laprade et al²⁸ conducted a cadaveric study to measure the distance between the neurovascular structures and the coracoid tip at 3- and 6-o'clock positions following the Latarjet procedure. The study found that the axillary and musculocutaneous nerves can be as close as 19.8 and 20.2 mm, respectively, to the medial side of the coracoid tip after the Latarjet procedure, which is much closer than the commonly cited ‘safe zone’ of 5 cm from the coracoid tip before the procedure.²⁸ Therefore, surgeons must be meticulous when dissecting or placing retractors to the glenoid's medial or inferior planes to avoid injuring these nerves during the revision surgery. A summary of perioperative and postoperative complications with appropriate methods for prevention and treatment is shown in Table 2.

Table 2.

Summary of Intraoperative and Postoperative Complications, Symptoms/Timing, and Prevention/Treatment

Complication	Symptoms/Timing	Prevention/Treatment
Graft related 1-Malposition of graft: a-Lateral position b -Medial position 2- Graft lysis 3- Graft fracture	Pain related to DJD Postoperative Recurrent instability Postoperative Asymptomatic Postoperative Intraoperative	Mild to mod revision of graft Distal tibia or ICBG severe consider arthroplasty Revision distal tibia or ICBG remplissage on/off track Observation Graft size/screws fixation
Soft-tissue (graft in appropriate position) Soft-tissue Laxity	Recurrent instability Postoperative	Soft-tissue procedure Bankart Capsular shift +/− remplissage for off track lesion
Neurological Axillary/Musculocutaneous	Deltoid or biceps intraoperative	Meticulous dissection/EMG and imaging/treatment dependent on the lesion or observation for recovery
Infection	Postoperative	Irrigation and débridement +/− preservation of graft

ICBG = iliac crest bone graft

Treatment Options and Outcomes

Several approaches and procedures have been detailed for the surgical management of recurrent instability after a failed Latarjet procedure. Soft-tissue procedures may be suitable for patients lacking notable bone loss or in instances of multidirectional instability. For cases exhibiting osseous deficiency, autogenous or allogeneic bone grafting options are available to address glenoid bone loss.

Soft-Tissue Procedures

Arthroscopic soft-tissue stabilization can be a viable treatment option for a selected patient population after a failed Latarjet procedure, particularly those with well-preserved bone stock. Radiographic evaluation should be performed to detect any newly developed bone loss. The arthroscopic approach can address various soft-tissue pathologies that contribute to recurrent instability after a failed Latarjet procedure. This approach can also avoid dissection in front of the glenoid, potentially minimizing the risk of neurovascular injury (Figure 2).

Figure 2.

Radiographs showing the recurrent instability after a Latarjet procedure in a contact athlete. A, CT scan depicting the coracoid bone block union and Hill-Sachs lesion. B, Arthroscopy showing healed bone block and soft-tissue laxity. C, Double row repair and arthroscopic capsular shift technique. D, A remplissage procedure for the Hill-Sachs lesion.

Boileau et al²⁹ conducted a study that involved 12 patients who had a failed Latarjet procedure and recurrent instability. These patients underwent arthroscopic Bankart repair with additional inferior capsular plication or rotator interval closure, in cases of excessive inferior and anterior laxity, respectively. The authors reported a low recurrence rate of 5% (1 patient) over an average follow-up of 43 months.²⁹

Similarly, the study by Lavoué et al³⁰ included 34 patients who underwent arthroscopic Bankart repair with or without Hill-Sachs remplissage stabilization after a failed Latarjet procedure. The authors reported a recurrence rate of 12% (5 patients), with four cases of subluxation and one case of dislocation, over an average follow-up period of 73 months. Two of the patients with recurrent instability required a second bony procedure.³⁰

Capsular reconstruction was also described after a failed Latarjet procedure for patients with a stretched capsule or multidirectional instability.³¹ Cuellar et al³¹ performed an arthroscopic capsular plication for 12 patients with recurrent instability after a failed Latarjet procedure. The authors reported a high incidence of capsular redundancy and Hill-Sachs lesions. At a mean follow-up of 2 years, no patient experienced recurrent instability. The high incidence of capsular redundancy was attributed to the omission of capsular plication during the primary Latarjet procedures, especially in patients with hyperlaxity.

Similarly, Castagna et al³² conducted a study to evaluate the outcomes of capsulorrhaphy with or without capsular plication in patients who experienced recurrent instability after a failed Latarjet procedure. The authors reported that 18 patients underwent the procedure, and at a mean follow-up of 69 months, three patients had recurrent dislocations (16.7%).³² Despite the recurrence rate, the authors noted that the functional outcomes were satisfactory in most patients.

