Shoulder and Elbow 2023, Jan, 09 | 12:00 am

Latarjet Procedure for Instability with Bone Loss

DEFINITION

Recognizing and properly addressing bone defects is crucial to achieving good surgical outcomes in shoulder instability.

One of the most important requirements for glenohumeral stability is a long congruent articular arc in which the humerus and glenoid remain in contact throughout motion. Loss of this congruent arc can occur from glenoid bone loss or defects in the posterior humeral head (ie, Hill-Sachs lesions) (FIGS 1 and 2).

We define glenoid bone loss requiring Latarjet as glenoid bone loss 25% or greater of the inferior glenoid diameter.

In the Latarjet procedure, the coracoid is transferred to the inferior glenoid and secured with two screws. As noted by Patte, the success of the Latarjet procedure can be attributed to the triple effect, which is composed of the following:

Lengthening of the articular arc by the bone graft The sling effect of the conjoined tendon

Tensioning of the lower subscapularis by means of the conjoined tendon in its new position (draped over the lower subscapularis)

 

 

 

FIG 1 • A. The anterior glenoid rim serves to “deepen the dish” of the glenoid and acts as a buttress to resist dislocation. B. A glenoid with bone loss has a decreased congruent arc with less resistance to shear forces and less resistance to obliquely applied off-axis loads. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC. Burkhart's View of the Shoulder: The Cowboy's Guide to Advanced Shoulder Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)

 

ANATOMY

 

In 1954, Latarjet14 described his technique for a coracoid bone graft to prevent anterior dislocation.

 

 

He detached the pectoralis minor from the coracoid, incised the coracoacromial ligament, left a stump of the coracoacromial ligament attached to the coracoid, then completed the osteotomy at the base of the coracoid so that it could be placed as a bone graft against the anterior glenoid neck.

 

The coracoid was passed through a split in the subscapularis and positioned so that its inferior surface was in contact with the anterior glenoid neck where it was secured with two screws (FIG 3). In doing so, the posterolateral surface of the coracoid was placed adjacent to the glenoid joint surface.

 

We call our surgical technique the congruent arc technique. This technique was first reported by Burkhart and DeBeer5 in 2000 and incorporated two important modifications:

 

 

The coracoid graft was rotated 90 degrees around its long axis so that the concave inferior surface of the coracoid became the extension to the glenoid concavity, providing

 

a much more anatomic articular arc to the reconstructed glenoid surface11 (FIG 4).

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FIG 2 • A. Normal relationship of the glenoid and humeral articular surfaces. B. Full external rotation still maintains contact between the humeral and glenoid articular surfaces. C. Large Hill-Sachs lesion creates an articular arc length mismatch. D. A small amount of external rotation will cause the Hill-Sachs lesion to engage the anterior corner of the glenoid. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC. Burkhart's View of the Shoulder: The Cowboy's Guide to Advanced Shoulder Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)

 

 

The capsule was reattached to the native glenoid by means of suture anchors so that the coracoid graft was extraarticular, thereby preventing abrasion of the humeral articular surface against the coracoid graft.

 

Use of the congruent arc technique, or the inferior aspect of the coracoid extending the glenoid, more closely restores normal glenohumeral contact forces compared to the posterolateral position described by

Latarjet.11

 

 

 

FIG 3 • Schematic of the French technique for Latarjet reconstruction. A. Sagittal and (B) axial schematics prior to Latarjet reconstruction. C,D. The coracoid is osteotomized, and the undersurface of the coracoid is fixed directly to the glenoid. The contour of the coracoid graft does not match the contour of the native glenoid. G, glenoid; H, humerus. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC, et al. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins, 2012.)

 

PATHOGENESIS

 

Bone lesions are present in up to 95% of patients with recurrent shoulder instability.10

 

Examining the glenoid alone, Sugaya et al19 reported that 90% of patients with recurrent instability have glenoid bone

 

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abnormalities (including bone loss or abnormal contour). Glenoid bone loss (distinct from abnormal contour alone) was seen in 50% of cases in over half of which the defect was greater than 5% of the glenoid width.

