Open Dynamic Anterior Stabilization After Failed Latarjet Procedure With Retained Coracoid Bone Block

Abstract

Recurrent anterior shoulder instability after Latarjet remains challenging and may result from graft malposition, nonunion, resorption, or unrecognized associated lesions. In cases with limited bone loss, revision options are not clearly defined. Dynamic anterior stabilization, which recreates a biceps‐based sling effect, offers an intermediate solution between soft‐tissue repair and bone reconstruction. Supported by biomechanical and clinical data, dynamic anterior stabilization preserves motion and shows low recurrence rates. This article describes the open dynamic anterior stabilization technique and its clinical outcomes as a revision strategy after a failed Latarjet while preserving bone stock.

Recurrent anterior shoulder instability remains a major challenge, particularly in young, athletic individuals with high functional demands. ¹ , ² Although the Latarjet procedure is considered the gold standard in cases of instability associated with significant glenoid bone loss, it is not without complications or failure. ³ Recurrences after Latarjet, although uncommon, remain a challenge for the surgeon and justify an optimized revision strategy. ⁴ Among the identified causes are graft malposition, nonunion, bone resorption, and associated lesions that were initially undiagnosed (Hill‐Sachs, SLAP, and capsulolabral insufficiency). ⁴ The most commonly used revision techniques, such as the Eden‐Hybinette procedure or capsuloplasties, provide acceptable outcomes but without a clear consensus regarding optimal indications. ⁴ , ⁵ , ⁶ In this therapeutic gray zone—where stability must be restored without necessarily requiring another bony augmentation—dynamic anterior stabilization (DAS) offers an appealing alternative. Derived from the transfer of the long head of the biceps through the subscapularis to recreate a “sling effect” similar to that of the coracoid bone block, DAS positions itself between an isolated Bankart repair and more extensive bony reconstruction. ³ , ⁷ , ⁸ Biomechanical studies have shown that DAS significantly reduces anterior translation compared with isolated Bankart repair, particularly in cases of moderate bone loss (<20%), ⁹ whereas clinical studies confirm its value in treating recurrent instability with minimal bone loss, preserving range of motion, and showing low recurrence rates. ¹⁰ Although DAS is currently described predominantly as an arthroscopic technique, ⁸ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ its application in open surgery represents an alternative in the setting of failed Latarjet procedures. In this article, we detail the surgical technique and clinical outcomes of open DAS as a revision option after failure of a Latarjet procedure.

SURGICAL TECHNIQUE

Preoperative Considerations

Recurrent dislocation or persistent instability after a previous Latarjet procedure represents the primary indication for revision using an open DAS technique. A preoperative magnetic resonance imaging or computed tomography arthrography (Figure 1) is systematically obtained to assess residual glenoid bone stock and evaluate associated soft‐tissue pathology.

FIGURE 1.

Preoperative axial CT arthrography of a left shoulder showing a residual bone block with good fusion but persistent anterior subluxation of the humeral head associated with anteroinferior arthropathy. Green: native glenoid. Yellow: coracoid bone block. (CT, computed tomography.)

Anesthesia and Patient Positioning

An interscalene nerve block is performed in addition to general anesthesia. The patient is placed in a slight beach‐chair position. A bump is positioned along the medial border of the scapula to increase glenoid retroversion and optimize anterior exposure.

Approach

A detailed video shows the step‐by‐step technique, facilitating reproducibility of this relatively simple surgical procedure (Video 1). A standard deltopectoral approach is reopened. The long head of the biceps tendon is identified in its groove (Figure 2). The rotator interval is opened, followed by a juxtaglenoid tenotomy of the biceps (Figure 3). The tendon is retrieved at the bicipital groove and secured with a traction suture.

VIDEO 1.

Download video file ^{(86.1MB, mp4)}

Surgical technique of a left shoulder describing the main steps of open dynamic anterior stabilization after failed Latarjet procedure with retained coracoid bone block. Video content can be viewed at https://doi.org/10.1002/atn2.70291.

FIGURE 2.

Left shoulder view in a beach‐chair position. On the left, the rotator interval is opened and the long head of the biceps is identified in its groove. On the right, juxtaglenoid tenotomy is performed. Blue: rotator interval. Black: long head of the biceps.

FIGURE 3.

Left shoulder view in a beach‐chair position. After subscapularis split and capsulotomy, the glenoid is exposed using a Fukuda retractor. Green: glenoid. White: humeral head.

