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Latarjet procedure versus iliac crest autograft transfer for anterior shoulder instability: a systematic review and meta-analysis of comparative studies

Journal of Orthopaedic Surgery and Research volume 20, Article number: 119 (2025) Cite this article

Abstract

Background

Anterior shoulder instability with glenoid bone loss presents a challenge in orthopedic surgery. The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are commonly employed for its management, but direct comparative evidence is insufficient.

Methods

Following PRISMA guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Randomized controlled trials (RCTs) and cohort studies directly comparing the Latarjet and ICBGT procedures were included. Primary outcomes included postoperative recurrent instability, apprehension test, and complications, while secondary outcomes comprised Rowe score, Subjective Shoulder Value (SSV), pain level assessed by visual analogue scale (VAS), range of motion (ROM), and radiologic outcomes. Quality assessment was performed using RoB2 and MINORS tools. The weighted mean difference (WMD) for continuous variables and odds ratio (OR) for dichotomous variables were calculated, along with 95% confidence intervals (CIs). Meta-analysis was performed using RevMan 5.4.1 software.

Results

A total of 6 studies with 409 patients were included. There was no significant difference in postoperative recurrent instability (OR, 1.33; 95% CI, 0.44 to 4.03; P = 0.61), positive apprehension test (OR, 0.78; 95% CI, 0.20 to 3.10; P = 0.73), revision surgery (OR, 2.06; 95% CI, 0.74 to 5.71; P = 0.16), mild complications (OR, 0.49; 95% CI, 0.23 to 1.06; 0.07), SSV (WMD, -1.94; 95% CI, -3.94 to 0.06; P = 0.06) or VAS score (WMD, 0.15; 95% CI, -0.17 to 0.47; P = 0.36) between the two procedures. The ICBGT group exhibited statistically superior Rowe scores (WMD, -3.10; 95% CI, -5.10 to -1.10; P = 0.002), as well as improved external (WMD, -5.32; 95% CI, -7.30 to -3.30; P < 0.001) and internal rotation (WMD, -5.11; 95% CI, -6.76 to -3.45; P < 0.001). However, these differences did not surpass the minimal clinically important difference (MCID). Radiological evaluations showed that the ICBGT procedure had statistically better outcomes in immediate glenoid augmentation, preservation and reduced fatty degeneration of the subscapularis (SSC) tendon, and graft remodeling at short-term follow-up.

Conclusions

The ICBGT procedure showed statistically superior Rowe scores and range of motion, but these differences may not be clinically significant. Both procedures had comparable outcomes in recurrent instability, apprehension test results, revision surgery, mild complications, SSV, and pain levels. ICBGT appears to offer advantages in glenoid augmentation and SSC preservation at short-term follow-up.

PROSPERO registration ID

CRD42024586157.

Background

Anterior shoulder instability with substantial glenoid bone loss remains a challenge for shoulder surgeons [1]. In cases of anterior shoulder instability with at least13.5% glenoid bone loss, soft tissue procedures have demonstrated unsatisfactory outcomes, necessitating the implementation of bone grafting techniques to restore glenoid anatomic structures and joint stability [2,3,4].

The two main bone grafting techniques are coracoid transfer techniques and free bone grafting techniques [5, 6]. The modern Latarjet procedure is the most commonly performed coracoid transfer technique, which involves the transfer of the coracoid process and attached conjoined tendons to the anterior glenoid rim [7]. This procedure primarily stabilizes the shoulder through the combined effects of the bone block and sling [8, 9], demonstrating low recurrence rates and favorable return-to-sports outcomes, particularly among overhead athletes [10,11,12,13]. Although most studies report relatively low complication rates, some research indicates that complications following both open and arthroscopic Latarjet procedures can occur at rates as high as 30%, with common issues including screw and graft problems, limited range of motion (ROM), shoulder dyskinesia, neurovascular injury, and secondary osteoarthritis [14,15,16,17,18]. Furthermore, the Latarjet procedure, particularly the arthroscopic approach, has a steep learning curve and increased complexity in revision surgery [19, 20].