 

 

 

 

FIG 4 • Schematic of the Burkhart-DeBeer modification of the Latarjet reconstruction. A. Sagittal view demonstrates glenoid bone loss. The undersurface of the coracoid is shaded in blue. B. Following coracoid osteotomy, the graft is rotated 90 degrees so the undersurface of the coracoid is flush with the glenoid and

forms a continuation of the concave glenoid articular arc. The graft is secured with two screws. C. Axial view demonstrates how the orientation change (compared to the original French technique [FIG 3]) provides a contour that more closely matches the native glenoid concavity and also provides greater length extension of the articular arc. G, glenoid; H, humerus. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC, et al. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins, 2012.)

 

 

Yamamoto et al20 introduced the concept of the “glenoid track” to describe the interaction between glenoid bone loss and Hill-Sachs lesions.

 

 

When the arm is raised, the glenoid contact area shifts from the inferomedial to the superolateral portion of the posterior articular surface of the humeral head, creating a zone of contact (glenoid track) between the glenoid and the humeral head. An intact glenoid track results in bony stability.

 

 

In cases with 25% or greater glenoid bone loss, bony stability is always compromised and bony augmentation is required.

 

In cases with less than 25% glenoid bone loss, the “glenoid track” can be used to define the Hill-Sachs lesion as “on track” or “off track” and therefore determine the need for remplissage in addition to arthroscopic Bankart repair.

 

NATURAL HISTORY

 

In the setting of glenoid bone loss 25% or greater of the inferior glenoid diameter, recurrence following arthroscopic Bankart repair is 67% to 75%.3,5 In such cases, recurrence can be dramatically reduced by the Latarjet procedure in which the coracoid is transferred to the glenoid.

PATIENT HISTORY AND PHYSICAL FINDINGS

 

A thorough history is essential and should elicit the mechanism of injury and prior treatments received.

 

 

Previous operative reports should be obtained and reviewed; they often yield valuable information about areas of bone deficiency, tissue quality, and fixation devices used.

 

Essential components of the history include age, mechanism of dislocations, number of dislocations, position of shoulder during dislocation, reduction efforts (self- or physician reduced), hand dominance, sport and work requirements, prior treatments, and patient's goals.

 

The physical examination determines the position and direction of instability as well as identifies or eliminates factors that contribute to instability:

 

 

Muscle tone or wasting

 

Range of motion, active and passive

 

 

Strength assessment (rule out concomitant rotator cuf tear) Position of apprehension

 

Relocation relief

 

 

 

Direction of instability (load and shift test) Generalized ligamentous laxity Neurovascular examination

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Our evaluation for bone loss is based on preoperative and intraoperative assessments. We routinely obtain anteroposterior (AP), transscapular lateral, and axillary radiographs of the glenohumeral joint. Radiographs are evaluated on all patients for the presence of glenoid bone loss or a Hill-Sachs lesion.

 

Although plain radiographs can grossly demonstrate bone defects, the severity is often underestimated. We therefore obtain a computed tomography (CT) scan with threedimensional (3-D) reconstructions on all individuals with suspected bone loss. Additionally, we have a low threshold

 

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for obtaining a CT in patients without plain radiographic evidence of bone loss but otherwise have risk factors for recurrence (eg, young patients, multiple dislocations). To estimate glenoid bone loss, bilateral 3-D CTs are obtained.

 

Assuming a normal contralateral shoulder, the percentage of bone loss is easily estimated by comparing the width of the glenoid on the affected side to the width of the glenoid on the normal shoulder in the en face view. In 96% of cases, this technique accurately stratifies glenoid bone loss as less than or greater than 25% of

glenoid width.9

 

 

DIFFERENTIAL DIAGNOSIS

Multidirectional instability Seizure disorders

 

 

NONOPERATIVE MANAGEMENT

 

 

There are few indications for nonoperative management of glenoid bone loss 25% or greater. However, uncontrolled seizure disorders must be recognized and may be contraindication to Latarjet reconstruction based on the high failure rate with this condition.18

 

In addition, infection and voluntary instability are contraindications to Latarjet reconstruction.