The subscapularis is split in line with its fibers; the muscular portion is further dissected using Mayo scissors. A capsulotomy is performed, and a Fukuda retractor is inserted to expose the coracoid bone block (Figure 3). The existing fixation hardware is identified and removed.

Biceps Fixation and Capsuloplasty

After placing a K‐wire in the desired position, adapting to the pre‐existing screw holes, a drill hole of appropriate size for the anchor is made (Figure 4). The interference anchor (TenoLok, CONMED, Utica, NY) is then inserted with the end of the biceps tendon positioned in an inlay position (Figure 4). Rotational movements and anterior subluxation of the humeral head are performed to ensure proper stability of the construct (Figure 5). Finally, a capsuloplasty is performed from the distal pole toward the proximal pole, restoring tension and reinforcing anterior stability. Table 1 summarizes the pearls and pitfalls of this technique.

FIGURE 4.

Left shoulder view in a beach‐chair position. On the left, a drill hole is made in the desired position. On the right, the interference anchor (TenoLok, CONMED, Utica, NY) is inserted. Green: glenoid. White: humeral head. Black: long head of the biceps.

FIGURE 5.

Left shoulder view in a beach‐chair position. Final view of the construct. Black: long head of the biceps. Blue: capsule. White: humeral head.

TABLE 1.

Pearls and Pitfalls

Pearls
Perform a subscapularis split combined with a wide capsulotomy to allow adequate visualization of the hardware and facilitate release of fibrotic tissue
Ensure the appropriate screwdriver is available for removal of the retained hardware
Do not hesitate to create a new trajectory for optimal anchor placement
Perform the capsulotomy from distal to proximal rather than from lateral to medial

Pitfalls
Failure to confirm that the long head of the biceps tendon has not been tenotomized
Inadequate exposure of the coracoid bone block
Use of a less secure fixation construct, such as an onlay pseudosuture, instead of a solid inlay anchor fixation

Postoperative Rehabilitation

Sling immobilization is applied for a duration of 4 weeks. The patient is allowed to mobilize the shoulder immediately as long as it remains below the pain threshold. A clinical follow‐up at 4 weeks allows the removal of the sling and the start of active rehabilitation with the physiotherapist. The return‐to‐sport activities is gradual, starting from the third postoperative month, with a return‐to‐contact sports between 4 and 6 months.

DISCUSSION

Recent clinical investigations have reported promising outcomes for the use of DAS as a first‐line treatment for recurrent anterior shoulder instability with bone loss <20%. ⁷ These findings are further supported by biomechanical studies, showing a significant reduction in anterior humeral head subluxation. ⁹

Although the Latarjet procedure is widely regarded as the gold standard, it is associated with a non‐negligible complication profile. ⁴ , ⁵ , ⁶ Persistent instability, postoperative apprehension, and residual pain are among the complications that may necessitate revision surgery. In such scenarios, where an additional bone graft may be inappropriate, ³ consideration of a less invasive surgical alternative is warranted.

Numerous arthroscopic surgical techniques have been described to restore capsular tensioning. ¹⁸ , ¹⁹ , ²⁰ , ²¹ However, given that capsular integrity may be compromised after a Latarjet procedure—particularly in cases of failure—it appears relevant to introduce higher quality soft tissues. The long head of the biceps can fulfill this dual function by providing both a stabilizing “hammock effect” and supplementary capsular reinforcement. Table 2 summarizes the advantages and disadvantages of this technique.

TABLE 2.

Advantages and Disadvantages

Advantages
Simple and reproducible surgical technique
Allows management of associated SLAP lesions
Enables treatment of potential hardware‐related impingement

Disadvantages
Does not restore bone stock
Does not address associated posterior instability
Does not allow filling of a humeral head Hills‐Sachs defect

This technique is indicated only in selected patients while preserving bone stock and cannot be generalized to cases with significant bone deficiency requiring bony augmentation procedures. The absence of restoration of bone stock represents a potential limitation in long‐term stability, particularly in high‐demand or contact athletes. This study lacks long‐term clinical and radiological outcomes, and further prospective comparative studies are needed to better define the indications and durability of this approach in the setting of failed Latarjet procedures. In addition, this technique does not address associated posterior instability or engage Hill‐Sachs lesions, which may require complementary procedures.

Persistent instability after a LATARJET procedure, although uncommon, remains a significant challenge for the surgeon. Achieving reliable and reproducible outcomes is therefore a primary objective. Our open DAS technique appears to offer a dependable solution to address these demands.

DISCLOSURES

The authors (C.H., G.L., Y.B.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.