Latarjet Procedure for Recurrent Anterior Shoulder Instability

Abstract

Background:

The Latarjet procedure is widely used to treat recurrent anterior shoulder instability, especially in cases with significant glenoid bone loss. The procedure involves transferring the coracoid process to the anterior inferior glenoid. Typically performed as an open surgery, arthroscopic Laterjet techniques have evolved, each offering unique benefits and challenges.

Indications:

The Latarjet procedure is indicated for patients with recurrent anterior shoulder instability, particularly those with substantial glenoid bone loss (typically >20%), or failed soft tissue (Bankart) repairs. It is also recommended for patients with engaging Hill-Sachs lesions (off-track), and high-risk individuals following their first dislocation. The glenoid track concept assists in evaluating bone loss and deciding when the Latarjet is warranted.

Technique Description:

The patient is positioned in a beach-chair setup with anesthesia administered. An anterior incision is made using a deltopectoral approach. The coracoid is mobilized and prepared for the congruent arc technique, then affixed to the anterior glenoid using screws. The joint is irrigated, and the capsule and subscapularis are repaired to ensure stability and preserved mobility.

Results:

The congruent arc modification has shown favorable outcomes, particularly in patients with significant glenoid bone loss. Meta-analyses reveal a low redislocation rate (1.1%) and high return-to-sport rate (94.3%). Graft integration rates are approximately 92.1%, and patients report improved shoulder function, with notable gains in Rowe and American Shoulder and Elbow Surgeons scores.

Discussion/Conclusion:

While the Latarjet procedure provides excellent stability and functionality for shoulder instability, risks such as graft fragmentation and screw malposition require careful planning and execution. The procedure's high success rate and favorable functional outcomes solidify its role in managing complex shoulder instability, ensuring its continued relevance in orthopaedic practice.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video is going to describe our technique for the open Latarjet procedure.

Background

We’ll start with the patient history. This patient is a 43-year-old male with a history of smoking who works as a handyman. He first underwent arthroscopic Bankart repair in October of 2022 and was able to get back to rock climbing and skydiving. A year and a half later, in April of 2024, he fell while snowboarding and had an acute dislocation. He was able to reduce his shoulder himself, continued snowboarding, and then redislocated it at home and was again able to get it back in by himself. Three weeks after the snowboarding fall, he dislocated the shoulder while shooting pool. He then saw his doctor and underwent a magnetic resonance (MR) arthrogram. Subsequently, he dislocated the shoulder a further 8 times, 1 of which required sedation in the emergency department to reduce.

Here’s a look at the MR arthrogram. You can see the axial views showing a significant bony Bankart lesion with a labral tear as well. Now we're looking at the sagittal views showing that the bone piece corresponds to around 20% of the glenoid area.

Indications

The main indications for the Latarjet procedure are recurrent anterior shoulder instability that has either failed a soft tissue repair or is presenting in a patient with significant glenoid bone loss. Typically, we talk about it being >20%, though that number is debatable.^4,6 Other surgical options for this injury would be an open or arthroscopic Bankart repair, though that would not address the bony loss. A distal tibial allograft is an option as well, which does address bone loss but is more costly, and we would use it here if the Latarjet failed.^1-3,5 Within the evaluation for instability, we start with an MR imaging, which allows excellent assessment of the labrum. However, it's important to note that a computed tomography (CT) scan is still the gold standard for evaluating glenoid bone loss. Contraindications are rare but include irreparable rotator cuff tears, severe glenohumeral arthritis, infection, and neurological disorders.

Technique Description

Here’s a look at our positioning. The patient is in a beach-chair position, elevated to around 45°, and the arm is in an arm holder, which can be moved throughout the case.

Portals are now made for arthroscopic evaluation of the shoulder joint. Here, the camera is placed in a posterior viewing portal, and access is gained to the joint. We can see the site of the anterior humeral bone loss, which is quite extensive, and you can see the Hill-Sachs lesion posteriorly as well. The arthroscopic view allows you to assess the amount of anterior glenoid bone loss as well as the size of the Hill-Sachs lesion and remove any loose bodies if needed. This image just shows our Mayo stand setup with all the equipment needed for the case. Here's a load-and-shift exam under anesthesia showing anterior subluxation of the shoulder.

