Management of Failed Latarjet Procedure Using a Distal Clavicular Autograft

Abstract

Background:

Latarjet procedure is the gold standard surgery in cases of shoulder instability with substantial bone loss. Recurrence is scarce but its management may be challenging. Numerous revision techniques, based on soft tissue repairs with autograft or allograft augmentations, have been developed. Autografts are associated with potential donor-site morbidity while allografts may generate additional costs. We present here the use of the ipsilateral distal clavicular osteochondral autograft in the setting of failed Latarjet procedure.

Indication:

The indication is a failed coracoid bone block procedure with recurrent instability and preoperative imaging demonstrating intact acromioclavicular (AC) joint with preserved coracoclavicular (CC) ligaments. This technique should not be used if there was a previous lesion of the CC ligaments during coracoid harvest.

Technique Description:

A delto-pectoral approach is used and extended superiorly to access the distal clavicle end as well as the glenohumeral (GH) joint anterior aspect. A distal clavicular osteochondral autograft is harvested with an oscillating saw after identifying the AC joint with a needle to prevent any resection medial to the CC ligament insertions, which would compromise distal clavicle stability. The GH joint anterior aspect is exposed, similar to the Latarjet procedure, to first remove the coracoid graft remnants along with any scar tissues surrounding the joint anterior aspect. Distal clavicular autograft is predrilled and fixed to the scapula using 2 cortical screws. The clavicular articular surface may be used to replace the glenoid cartilage defect. In this case, the anatomy of the distal clavicle did not allow us to perform such articular replacement.

Results:

Return to daily activities was authorized after 3 weeks postoperatively. After 6 weeks, shoulder pain lowered and no clavicle instability or donor-site complication was reported. Return to sport is expected in 50% of cases, compared with other revision procedures. Computed tomography (CT) scan showed an adequate positioning of the bone block and its fusion at 3 months postoperatively.

Conclusion:

In the setting of a failed Latarjet procedure with recurrent shoulder instability, distal clavicular autograft appears to be a reliable option to reduce donor-site morbidity and avoid additional costs. A prospective clinical study is needed to evaluate this technique in the long term.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video we will be presenting the management of failed Latarjet procedure using distal clavicular autograft.

There are no relevant disclosures to be mentioned.

We will be reviewing the following items: background, indications and contraindications, patient presentation, preoperative imaging, patient positioning, surgical procedure, potential complications, postoperative and return-to-sport guidelines, and patient outcomes.

Latarjet procedure is the gold standard to address recurrent anterior shoulder instability with glenoid bone loss. Failure rates with recurrent shoulder instability following Latarjet procedure range from 0% to 18%. Additional fixation devices have been developed and recurrent dislocation rate is higher with cortical button than screw fixation (8.3% vs 2.3%). Surgical treatment options following a failed Latarjet technique include soft tissue procedures augmented with autograft/allograft bone blocks. Herein, we present the use of an ipsilateral distal clavicular osteochondral autograft to address a failed Latarjet procedure with recurrent anterior shoulder instability and intact acromioclavicular (AC) joint on preoperative imaging.

Tokish first described using this autologous osteoarticular graft in an arthroscopic stabilization technique to treat glenohumeral (GH) anterior instability with glenoid bone loss. With a minimal additional donor-site morbidity, such technique allows the use of a corticocancellous graft with a cartilaginous surface that can potentially replace the glenoid articular defect. Moreover, it has been shown to provide a larger restoration of the glenoid surface than the traditional coracoid bone block on a cadaveric study.

Such technique can be used in patients with recurrent instability after failed primary Latarjet procedure. However, this technique should not be used if there was a previous lesion of the coracoclavicular (CC) ligaments during coracoid harvest. Thus, preoperative clinical examination and shoulder magnetic resonance imaging (MRI) are mandatory to evaluate them. In addition, AC osteoarthritis is a relative contraindication. Similar to the Latarjet procedure, it should not be performed on patients with multidirectional instability.

To illustrate this method, we report the case of a 24-year-old nurse, right-handed, with recurrent left shoulder instability after an arthroscopic Latarjet procedure fixed with a single cortical button. The previous surgery was performed when she was 20 years old after multiple episodes of anterior shoulder dislocations, the first being at the age of 14.

Preoperatively, she had active anterior elevation of 160°, external rotation of 70°, and internal rotation at T12. She presented with a persistent anteroinferior apprehension. She had no pain or instability on the AC joint.

The preoperative arthro-computed tomography (CT) scan demonstrated satisfactory healing of the previous coracoid graft, but this was placed at the upper part of the glenoid rim. There was no AC arthritis or subluxation of the shoulder. The magnetic resonance imaging (MRI) showed preserved CC ligaments.