 

SURGICAL MANAGEMENT

 

Our main indications for performing an open Latarjet procedure are the following:

 

 

Glenoid bone loss of 25% or greater of the inferior glenoid diameter (inverted pear glenoid)

 

Deep Hill-Sachs lesion that engages in a position of 90-degree abduction plus 90-degree external rotation (position of athletic function)

 

In general, we have found that a large engaging Hill-Sachs lesion usually occurs in combination with an inverted pear glenoid, so such a case satisfies both indications. Also, when there is a large Hill-Sachs lesion, the coracoid bone graft in the Latarjet procedure will lengthen the articular arc to such an extent that the Hill-Sachs lesion will not be able to engage the glenoid rim. In this way, the Latarjet procedure effectively addresses the Hill-Sachs lesion without the need for an additional bone graft to the humeral defect.

 

One relative indication for the Latarjet reconstruction is in the patient with severe soft tissue loss involving the anterior labroligamentous complex.

 

 

Such soft tissue deficiency can occur due to thermal capsular necrosis or due to multiple failed soft tissue

procedures for instability. Although some authors have recommended soft tissue allografts, we have preferentially done the Latarjet reconstruction without soft tissue augmentation.

 

Alternatively, we have noted that there are occasional cases with partial loss of the capsule (thermal capsular necrosis; multiple failed surgeries) without any significant bone loss. We have found that such cases may be amenable to arthroscopic repair using a flap of the deep surface of the subscapularis to

augment or to substitute for the anterior capsule.8

 

Preoperative Planning

 

 

Preoperative radiographs, MRI, and CT are reviewed prior to surgery as noted previously. An examination is performed under anesthesia to assess the extent of instability.

Positioning

 

The procedure is usually performed under general anesthesia. The patient is first positioned in the lateral decubitus position for an arthroscopy to confirm the extent of bone loss. The coracoid transfer is best performed in the beachchair position.

 

Approach

 

Diagnostic arthroscopy uses posterior and anterosuperolateral portals. Additional portals are established as necessary if further treatment is required (eg, superior labrum anterior to posterior [SLAP] repair).

 

 

The coracoid transfer is performed through a standard deltopectoral approach which begins at the level of the coracoid and extends distally.

 

TECHNIQUES

  • Assessment of Bone Loss

    We perform an arthroscopic assessment of bone loss in all patients with instability who are managed surgically.

    Through an anterosuperolateral viewing portal, the width of the inferior glenoid is assessed with a calibrated probe inserted through the posterior portal.7

    The bare spot of the glenoid marks the center of the glenoid and is used to compare the posterior glenoid width to the anterior width.

    The posterior proximal humerus is assessed for the presence and severity of a Hill-Sachs lesion.

    A calibrated probe can be used to estimate the Hill-Sachs interval (HSI).

    The HSI is the distance from the rotator cuff attachments to the medial rim of the Hill-Sachs lesion, and it is equal to the width of the Hill-Sachs lesion plus the width of the intact bone bridge (BB) between the rotator cuff and the Hill-Sachs (HSI = width of Hill-Sachs lesion + width of BB).

    If glenoid bone loss is 25% or greater, we next address any associated pathology that is amenable to arthroscopic repair. We previously reported a 64% incidence of SLAP lesions in our patients who

    underwent Latarjet reconstruction.2 In these cases, we perform an arthroscopic SLAP repair using previously described techniques.8

    Next, we turn the patient supine and adjust the table to a modified beach-chair position, then reprepare and redrape for the open Latarjet.

     

  • Coracoid Osteotomy

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    A standard deltopectoral incision is used. The coracoid is exposed from its tip to the insertion of the coracoclavicular ligaments at the base of the coracoid. The coracoacromial ligament is sharply dissected from the lateral aspect of the coracoid, and the pectoralis minor tendon insertion on the medial side of the coracoid is also sharply dissected from the bone. The medial surface of the coracoid, from which the pectoralis minor is detached, is the surface that will later be in contact with the anterior glenoid neck when the graft is secured by screws.

