Open Latarjet for Traumatic Shoulder Dislocation: A Technical Note

Abstract

Background:

The Latarjet procedure is a common technique for treating symptomatic, recurrent anterior shoulder instability with significant glenoid bone loss and employs a standard subscapularis split to ensure optimal exposure and functional outcomes.

Indications:

This procedure is indicated for primary or recurrent anterior instability, particularly in high-risk patients with approximately 15% anterior glenoid bone loss.

Technique Description:

The patient is positioned in a beach-chair position, and sharp dissection is initiated at the superior aspect of the coracoid tip and extended inferiorly by 4 to 6 mm. The lateral border of the conjoint tendon is identified and released from the clavipectoral fascia. The coracoacromial (CA) ligament is identified and released from the coracoid using Bovie electrocautery, leaving a small segment for later capsular closure. The pectoralis minor is released from the medial coracoid border, exposing the coracoid base. After measuring the coracoid, an oscillating saw and osteotome are used to harvest the bone graft. The coracohumeral ligament is released, and the graft is prepared with a flat, bleeding surface to ensure optimal contact with the glenoid neck. Two drill holes are placed through the coracoid tip. Next, the subscapularis is split at the junction of the superior two-thirds and inferior one-third of the muscle belly, and the split is completed laterally. The plane between the subscapularis and capsule is developed. A horizontal split in the capsule is made to visualize the glenoid neck and anterior glenoid face. The anterior glenoid surface is cleared of capsule and decorticated. The graft is drilled using an offset guide, and cannulated screws are placed for fixation. A suture anchor is placed between the coracoid graft drill holes to secure fixation, while a suture is passed through the CA ligament stump and anteroinferior capsule, reinforcing the glenohumeral ligament complex and augmenting anterior stability.

Results:

Early outcomes of the standard Latarjet technique are favorable, including reduced recurrence of instability through glenoid augmentation and a conjoint tendon sling effect, with lower complication and reoperation rates and higher return to sport rates compared with other stabilization surgeries (eg, arthroscopic Bankart).

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.

Discussion/Conclusion:

Surgeons should consider the Latarjet technique in indicated patients.

Graphical Abstract.

This is a visual representation of the abstract.

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DOI: 10.1177/26350254251387734.M1

Video Transcript

Here we present a surgical technique video for an open Latarjet procedure in a case of traumatic shoulder dislocation.

Background

Introduction: Definition, Incidence, and Associated Pathologies

The Latarjet procedure utilizes a coracoid bone graft transfer to reshape the anterior glenoid arc. As studies^3,6 continue to demonstrate promising outcomes from the Latarjet procedure, its incidence has risen significantly, with a steady upward trend since the early 2000s. The Latarjet procedure aims to reduce recurrent instability and dislocation arthropathy by repairing the anterior glenoid fossa and creating a dynamic sling via the conjoint tendon. This procedure offers better anterior stability compared with arthroscopic Bankart repair, which may be less effective in patients with bone loss or high-risk profiles.^7,8 The open Latarjet technique utilizes a subscapularis split, which remains the standard approach in modern practice. The split is commonly performed at the junction of the superior two-thirds and inferior one-third of the muscle belly. This location balances optimal exposure of the glenoid with preservation of subscapularis function.^7,8

Case Presentation: Patient Presentation History

We performed this technique on a 16-year-old female patient with a history of traumatic shoulder dislocation with subsequent recurrent dislocation events.

Case Presentation: Physical Examination

On physical examination, the patient demonstrated a painful, restricted active range of motion (ROM), with forward elevation limited to 110° and external rotation to 20°. Apprehension and relocation tests were positive, and the anterior load-and-shift test revealed increased translation. Rotator cuff strength was 5/5 throughout—including supraspinatus, infraspinatus, teres minor, and subscapularis—with no lag signs or weakness. Beighton scoring revealed no evidence of generalized ligamentous laxity.

Computed Tomography (CT) Scan

A (CT) scan showed approximately 15% glenoid bone loss on the anteroinferior aspect of the glenoid and no significant Hill-Sachs lesion.