Overall, the findings suggest that arthroscopic soft-tissue stabilization may be a useful addition to the Latarjet procedure in patients with hyperlaxity to prevent recurrent instability. However, further studies are needed to determine the long-term outcomes and potential complications of these procedures.

Glenoid Bone Grafting

Autografts

Eden and Hybinette are credited with performing the first free autologous bone grafting on the anterior glenoid rim in 1918,^33,34 where they positioned an iliac crest bone graft (ICBG) under the anterior glenoid periosteum without further fixation. Later modifications added rigid screws to the graft.³³ The primary advantage of ICBG is its capacity to reconstruct a large glenoid bone defect and shape the graft to match the contour of the anterior glenoid surface. However, it is biomechanically less advantageous than the Latarjet procedure, which uses the sling effect of the conjoined tendon.³⁵ Despite this, ICBG has been successfully used as a revision method after a failed Latarjet procedure with favorable outcomes.

Lunn et al³³ conducted a study to evaluate the outcomes of a modified Eden-Hybinette procedure in 34 patients who had recurrent instability after a failed Latarjet procedure. Most patients in their study reported good to excellent satisfaction at a mean follow-up of 7 years, which may suggest that this procedure could be a viable option for patients who have had a failed Latarjet procedure. The low rate of recurrent dislocations reported in their study is also promising because only four patients had recurrent dislocations (11%). Rouxel et al³⁴ reported the outcomes of 17 patients who underwent a modified Eden-Hybinette procedure after a failed Latarjet procedure and reported no recurrent dislocations. Similarly, Flurin et al³⁶ reported that 86% of their patients did not experience recurrent dislocations and 80% were satisfied with the procedure at a follow-up of 3.2 years. It is important to note that these studies were conducted on a relatively small number of patients, and their results may not be generalizable to the larger population.

An arthroscopic Eden-Hybbinette procedure for the treatment of a failed Latarjet procedure has also been described. Giannakos et al³⁷ studied 12 patients who underwent an all-arthroscopic Eden-Hybinette procedure after a failed Latarjet procedure. The study reported an average follow-up of 28 months and found that none of the patients experienced recurrent dislocations, although two patients did experience persistent subluxations. Similarly, Boileau et al³⁸ followed a group of patients for an average of 21 months after surgery and found that one of seven patients experienced recurrent instability. Martínez-Catalán et al³⁹ focused on the outcomes of 17 patients who underwent an arthroscopic Eden-Hybinette procedure and capsular advancement after a failed Latarjet procedure. The study followed these patients for an average of 3 years and found that the rate of recurrent instability was 11.7%. One patient in the study required revision surgery, which represented 5.8% of the study population. Although the results are promising, it is important to note that the all-arthroscopic Eden-Hybinette procedure is technically challenging and may not be suitable for all patients.

Although autogenous ICBG can be effective in regaining stability, it has some limitations. One potential drawback is that the absence of articular cartilage in the graft can increase the risk of postoperative osteoarthritis. In addition, the nonanatomic nature of the graft may also contribute to this risk. Although no long-term follow-up studies on the use of ICBG after a failed Latarjet procedure, short- and mid-term follow-up studies have shown that osteoarthritic changes can occur in up to 50% of patients. This indicates a considerable risk of developing osteoarthritis after this type of surgery, particularly in revision surgeries accompanied by repeated dislocations.^{33,34,35,36,37,38,39} Furthermore, bone graft resorption remains a notable concern and may occur to various extents. However, its effects in revision cases are less documented, largely because of the lack of long-term studies, emphasizing the necessity for further research to understand its full impact.

The distal clavicle autograft (DCA) is a potential option for providing an anatomical source of bone and cartilage to replace bone loss on the glenoid. Compared with allografts, a DCA is cost-effective, locally available, and carries a lower risk of infection. Biomechanical studies have also suggested that a DCA can be an effective option for restoring bone loss on the glenoid.⁴⁰ These studies have suggested that a DCA has the potential to markedly increase the radius of the glenoid, theoretically allowing for the restoration of bone loss approaching up to 50% of the glenoid width, although achieving such a substantial restoration may be technically challenging and is not consistently anticipated in every case.⁴⁰ This is compared with the coracoid graft, which can restore an average of 33% of bone loss.⁴⁰ Tokish et al⁴¹ and Hassebrock et al⁴² have both described arthroscopic techniques for reconstructing a deficient glenoid using a DCA fixed to the glenoid with screws or suture anchors. However, these reports are based on technical notes rather than clinical studies, and there is a lack of available evidence to validate the initial promising biomechanical reports.