     

    Coracoid osteotomy may be performed with an osteotome or angled saw blade (TECH FIG 1). We believe that an osteotome should be used only in thin patients. In a muscular patient with a large deltoid and pectoralis major, the bulk of these muscles may prevent a proper angle of approach anterior to the glenoid, resulting in the possibility of intra-articular glenoid fracture. Neurovascular structures are protected by retractors medial and inferior to the saw blade or osteotome. With either technique, the osteotomy is made just anterior to the coracoclavicular ligaments in order to obtain as much length to the coracoid graft as possible. A graft measuring 2.5 to 3.0 cm in length is ideal, although in small patients, a graft of 2.0 cm is adequate for fixation with two screws.

     

     

     

    TECH FIG 1 • Coracoid osteotomy may be performed with (A) an osteotome or (B) an angled saw blade. C, coracoid. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC, et al. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins, 2012.)

     

     

    The conjoined tendon is left attached to the coracoid graft to maintain vascularity of the graft and to augment stability of the glenohumeral joint by providing a sling effect upon completion of the procedure. After mobilization of the coracoid and conjoined tendon, the musculocutaneous nerve is protected by retracting the coracoid medially, thereby preventing any stretch injury to the nerve.

  • Glenohumeral Joint Exposure and Glenoid Preparation

     

    Once the coracoid has been osteotomized, there is a clear view of the anterior shoulder. The upper half of the subscapularis tendon is detached distally and reflected medially (TECH FIG 2). The insertion of the lower half of the subscapularis is preserved. After detachment of the upper subscapularis tendon, the plane between lower subscapularis tendon and anterior joint capsule is developed.

     

    Alternatively, the glenoid may be exposed by using a subscapularis split approach. One of us (PJD) prefers this technique. The subscapularis split is made through the muscular

     

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    fibers at the junction of the middle and inferior thirds of the muscle. The capsule is bluntly dissected from

    the subscapularis, and then the capsular incision is made.

     

     

     

    TECH FIG 2 • Management of the subscapularis tendon. Detach the superior half of the tendon, then develop a plane between the inferior half of the subscapularis and the capsule. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC. Burkhart's View of the Shoulder: The Cowboy's Guide to Advanced Shoulder Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)

     

     

    This approach has been reported to lead to greater preservation of strength and less fatty atrophy of the subscapularis postoperatively.17

     

    However, visualization can be quite limited, and the position of the split severely limits the surgeon's ability to change the position of the graft on the glenoid if needed. We therefore advise this technique only if the surgeon is very comfortable with the approach because in our opinion, graft position is paramount to the approach.

     

     

     

    TECH FIG 3 • A. Outline of capsulotomy. B. Dissect the capsule 1 cm medial to the glenoid rim before detaching it from the glenoid neck to preserve as much capsular length as possible for later reattachment. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC. Burkhart's View of the Shoulder: The Cowboy's Guide to Advanced Shoulder Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)

     

     

    The capsular incision is begun 1 cm medial to the rim of the glenoid by subperiosteal sharp dissection to preserve enough capsular length for later reattachment (TECH FIG 3). The anterior glenoid neck is prepared as the recipient bed for the coracoid bone graft by means of a curette or a burr, being careful to preserve as much native glenoid bone as possible. “Dusting” of the anterior glenoid neck to a bleeding surface is performed with a high-speed burr without actually removing bone.

  • Coracoid Graft Preparation

     

    While stabilizing the coracoid with a Kocher grasper, use an oscillating saw to remove a thin sliver of bone from the medial coracoid surface where the pectoralis minor had been inserted. This is the surface that will be in contact with the anterior glenoid neck (TECH FIG 4).

     

     

     

    TECH FIG 4 • Coracoid graft preparation. A. The coracoid is grasped with an instrument. B. A straight saw blade is used to remove a thin sliver of bone from the medial surface. (continued)

     

     

    Grasp the coracoid graft with the grasping Coracoid Drill Guide (Arthrex, Inc., Naples, FL) (TECH FIG 4).