Some proposed glenoid reconstruction with a free bone grafting as a potential alternative to the Latarjet procedure or as a salvage option following failed Latarjet surgeries [21,22,23]. A commonly used free bone grafting technique is the iliac crest bone graft transfer (ICBGT), also known as the modern Eden-Hybinette procedure [24,25,26]. The ICBGT involves harvesting a bone graft from the iliac crest and transplanting it to the anterior glenoid rim, primarily stabilizing the shoulder by restoring glenoid concavity without the sling effect [27, 28]. The ICBGT procedure has shown great clinical outcomes, with advantages including less soft-tissue damage, easy graft preparation, better outcomes for rotation, and preservation of the integrity of the subscapularis (SSC) tendon [24, 25, 29,30,31,32,33]. Drawbacks mainly include donor-site complications, graft resorption, and the minimal risk of disease transmission [26, 34].

Although some studies have reported comparable clinical outcomes between the Latarjet procedure and free bone grafting techniques, evidence directly comparing the Latarjet and ICBGT procedures showed conflicting results [22, 35]. The comparison between these two procedures is still debated, and a systematic review and meta-analysis of comparative studies is lacking.

The primary objective of this study is to perform a comprehensive systematic review and meta-analysis of existing studies which directly comparing the Latarjet procedure and ICBGT for the management of shoulder instability with glenoid bone loss. The hypothesis is that ICBGT would demonstrate comparable clinical outcomes but fewer complications compared to the Latarjet procedure.

Methods

Literature search

This systematic review and meta-analysis strictly adhered to the requirements outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [36]. The study was preregistered in The International Prospective Register of Systematic Reviews (PROSPERO) under the registration ID CRD42024586157. Two independent reviewers conducted a comprehensive search of the PubMed, EMBASE, Cochrane Library, and Web of Science databases, including records up to September 10, 2024. The main search phrases utilized were as follows: (“Latarjet” OR “Bristow” OR “coracoid Transfer”) AND (“iliac crest bone” OR " iliac bone” OR “J-bone” OR “J-shaped” OR “free bone”) AND (“anterior shoulder instability” OR “shoulder instability” OR “glenohumeral instability” OR “recurrent shoulder instability” OR “shoulder dislocation” OR “recurrent shoulder dislocation”). Any discordance encountered during the search was resolved through consultation with a third researcher.

Inclusion and exclusion criteria

Inclusion criteria

(1) patients included had a confirmed diagnosis of anterior shoulder instability with recurrent dislocations (≥ 2); (2) randomized controlled trials (RCTs), cohort studies, and case-control studies; (3) Latarjet procedure and ICBGT were directly compared.

Exclusion criteria

(1) presence of other shoulder conditions such as rotator cuff injury, infection, tumor, and severe osteoarthritis; (2) any previous shoulder surgery except for shoulder stabilization procedures; (3) posterior or multidirectional shoulder instability; (4) neuromuscular diseases including seizure disorders; (5) not written in English.

Data extraction

Two researchers independently extracted data from the included studies, with any disagreements resolved by a third author. We communicated with the authors of the studies to obtain supplementary information as needed. The extracted information included first author, year of publication, country where the study was conducted, level of evidence (LOE), sample size, patient demographic data (mean age, gender), preoperative glenoid defect, follow-up periods, surgical details, and rehabilitation protocols.

The primary outcomes included recurrent instability, a positive apprehension test, revision surgery, and mild complications. Recurrent instability was defined as any postoperative subluxation or dislocation, regardless of whether additional surgical intervention was required. Revision surgery was defined as a further procedure necessitated by postoperative complications directly related to the initial surgery, such as recurrent dislocations, and screw-related problems. Mild complications referred to postoperative events attributed to the surgery that caused discomfort, inconvenience, or temporary functional limitations, typically resolving on their own or with non-invasive treatment.

Secondary outcomes were Rowe score, Subjective Shoulder Value (SSV), pain level assessed by visual analogue scale (VAS), range of motion (ROM), and radiologic outcomes at final follow-up. The minimal clinically important difference (MCID) for Rowe score was determined as a minimum of a 9.7-point change in Rowe score [37, 38], 12.1-point change in SSV [39], 1.1-cm change (on a 10-cm scale) in VAS [40], and a minimum of a 10-degree change in ROM [41].