Indications

Surgical Indications for the Latarjet Procedure

Recent consensus guidelines suggest that arthroscopic Bankart repair with remplissage may be appropriate for patients with on-track Hill-Sachs lesions and minimal glenoid bone loss. ⁴ However, in this case, the Hill-Sachs lesion was off-track, and the patient had previously failed a Bankart repair. Given the persistent instability and presence of a discrete bony Bankart fragment, the Latarjet procedure was selected as a more definitive option to address both the bone loss and capsulolabral insufficiency.^1,2

Preoperative Examination Under Anesthesia and Surgical Exposure

An examination under anesthesia was performed to assess her ROM and stability. Anterior load and shift testing demonstrated 2B laxity, indicating moderate humeral head translation to the glenoid rim with spontaneous reduction, while posterior load and shift showed 1B laxity, reflecting minimal translation with spontaneous reduction. She also had significant inferior instability, with a 2-cm inferior displacement of the humeral head and a sulcus sign.

Technique Description

Procedure Preparation

The patient is positioned in a beach-chair position. Landmarks identified are the tip of the coracoid process and the axillary fold. We typically begin at the superior aspect of the tip of the coracoid and extend inferiorly with a vertical incision approximately 4 to 6 cm in length. Sharp dissection is used to pass through the skin and subcutaneous tissues down to the deltopectoral interval. Self-retaining Gelpi retractors are used for visualization. The fascia between the deltopectoral interval is identified and incised. The cephalic vein is then seen below the interval. We prefer to take the cephalic vein laterally with the deltoid for retraction and protection throughout the case.

The lateral border of the conjoined tendon is then identified and released from the clavipectoral fascia. Next, the CA ligament is identified and released from the coracoid using Bovie electrocautery, leaving a small segment intentionally preserved for later incorporation into the anteroinferior capsular repair. The plane between the pec minor and the medial aspect of the conjoined tendon is then identified and incised with scissors. This will allow for safe detachment of the pec minor from the medial aspect of the coracoid tip and mobilization of the coracoid.

Latarjet Procedure

At this point, we measure the coracoid length by marking the coracoid tip and using a ruler to check the vertical length. It measures approximately 22 to 25 mm. A retractor is placed medially, and an oscillating saw is used at the marked distance, working from medial to lateral, with care being taken not to plunge deep. The remainder of the osteotomy is completed with an osteotome. Bone wax may be applied to the osteotomy site to mechanically seal bleeding cancellous bone surfaces and maintain a clearer operative field during graft preparation and fixation. Completion of mobilization is performed by releasing the coracohumeral ligament off the lateral base of the coracoid. A specialized clamp is used to control the coracoid, and any soft tissue is removed from the undersurface of the coracoid. The coracoid is then prepared to a flat, bleeding surface using a combination of the saw and bur on its undersurface. This surface must be flat to match the glenoid neck for compression and to ensure complete contact over the entire surface. Next, a custom aiming guide is used to place 2 drill holes through the coracoid tip, and the corresponding entrance area is marked on the anterior aspect of the coracoid. The offset distance from the lateral edge of the coracoid to the hole is then measured to prepare for further insertion, as shown later during fixation of the glenoid. Next, a depth gauge is used to measure the thickness of the coracoid graft.