    Position the guide on the graft so that the elongated clearance slots are on the freshened surface of the coracoid that will eventually be in contact with the glenoid. The Coracoid Drill Guide allows the surgeon to drill two parallel 4-mm holes through the graft. Care is taken to ensure that the holes are centered on the graft and are perpendicular to the prepared bone surface.

     

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    TECH FIG 4 • (continued) Coracoid graft preparation. C. The medial surface has been cut and will be secured to the glenoid rim. D. The Coracoid Drill Guide has slots for drilling the coracoid in preparation for Latarjet. E. The elongated slots are placed on the medial surface of the coracoid graft (the side which will rest against the glenoid). The guide facilitates placement of two 4-mm parallel drill holes. C, coracoid graft. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC, et al. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins, 2012.)

  • Graft Positioning and Fixation

 

Prior to the development of the Glenoid Bone Loss Set (Arthrex), the coracoid graft had to manually be positioned on the glenoid in a freehand manner. This was technically very difficult and was not easily reproducible. The Parallel Drill Guide (Arthrex) has greatly simplified this part of the procedure and has also made it very reproducible.

 

The pegs on the Parallel Drill Guide mate with the predrilled holes on the coracoid graft (ie, those that were created with the Coracoid Drill Guide) to allow for easy control and positioning of the coracoid graft onto the glenoid. Three offset sizes are available (4, 6, and 8 mm) to adapt to various graft diameters.

Some additional shaping of the graft with a rongeur or a power burr may be required to obtain the best possible fit of the guide against the graft. An optimal fit occurs when the coracoid is flush under the overhanging offset fin once the pegs are fully engaged (TECH FIG 5).

 

The glenoid is optimally exposed by placing a Fukuda retractor to lever the humeral head posteriorly and by placing a twopronged Hohmann retractor medially to retract the medial soft tissues.

 

Proper position of the coracoid bone graft relative to the glenoid is critical. The graft must be placed so that it serves as an extension of the articular arc of the glenoid (TECH FIG 5). The Parallel Drill Guide is invaluable in placing the graft flush with the articular surface of the glenoid so that it is neither too far medial nor too far lateral. It is important to be sure that the guide is angled slightly medially, toward the face of the glenoid, to achieve the proper screw insertion angle and to avoid any potential screw penetration into the articular cartilage.

 

The safe zone for the suprascapular nerve is no more than 10 degrees medial to the surface of the glenoid.13

 

Use a pin driver to advance the shorter (6 inch) of the two guidewires directly through the lower hole of the guide and graft, and then into the glenoid neck. The guidewires are not terminally threaded to allow for better feel when the posterior glenoid cortex is penetrated. Next, advance the longer (7 inch) guidewire through the second guide cannulation (TECH FIG 5).

 

Next, remove the Parallel Drill Guide. Hold the graft firmly against the glenoid with an instrument (as the pegs may be tightly wedged into the coracoid drill holes) while the Parallel Drill Guide is withdrawn, leaving both guidewires in place. Use the 2.75-mm cannulated drill to penetrate only the near cortex of the native glenoid prior to screw insertion. Due to the potential proximity of the screws to the suprascapular nerve posteriorly, it is advisable to rely on the self-drilling and self-tapping nature of the screws to penetrate the posterior glenoid cortex.

 

The screw length depth gauge can then be used to help determine the proper screw length. Screw length is read directly from the back end of the shorter 6-inch guidewire and from the laser line of the longer 7-inch guidewire. We have found that the most common screw lengths are 34 mm for the more inferiorly positioned screw and 36 mm for the superior screw.

 

Each screw is inserted over its guidewire using a cannulated hex driver. One must be careful not to overtighten the screws as this

 

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may crack or damage the graft. Once the screws are almost fully seated, the surgeon double-checks the position of the coracoid graft. If the position is satisfactory, the guide pins are removed and the screws are advanced to their fully seated position. Intraoperative AP and axillary x-rays are taken to confirm satisfactory position of the screws and graft.