Quality assessment

Two researchers independently assessed the methodological quality of the included studies using the revised Cochrane Risk of Bias 2 (RoB2) tool for RCTs [42], and the Methodological Index for Non-Randomized Studies (MINORS) for cohort studies and case-control studies [43]. Any discrepancies among authors were resolved through thorough discussion and subsequent review by a third investigator. Assessment for publication bias was omitted due to the number of studies included in this field is fewer than ten, as recommended by the Cochrane Handbook.

Statistical analysis

Statistical evaluations were conducted using Manager V.5.4.1 (The Cochrane Collaboration, Software Update, Oxford, UK). We calculated the weighted mean difference (WMD) and pooled odds ratio (OR) with corresponding 95% confidence intervals (CIs) to assess continuous variables and dichotomous variables, respectively. Heterogeneity among studies was assessed using Cochrane’s Q statistics and I2 statistics, with I2 < 50% considered acceptable heterogeneity and a fixed-effect model applied. When I2 > 50% or not applicable, a random-effects model was applied. We adopted forest plots to visualize the pooled effect sizes. P values less than 0.05 were considered statistically significant.

Results

Characteristics of the included studies

A total of 307 studies were initially identified after the searches in PubMed, EMBASE, The Cochrane Library, and Web of Science. After removing 235 duplicate studies, the titles and abstracts of the remaining 72 publications were screened. Subsequently, 62 studies were further discarded, and the full texts and references of 10 articles were reviewed for eligibility. Two case series and one conference poster were eliminated. Finally, a total of 6 studies [35, 44,45,46,47,48] were included (Fig. 1). Table 1 outlines the characteristics of these included studies. The surgical details and rehabilitation protocols of the included studies are presented in Table 2.

Table 1 Characteristics of the included studies
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Table 2 Surgical detail and rehabilitation protocol
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Table 3 Quality assessment of the non-RCT studies using the Methodological Index for Non-randomized studies (MINORS) criteria
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Fig. 1
figure 1

PRISMA flow chart of literature retrieval

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Quality assessment

The quality assessment of the included RCTs used the revised ROB-2 tool, as depicted in Fig. 2. Cohort studies were evaluated for quality using the MINORS criteria, the results of which are presented in Table 3.

Fig. 2
figure 2

Risk of bias graph (A) Graph of the risk of bias summary for the included studies; (B) Graph of the risk of bias for each included study

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Recurrent instability and positive apprehension test

Four [35, 46,47,48] studies reported the rates of recurrent instability. The Latarjet group (8/149, 5.4%) and the ICBGT group (5/127, 3.9%) demonstrated comparable rates of recurrent instability (OR, 1.33; 95% CI, 0.44 to 4.03; I2 = 0%; P = 0.61) (Fig. 3A).

Two [35, 47] studies reported postoperative apprehension test outcomes. The Latarjet group exhibited 4 cases with a positive postoperative apprehension test (4/50, 8%), while the ICBGT group had 5 cases (5/50, 10%). No significant difference was observed between the two groups (OR, 0.78; 95% CI, 0.20 to 3.10; I2 = 0%; P = 0.73) (Fig. 3B).

Fig. 3
figure 3

Meta-analysis of rates of (A) recurrent instability and (B) positive apprehension test

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Revision surgery

Five [35, 44, 46,47,48] studies reported the rates of revision surgery. There was no statistically significant difference between the Latarjet group (12/169, 7.1%) and the ICBGT group (4/147, 2.7%) (OR, 2.06; 95% CI, 0.74 to 5.71; I2 = 0%; P = 0.16) (Fig. 4).

Fig. 4
figure 4

Meta-analysis of revision surgery rates

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Mild complications

Five [35, 44, 46,47,48] studies reported mild complications. No statistically significant difference was observed between the Latarjet group (13/169, 7.7%) and the ICBGT group (22/147, 15.0%) (OR, 0.49; 95% CI, 0.23 to 1.06; I2 = 0%; P = 0.07) (Fig. 5).