Once the coracoid is prepared, we turn our attention to the subscapularis split. We perform a standard horizontal split through both the muscle belly and tendon of the subscapularis at the junction of the superior two-thirds and inferior one-third. This provides excellent glenoid exposure while preserving the integrity of the subscapularis. Next, we use Metzenbaum scissors to find the plane between the muscle and the capsule. We put the arm in approximately 15° of external rotation to help us find this plane. A Gelpi retractor is placed between the split, followed by a Bankart retractor for further visualization. At this point, we complete the lateral split to allow for full visualization. Next, we make a horizontal split in the capsule. We start at the joint line and move from laterally to medially, protecting the underlying cartilage. A Fukuda retractor is inserted into the glenohumeral joint to allow for appropriate visualization of the glenoid neck. A Bovie is then used to clear the anterior capsule off the glenoid. We do this by performing a T-capsulotomy, starting medially, and moving the long limb of the T-capsulotomy laterally toward the already established capsular split. Next, we dissect the inferior and superior aspects of the capsule from the glenoid face. The glenoid face is then fully decorticated with a bur to match the corresponding graft size. Drill holes were created using a 3.2-mm drill bit, and 4 mm partially threaded cannulated screws were used for fixation of the coracoid graft to the glenoid. The depth gauge measures the depth of drilling into the glenoid, which is then added to the previously measured thickness of the coracoid graft to determine the appropriate screw length. A matching screw is then inserted into this part of the coracoid graft. A K-wire is used as a joystick to control and place the coracoid graft in line with the previous drill hole. At this point, the inferior screw is inserted. Manual proprioceptive feedback is used to ensure the graft is flush or just medial to the glenoid surface. Once the glenoid is appropriately positioned, a second hole is then drilled. Afterward, an appropriately lengthened cannulated screw is placed. It is critical to ensure that the screw is not overtightened during insertion. We recommend two-finger tightness to avoid overcompression, which may result in graft fracture by creating stress risers in the coracoid.

Closure

A final manual check is performed to confirm that the graft is placed just medial to the surface. Intraoperative fluoroscopy was not used because the graft position and screw trajectory were confirmed through direct visualization and tactile feedback.

Next, an anchor is inserted between the 2 drill holes on the coracoid to secure the graft and assist in subsequent closure. For capsular repair, a suture from the previously placed anchor is passed first through the preserved CA ligament stump, then through the inferior flap created by the T-capsulotomy. Additional sutures are used to close the horizontal limb of the T-capsulotomy. The knot is tied extra-articularly to complete this reinforcement.

The subscapularis split is then closed in an interrupted fashion using figure-of-8 nonabsorbable sutures. Although not universally performed, subscapularis split closure helps minimize dead space, reduce hematoma, and support postoperative muscle healing and function. The deltopectoral interval is closed using interrupted sutures, followed by subcutaneous closure with buried absorbable sutures and final skin closure.

Results

A standard dressing is applied, and the patient is placed in a standard abduction sling for 4 to 6 weeks to protect the graft and surgical repair.

At 2 weeks postoperatively, supervised passive ROM exercises are initiated within a protected arc, limiting forward flexion to 90° and external rotation to 30°.

At 3 to 4 weeks, active-assisted ROM is introduced to gradually increase motion, focusing on restoring forward flexion, abduction, and controlled external rotation while avoiding excessive strain on the anterior capsule.

By weeks 6 to 8, submaximal isometric strengthening of the rotator cuff and scapular stabilizers is initiated once healing is clinically or radiographically confirmed. This progresses to isotonic strengthening with resistance bands or light weights around 8 to 10 weeks.

At 3 months, patients typically begin functional strengthening and neuromuscular control drills—including closed-chain scapular work and proprioceptive training.

Full return to contact sports is generally permitted within 9 months, contingent upon meeting objective criteria—including symmetric shoulder ROM—at least 90% rotator cuff strength compared with the contralateral side, and pain-free performance of sport-specific tasks, such as push-ups, overhead presses, or throwing motions.

Discussion/Conclusion

Better Outcomes? Latarjet Versus Remplissage

Recent comparative studies have evaluated outcomes of arthroscopic Bankart repair with remplissage versus the Latarjet procedure in patients with subcritical bone loss and off-track Hill-Sachs lesions.^4,5 Yang et al ⁹ found that although both procedures yielded acceptable results, the Latarjet technique resulted in lower recurrence (5.5% vs 13%) and revision rates (6.6% vs 16.3%).

Better Outcomes? Long-Term Studies

Further, long-term studies suggest that the standard Latarjet procedure may be a more durable operation for preventing recurrent instability and revision surgery than the arthroscopic Bankart procedure, particularly in cases with significant glenoid bone loss. ¹⁰