Allograft

The use of allografts for restoring the glenoid surface in cases of recurrent shoulder instability after a failed Latarjet procedure has been described in the literature. Allografts are advantageous because they can fill large bony defects without causing donor-site morbidity. Various allograft donor sites have been proposed, including the distal part of the tibia, the glenoid, the femoral head, and the humeral head.^43,44

The use of fresh lateral distal tibial allografts is particularly advantageous because of their osteochondral nature, which matches the curvature of the humeral head throughout the range of motion. In addition, the dense weight-bearing subchondral bone stock of the tibia provides greater biomechanical properties compared with other bony augmentation procedures.^43,44 This makes fresh lateral distal tibial allografts an ideal choice for restoring the glenoid surface in cases of recurrent shoulder instability after a failed Latarjet procedure (Figure 3).

Figure 3.

A failed Latarjet procedure with recurrent dislocation. A, AP radiograph (B) CT scan showing bone block lysis and inappropriate position. C, Clinical photograph. D, Radiograph demonstrating the implemented distal tibial allograft and remplissage procedure for the off-track humeral lesion.

Provencher et al⁴³ conducted a study involving 31 patients who received a fresh lateral distal tibial allograft after a failed Latarjet procedure. The patients were followed up for an average of 47 months, during which no cases of recurrent instability were reported. The authors also reported excellent patient-reported outcome scores and a 92% union rate of the allograft based on CT imaging analysis. However, despite the initial positive outcomes reported by Provencher et al,⁴³ more clinical and radiographic studies with longer follow-up duration are needed to evaluate and confirm the long-term success of the fresh distal tibial allograft. In addition, several limitations associated with the use of allografts exist, including the risk of disease transmission, prohibitive cost, and low viability of chondrocytes. A summary of the advantages and disadvantages of the different graft options is shown in Table 3.

Table 3.

The Advantages and Disadvantages of Bone Graft Options

Bone graft	Advantages	Disadvantages
Iliac crest autograft	Can fill large osseous defect outcomes similar to the Latarjet procedure Cost-effective	Donor-site morbidity
		No articular cartilage
Distal part of clavicle autograft	Osteochondral Can fill large bone defect Cost-effective	Donor-site morbidity
Fresh lateral distal part of tibia allograft	Osteochondral Match the radius of curvature with humeral head Can fill large bone defect No donor-site morbidity	Allograft No articular cartilage Expensive
Glenojet (allograft)	Preshaped, predrilled Less surgical time Can fill large bone defect No donor-site morbidity	Allograft No articular cartilage Expensive

Authors' Preferences for Surgical Treatment

Our current treatment algorithm for recurrent instability after a failed Latarjet procedure includes an initial history and physical examination, complemented by a CT scan to assess graft healing, reabsorption, and position. In the event of graft malposition or inadequacy, we prefer performing a bone graft procedure, ideally using a fresh distal tibial allograft. If an allograft is not accessible, an ICBG through a modified Eden-Hybinette procedure is our second choice. For patients presenting off-track lesions on the humeral head, a remplissage procedure is undertaken. If the coracoid has healed in an optimal position without notable bone loss, recurrent instability is addressed with a Bankart soft-tissue procedure, incorporating a remplissage procedure for an off-track lesion on the humeral head. However, specific treatment strategies may vary based on individual patient factors and surgeon preferences, and thus, this algorithm serves as a general guideline, not a definitive treatment plan for all cases of recurrent instability after a failed Latarjet procedure.

Summary

Addressing recurrent instability after a failed Latarjet procedure is a challenging endeavor that necessitates a technically demanding salvage procedure. First, discerning the underlying reasons for the initial Latarjet procedure's failure is paramount. Recurrent instability can arise from factors such as implant malposition, bone graft nonunion, or capsular laxity. Accurately diagnosing these causes guides the selection of suitable management strategies. Depending on the cause of failure, patient-specific factors, and the surgeon's experience, surgical options for managing recurrent instability after a failed Latarjet procedure may include bone graft reconstruction or soft-tissue procedures. Soft-tissue procedures can be considered for patients without notable bone loss or with multidirectional instability, whereas bone grafting procedures serve as effective solutions for those with substantial bone loss. Autografts can be sourced from the iliac crest or distal clavicle, whereas allografts can be obtained from the femoral head, glenoid, humeral head, or distal tibia.