 

 

 

TECH FIG 5 • The Parallel Drill Guide. A. Pegs on the guide mate with the predrilled holes in the coracoid graft. Different offsets are available to accommodate grafts of varying thickness. A 6-mm offset guide is pictured. B. An optimal fit occurs when the overhanging fin is flush with the coracoid graft. C. Correct placement of the coracoid bone graft occurs when the graft is flush with the glenoid surface so that the arc of the glenoid is effectively extended. The Parallel Drill Guide facilitates proper placement of the graft. D. Securing the coracoid bone graft. Guidewires are inserted through the Parallel Drill Guide to temporarily hold the graft in place. E. The drill guide is removed and the appropriate screw length can be measured. F. Final appearance of secured graft after placement of two cannulated 3.75-mm screws. The graft is flush with the glenoid articular surface and extends the native glenoid arc. C, coracoid graft; G, glenoid. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC, et al. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins, 2012.)

 

 

At this point, the surgeon assesses the stability of the Latarjet construct. One of the most amazing things about this construct is that, with the arm in abduction and external rotation and with a manually applied, anteriorly directed force, the shoulder cannot be dislocated even though the capsule has not yet been

 

repaired.

 

  • Closure

     

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    Place three BioComposite SutureTak anchors (Arthrex) into the native glenoid above, between, and below the cannulated screws to repair the capsule. This makes the graft an extraarticular structure and prevents its articulation directly against the humeral head, eliminating any abrasive potential of the graft against the articular cartilage of the humerus (TECH FIG 6).

     

    If a subscapularis split has been used, the upper and lower subscapularis muscle segments will reapproximate themselves once the retractors have been removed, and no sutures are necessary. When the upper subscapularis has been detached and retracted medially during the exposure, it is usually repaired back to its stump with no. 2 FiberWire suture (Arthrex). If the tendon stump is of poor quality, then BioComposite CorkScrew FT suture anchors (Arthrex) are used. After subscapularis repair, a standard skin closure is performed.

     

     

     

    TECH FIG 6 • Suture anchors are placed at the interface of the graft and the native glenoid arc and used to repair the anterior capsule so that the coracoid graft remains extra-articular. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC. Burkhart's View of the Shoulder: The Cowboy's Guide to Advanced Shoulder Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)

     

     

    It is not necessary to reattach the pectoralis minor to the residual coracoid base or adjacent soft tissues because it does not retract. We have not observed any residual symptoms or cosmetic deformity relative to the unrepaired pectoralis minor.

     

    PEARLS AND PITFALLS

     

     

     

     

     

    Exposure

  • Begin with a formal deltopectoral approach and an L-shaped incision of the subscapularis to obtain optimal exposure.

  • As comfort is gained, the incision may be decreased and a subscapularis split may be considered.

     

    Graft harvest

    • Aim to harvest a graft of 2.5-3 cm.

    • A flare of bone at the base of the graft usually indicates an adequate osteotomy.

 

Graft placement

  • Placing the graft flush with the native glenoid is the most critical portion of the procedure and is important to avoid glenohumeral arthritis.

     

    Securing the graft

    • Self-drilling, self-tapping screws minimize the risk of injury to the suprascapular nerve.

    • The safe zone for screw angle is no more than 10 degrees medial to the surface of the glenoid.

 

 

 

POSTOPERATIVE CARE

 

The patient uses a sling for 6 weeks, with external rotation restricted to 0 degrees.

 

After 6 weeks, the sling is discontinued and overhead motion is encouraged. Gentle external rotation

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stretching is begun at 6 weeks postoperatively, with the goal that at 3 months postoperative, external rotation on the operated shoulder will be half that on the opposite shoulder.

 

At 3 months postoperative, the patient begins strengthening with elastic bands.

 

At 6 months, he or she progresses to weightlifting in the gym if the graft remains in good position and shows early signs of consolidation.