Now we begin the open procedure by using the standard deltopectoral interval. Care is taken to avoid damaging the cephalic vein. Blunt dissection is utilized, and the conjoint tendon is palpated, as well as the coracoid itself. A retractor is then placed at the base of the coracoid where it meets the scapula to allow delineation of its boundaries. Here you see the fascia overlying the coracoid being removed, and then again, the boundaries of the coracoid are marked out with the bovie. The pectoralis minor tendon is also released off the medial aspect of the coracoid. We're preparing to use the guillotine osteotome to osteotomize the coracoid at its base. Here we're measuring the coracoid to ensure that our osteotomy will provide us with ≥2 cm of bone. After the initial osteotomy, a small curved osteotome is used to complete the cut.

The remaining soft tissue is removed from the coracoid.

Here, the deep part of the pectoralis minor tendon is being released.

Now a handheld saw is being used to remove the excess bone. The coracoid graft here is evaluated to see if there's adequate size to perform a congruent arc technique. In this case, we decided to proceed with the congruent arc modification to the Latarjet technique, which involves rotating the coracoid by 90° so that its medial face is opposed to the anterior glenoid. It's crucial to prepare the graft well and decorticate it so that you can get good bony fixation and healing. The parallel drill guide is used to place two 4-mm holes into the graft to prepare for screw fixation. The lengths are measured with a standard depth gauge. We'll now turn our attention toward exposing the glenoid. The subscapularis tendon is identified and is split down the junction of its middle and inferior thirds. The axillary nerve has been palpated and will be avoided throughout the case. The tendon is split, and then a sponge is used to help divide the interval between the subscapularis muscle belly and the capsule. Here you see further dissection of the subscapularis tendon and the interval between the tendon and the joint capsule.

Care is taken to maintain these tissue planes to allow for a layered closure. Here you're seeing the capsule being split sharply with a knife, and the glenoid will now be exposed medial to the labrum. This elevator is being used to free the soft tissue off the remaining bony aspect of the labrum. It's crucial to prepare a bed of bleeding bone for the graft to heal. Scar, residual labrum, and previous anchors are being removed now from the remaining glenoid.

Again, this is essential to remove all debris to ensure that the coracoid graft can heal well to the remaining glenoid. You can see now we've prepared a nice bleeding bed of bone at the remaining glenoid. You can also note the previous tunnels from the suture anchors used in his Bankart repairs.

Now that the glenoid is adequately prepared, we'll get ready to place our screws in the graft.

Here, the guide wire is being placed and then overdrilled to put the inferior screw in. These will be 3.75-mm screws.

In this patient, specifically, we decided to use this figure-of-8 plate as a washer due to concerns over his bone quality and his advanced age for this procedure.

Here, we're using a partially threaded, cannulated screw over the guide wire. The partially threaded screw helps obtain compression of the graft onto the remaining glenoid. Now that the inferior screw has locked the position of the graft in place, the superior hole is drilled and a fully threaded screw is placed across the graft and into the remaining glenoid. A bur is then used to shave down a prominent portion of the graft inferiorly, and pulse lavage is used to irrigate the wound. The capsule is now repaired with a No. 2 nonabsorbable suture (Arthrex FiberWire). Two grams of vancomycin powder are placed as infection prophylaxis. The subscapularis split is then repaired with another No. 2 nonabsorbable suture. We now close the deltopectoral interval and then close the skin in a layered fashion with 3-0 Vicryl and 4-0 Monocryl (both Ethicon).

Results

Some pros of this surgery include accurate graft positioning—it is essential to have the coracoid graft at the inferior aspect of the glenoid, which can be optimized by using preoperative CT scans, including 3-dimensional reconstructions. Important pitfalls to avoid are overtightening the screws (which can lead to graft fracture), nerve injury (especially the musculocutaneous and axillary nerves), and improper graft placement.

Postoperative radiographs show screw fixation and placement of our graft. Postoperatively, the patient is placed in a sling for 3 weeks and allowed to perform passive external rotation exercises. They begin active range of motion at 4 weeks and can return to sport once their bone block is fully healed, typically around the 4-month mark. In high-level athletes, we will verify this healing with a CT scan.

Discussion/Conclusion

Overall, the Latarjet procedure has about a 90% success rate with a return to sport in around 6 months and lower recurrence than the Bankart procedure in patients with bone loss. There is an increased risk of arthritis especially if the graft is malpositioned, and there is a 10% complication rate, including infection, nerve injury, graft nonunion, and recurrent instability.