The procedure is performed under general anesthesia and interscalene nerve block in an outpatient clinic. The patient lies supine with the upper part of the orthopedic table flexed at 15°. A folded drape is placed under the medial border of the scapula, with the ipsilateral arm resting on a table.

The skin incision is centered on the AC joint and prolonged distally as a delto-pectoral approach. Exposition of the distal part of the clavicle and location of the AC joint, with the help of a needle, are the first step.

The superior AC capsule is opened and partially resected to expose the cartilaginous surface of the distal clavicle, taking care not to cut the CC ligaments. Using a 1-cm-wide saw blade, 1.5 to 2 cm of the distal clavicle end is harvested subperiosteally. The graft is placed on the back table. The periosteal flap is closed with absorbable no 2 interrupted stitches. In the same way, the gap between the trapezius and the deltoid is closed.

The delto-pectoral dissection starts at the Mohrenheim fossa and the cephalic vein is retracted laterally. A Kolbel retractor is placed to recline the deltoid and the pectoralis major. With the arm in external rotation and the elbow close to the body, a horizontal split of the subscapularis is performed at the junction of the upper half part and lower half part. The joint line is identified and a T-shaped capsulotomy is performed. A Gelpi retractor is used to expose the glenoid rim and a Fukuda retractor is used to seclude the humeral head. A Link retractor protects the axillary nerve and a Hohmann retractor is positioned under the scapular neck.

The previous coracoid bone block and its cortical button are removed to avoid any conflict with the clavicular graft. The anteroinferior glenoid rim is decorticated using a curved osteotome until bleeding bone is exposed and a straight surface is obtained. A bone awl is used to mark the inferior hole and then retract the superior subscapularis. A 2.5-mm drill bit is used to drill the inferior hole, parallel to the joint surface.

The graft is prepared with removal of the soft tissue around the bone. In this case, the articular surface of the distal clavicle is too narrow to be used and is subsequently resected. The graft is reshaped to measure 2 cm in length by 1 cm in wide. Its inferior cortex is removed to ensure appropriate fusion with the scapula.

The graft is held with a Museux forceps and two 2.5 mm drill holes are drilled perpendicular to the longest axis of the graft, 1 cm apart. A K-wire is passed through the graft and the inferior glenoid hole to maintain its position during screw fixation. A first inferior partially threaded screw ensures a contact between the bone and the graft. While controlling the position of the bone block, the superior hole is drilled and a second screw is inserted. The 2 screws are then tightened progressively until satisfactory compression is obtained. The capsule is finally closed with absorbable no 2 interrupted stitches, with the arm in neutral rotation, and so is the subscapularis tendon.

At the end of the procedure, the arm is placed in a sling for 3 weeks.

This surgery has potential complications similar to the Latarjet procedure, including iatrogenic axillary nerve lesion and GH cartilaginous lesions. Preparation of the bone block and its positioning present the same risks as well as in a classic Latarjet procedure. To avoid errors during clavicular harvest, it is important to clearly identify the AC joint. One must ensure the presence of CC ligaments with preoperative clinical examination and shoulder MRI to avoid postoperative clavicle instability. If the articular surface of the clavicle is to narrow, it cannot be used and the graft has to be remodeled. Other complications of distal clavicular excision have been reported: fracture of the clavicle, heterotopic ossifications, and osteolysis of the distal clavicle.

A resting shoulder sling is maintained for 3 weeks. Pendulum exercises are done by the patient in the early days. A shoulder rehabilitation protocol starts a few days after the surgery with a physiotherapist and a self-rehabilitation program (Liotard protocol). Return to work depends on its nature but can be as early as 5 days for office work. The patient is allowed to drive at 3 weeks postoperatively. Return to noncontact sport can be resumed 6 weeks after the surgery and all sports after 3 months postoperatively. It is expected to be achieved in 50% of cases, compared with other revision procedures.

Early follow-up includes visits at 3 weeks and 3 months with CT scans, to appreciate first bone block position and then its fusion.

At 3 months postoperatively, the patient presented with no pain and no recurrent instability.

She had active anterior elevation of 140°, external rotation of 70°, and internal rotation at T10. She could resume her daily activities. CT scan confirmed the good position of the graft and its fusion with the scapula, without clavicular elevation. Return to sport was not yet achieved.

Distal clavicular autograft for treating recurrent shoulder instability appears to be a reliable option, with low additional donor-site morbidity and costs. A prospective clinical study is needed to evaluate this technique in the long term.

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