Fig. 5
figure 5

Meta-analysis of mild complications rates

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Functional scores

Four [35, 44, 46, 48] studies reported postoperative Rowe scores. The Latarjet group exhibited statistically lower Rowe scores compared to the ICBGT group (WMD, -3.10; 95% CI, -5.10 to -1.10; I2 = 4%; P = 0.002) (Fig. 6A). However, this difference did not meet the MCID for Rowe score.

Three [35, 46, 48] studies reported postoperative SSV. No statistically significant difference was found between the two groups (WMD, -1.94; 95% CI, -3.94 to 0.06; I2 = 4%; P = 0.06) (Fig. 6B).

Fig. 6
figure 6

Meta-analysis of functional scores: (A) Rowe score and (B) SSV

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Pain level

Two [35, 46] studies reported postoperative VAS score. There was no significant difference between the two groups (WMD, 0.15; 95% CI, -0.17 to 0.47; I2 = 0%; P = 0.36) (Fig. 7).

Fig. 7
figure 7

Meta-analysis of VAS score

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ROM

Three [35, 44, 48] studies reported postoperative external rotation and internal rotation at 90 degrees abduction. Compared to the ICBGT group, the Latarjet group had statistically reduced external rotation (WMD, -5.32; 95% CI, -7.30 to -3.30; I2 = 0%; P < 0.001) (Fig. 8A) and internal rotation (WMD, -5.11; 95% CI, -6.76 to -3.45; I2 = 0%; P < 0.001) (Fig. 8B). However, these differences did not meet the MCID for ROM.

Fig. 8
figure 8

Meta-analysis of ROM: (A) external rotation and (B) internal rotation at 90 degrees abduction

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Radiologic outcome

Three [35, 45, 47] studies reported postoperative radiologic outcomes.

Moroder et al. [35]’s immediately postoperative computed tomography (CT) scans revealed a significantly enhanced postoperative glenoid augmentation effect associated with the ICBGT group, with increased surface area (P = 0.001), reduced defect area (P = 0.003), expanded diameter (P = 0.009), greater depth (P = 0.034), and heightened retroversion (P = 0.002) compared to the Latarjet group. However, over the 12-month and 24-months follow-up periods, only a lower defect area was observed in the ICBGT group (P = 0.023 and P = 0.030, respectively), while all other parameters demonstrated no statistically significant differences between the two groups.

Siegert et al. [45]’s postoperative CT scans at over 12-month follow-up revealed notable differences between the Latarjet and ICBGT groups concerning SSC fatty muscle infiltration. The Latarjet group exhibited a significant increase (5.3% ± 4.5% vs. 2.3% ± 1.7%; P = 0.001), despite comparable preoperative levels. Moreover, a subset of Latarjet patients (15.4%) experienced progression from Goutallier grade 0 to grade 1, contrasting with stability in the ICBGT group. Additionally, the Latarjet group displayed a substantially elevated rerouting angle of the SSC muscle compared to the ICBGT group at follow-up (11.8° ± 2.1° vs. 7.5° ± 1.3°; P < 0.001), positively correlating with fatty muscle infiltration (R = 0.447; P = 0.008). Furthermore, while SSC/infraspinatus tendon thickness ratios were initially similar between groups, they were significantly lower in the Latarjet group at follow-up (0.7 ± 0.3 vs. 1.0 ± 0.2; P < 0.001).

In the study by Elwan et al. [47], radiographic evaluation was performed using CT scans after a minimum of six months post-surgery for all patients. The ICBGT group demonstrated superior performance compared to the Latarjet group across various parameters. Specifically, the ICBGT showed significant advantages in surface area (P = 0.02), defect area (P = 0.003), diameter (P = 0.009), depth (P = 0.034), and retroversion (P = 0.002). Prior to surgery, 83% of ICBGT patients and 68% of Latarjet patients exhibited off-track Hill-Sachs lesions (P = 0.206). After surgery, only 14% of ICBGT patients and 28% of Latarjet patients presented off-track abnormalities (P = 0.310).