 

Contact sports or heavy labor are generally allowed when the bone graft appears radiographically healed, which is usually 9 to 12 months postoperative.

 

OUTCOMES

There are few reports of the Latarjet procedure in the English language literature.1,4 There are many reports of the Bristow procedure (often called the Latarjet-Bristow procedure), which is a significantly different procedure that transfers only the coracoid tip to the glenoid neck.

Regarding the Latarjet procedure, Burkhart et al6 reported the results of 102 patients at an average of 59 months after reconstruction. There were four recurrent dislocations and one recurrent subluxation (4.9% recurrence rate). All recurrent dislocations were related to violent trauma in the early postoperative period and occurred with graft dislodgement. Patients achieved an average of 180 degrees of forward elevation (2 degrees improved from preoperative range) and an average of 48 degrees of external rotation with the arm at the side (5 degrees less than preoperative range). The mean Constant score was 94, and the mean Walch-Duplay score was 92 at final follow-up. Five complications were reported, including two hematomas, two loose screws that did not require removal, and one fibrous union.

 

Allain et al1 retrospectively reviewed 58 shoulders at an average of 14 years after the Latarjet procedure for recurrent anterior instability. Although six patients had a positive apprehension sign, there were no cases of postoperative dislocation and only one subluxation. Overall, 20% of the shoulders developed clinically significant glenohumeral arthritis. Interestingly, although over 30% of the subscapularis tenotomy repairs were performed by overlapping the subscapularis tendon edges (as opposed to side to side) in which there was an average 29 degrees of external rotation loss, there was no statistically significant association between the type of subscapularis repair and development of glenohumeral arthritis. Significant glenohumeral arthritis was seen in 27% of grafts placed too far laterally, compared to no cases in which the graft was placed perfectly or medially.

 

 

 

COMPLICATIONS

The majority of the reported complications are related to the coracoid graft harvest and the position of graft fixation along the glenoid.

Scapula fracture can occur during graft harvest with the osteotome, and in most cases, we prefer the angled saw blade.

The tendency is to obtain an undersized graft. The goal is to obtain a graft of 2.5 to 3 cm. A flare of bone at the base of the graft usually indicates an adequate osteotomy.

Late graft fracture and recurrent dislocation have occurred after traumatic athletic injury. We recommend avoiding contact sports until 9 to 12 months postoperative.

Fibrous union or nonunion of the graft occurs in less than 1% of cases in our experience.4 It is minimized by placing two screws in a compression technique, decorticating the coracoid graft and preparing the glenoid.

Significant glenohumeral arthritis has been reported to develop in 20% of shoulders at 14 years of follow-up.1 However, at long-term follow-up, arthritis is less frequent following surgical stabilization compared to

untreated recurrent dislocations.12 Postoperative arthritis is best avoided by careful attention to graft position.

Postoperative infection and/or hematoma are uncommon.

Recurrence is less than 5% and surgical treatment of a failed Latarjet procedure requires an iliac crest autograft15 or tibia plafond allograft.

There is evidence that postoperative fatty degeneration is decreased using a subscapularis split

approach compared to an L-shaped subscapularis incision.17 However, the subscapularis split exposure is less forgiving, and because we feel that graft position is the most important part of the procedure, we recommend the L-shaped incision, particularly for surgeons who perform few Latarjet procedures.

Suprascapular nerve injury has been described.16 To avoid injury, we recommend orienting screws within 10 degrees of the face of the glenoid, only drilling the anterior cortex of the glenoid and inserting self-tapping, self-drilling screws.

 

REFERENCES

  1. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior

    instability of the shoulder. J Bone Joint Surg Am 1998;80:841-852.

     

     

  2. Arrigoni P, Huberty D, Brady PC, et al. The value of arthroscopy before an open modified latarjet reconstruction. Arthroscopy 2008;24:514-519.

     

     

  3. Boileau P, Villalba M, Hery JY, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 2006;88:1755-1763.

     

     

  4. Burkhart SS. The bare spot of the glenoid. Arthroscopy 2007;23:449; author reply 449-450.

     

     

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