Discussion

This systematic review and meta-analysis examined 409 patients to provide a comprehensive comparison between the Latarjet and ICBGT procedures. The main findings of this study are that there was no significant difference in postoperative recurrent instability, apprehension test, revision surgery, mild complications, SSV or pain level between the two procedures. The ICBGT group exhibited statistically superior Rowe scores, as well as improved external and internal rotation at 90 degrees abduction. However, these differences did not surpass the MCID. Radiological evaluations revealed several advantages associated with the ICBGT procedure. These includ a greater immediately postoperative glenoid augmentation effect, improved preservation and reduced fatty degeneration of the SSC, and superior graft remodeling observed at short-term (less than 24 months) follow-up.

To the best of our knowledge, this systematic review and meta-analysis represents the first attempt to directly compare the Latarjet and ICBGT procedures. A recent systematic review and meta-analysis of 70 studies [22], comprising a total of 4540 shoulders, investigated outcomes following 3917 shoulders undergoing the Latarjet procedure and 623 receiving free bone block stabilization. Results indicated no significant differences between the two procedures concerning the rates of recurrent instability, other complications, progression of osteoarthritis, or return to sports rates. Both procedures improved patient-reported outcomes, with a notably greater increase in American Shoulder and Elbow Surgeons score observed after free bone block procedures. However, this analysis only included two studies directly comparing the Latarjet procedure to free bone block procedures, one using distal tibial allograft transfer and the other employing ICBGT. The reliance on mostly case-series studies and the scarcity of direct comparisons limited the conclusions drawn from this previous systematic review and meta-analysis.

In contrast, our analysis included four RCTs [35, 44, 47, 48] and two retrospective cohort studies [45, 46] directly comparing the Latarjet and ICBGT procedures. Notably, the findings regarding postoperative instability in our study were consistent with those of the prior review [22]. This also mirrors the findings of prior clinical studies, which demonstrated a high rate of stabilization success for both procedures, even over the long term [10,11,12,13, 24, 25, 29,30,31,32,33, 49]. However, our study did not reveal clinical superiority of the ICBGT procedure over the Latarjet procedure in terms of patient-reported outcomes, pain levels, or ROM, despite certain statistically significant differences observed. Additionally, this study conducted a qualitative analysis of radiological outcomes based on three included studies, all of which used CT scans. These three studies indicated that the ICBGT procedure outperformed the Latarjet procedure in terms of glenoid augmentation and preservation of SSC structural integrity immediately post-surgery and during short-term follow-ups.

In this study, we performed separate analyses for revision surgeries and mild complications. Although no significant difference was observed between the two procedures in terms of revision surgeries or mild complications, a trend emerged showing a higher rate of revision surgeries (7.1% versus 2.7%) and a lower rate of mild complications (7.7% versus 15.0%) associated with the Latarjet procedure. The revision surgeries primarily involved issues with screws and grafts. These complications have been well-documented in the literature [14,15,16,17,18] and remain a key driver for the exploration of alternative fixation techniques, such as resorbable materials or suture buttons [50,51,52,53]. Regarding mild complications, most cases in the ICBGT group involved sensory abnormalities and discomfort around the donor site, which typically improved with time or non-invasive treatments. In contrast, the majority of cases in the Latarjet group were related to scapular dyskinesis, a phenomenon that has been extensively reported [54].

While the differences in ROM between the two procedures may not reach clinical significance, it is noteworthy that the Latarjet procedure demonstrated impaired recovery in both external and internal rotation compared to the ICBGT procedure. This finding aligns with prior studies [9, 55, 56]. Sinha et al. [56] showed a significant decrease in abduction, forward flexion, external rotation, and internal rotation following open Latarjet procedures, with no impact on muscle strength. Similarly, Caubère et al. [55] observed reduced internal and external rotation strength in patients who underwent open Latarjet procedures. Conversely, such loss of range of motion after the ICBGT procedure has not been widely reported by clinical studies. One explanation for the discrepancies in ROM could be the permanent split of the subscapularis by the conjoined tendon, leading to potential structural alterations or limitations in movement of the muscle and tendon. A biomechanical assessment in cadaveric models demonstrated a notable decrease in overall rotational capacity at 90 degrees of abduction when the conjoined tendon was loaded rather than unloaded [9]. Our analyses of radiological outcomes also support this hypothesis, as Siegert et al. [45] confirmed that the decrease in internal rotation capacity following the Latarjet procedure is radiographically associated with slight fatty degeneration and significant thinning of the SSC tendon during short-term follow-up.

Some have suggested that the Latarjet procedure is limited by the size of the coracoid graft, its ability to anatomically reconstruct glenoid defects, and a relatively high rate of graft resorption [57, 58]. In contrast, free bone block procedures like ICBGT offer better anatomical reconstruction by increasing glenoid depth and optimizing graft sizing based on preoperative measurements [59,60,61]. Our meta-analysis found that the ICBGT group generally showed superior short-term results in terms of glenoid surface area, defect size, and joint retroversion. While our analysis of radiological outcomes partially supports the potential superiority of ICBGT, several limitations, including variability in surgical techniques, a lack of standardized radiographic criteria, and insufficient long-term follow-up, prevent the conduction of a meta-analysis and the ability to draw more definitive conclusions. Although ICBGT appears to offer short-term advantages, the effects of graft resorption and long-term bone remodeling are still inconclusive. Further studies with standardized methods and extended follow-up are needed to establish clearer conclusions.

This study has several limitations. First, the number of available studies was limited due to the scarcity of directly comparative study designs in the literature. Second, although the patient cohorts in the two groups were well-matched, there were inevitable differences in important factors such as sports activity level, preoperative glenoid defect, surgical techniques, rehabilitation protocols, and follow-up durations across studies. Notably, the variability in surgical techniques could significantly influence the outcomes. In the Latarjet procedure, while all studies used screws, the management of the capsuloligamentous apparatus differed, which may impact clinical outcomes, particularly rotational function. Similarly, in the ICBGT group, four studies used screws for fixation, while two did not, potentially introducing bias, as screws can cause pain or conflict with the subscapularis tendon, affecting clinical results [53]. These variations in technique may limit the generalizability of the findings and warrant further investigation. Third, some studies employed the Latarjet or ICBGT procedure as primary treatments, while others used them for revision surgeries, which could affect outcomes due to prior stabilization procedures. Finally, a major limitation is the lack of a minimum follow-up period, as studies with less than 24 months of follow-up may underestimate complication rates, such as graft resorption and joint degeneration. Only two of the included studies reported outcomes beyond 24 months, highlighting the need for studies with longer follow-up.

Conclusions

The ICBGT procedure showed statistically superior Rowe scores and range of motion, but these differences may not be clinically significant. Both procedures had comparable outcomes in recurrent instability, apprehension test results, revision surgery, mild complications, SSV, and pain levels. ICBGT appears to offer advantages in glenoid augmentation and SSC preservation at short-term follow-up. However, due to the limited sample size and lack of long-term follow-up, these conclusions should be interpreted with caution.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

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Funding

This research was funded by the Science and Technology Plan Projects of Tibet Autonomous Region (XZ202201ZY0041G, XZ202403ZY0025), and Chengdu Medical Research Project (2024158).

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  1. Lang Li and Bofang Zeng contributed equally to this work.

Authors and Affiliations

  1. Department of Orthopedics, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People’s Republic of China

    Lang Li, Bofang Zeng, Sha Wan, Kefu Lin & Zhen Tian

  2. Department of Rehabilitation, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region (Hospital.C.T.), Chengdu, 610041, People’s Republic of China

    Meng Ding

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Contributions

LL conceived the idea; LL and BZ: screened the literature, extracted data, assessed the methodological quality of the enrolled studies and performed the data analyses; MD, SW, KL, and ZT: prepared the tables and figures. All authors contributed to the writing and revisions. All authors contributed to the review and editing of the manuscript. All authors have read and agreed to the published version of the manuscript.

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Li, L., Zeng, B., Ding, M. et al. Latarjet procedure versus iliac crest autograft transfer for anterior shoulder instability: a systematic review and meta-analysis of comparative studies. J Orthop Surg Res 20, 119 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13018-024-05425-0

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Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X