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. 2017 Jun 19;6(3):e791–e799. doi: 10.1016/j.eats.2017.02.009

Latarjet Technique for Treatment of Anterior Shoulder Instability With Glenoid Bone Loss

Kevin J McHale a, George Sanchez b, Kyle P Lavery c, William H Rossy d, Anthony Sanchez e, Marcio B Ferrari b, Matthew T Provencher b,f,∗
PMCID: PMC5495908  PMID: 28706833

Abstract

Anterior glenohumeral instability is a common clinical entity, particularly among young athletic patient populations. Nonoperative management and arthroscopic treatment of glenohumeral instability have been associated with high rates of recurrence, particularly in the setting of glenohumeral osseous defects. Coracoid transfer, particularly the Latarjet procedure, has become the treatment of choice for recurrent anterior glenohumeral instability in the setting of osseous deficiencies greater than 20% to 30% of the glenoid surface area and may also be considered for the primary treatment of recurrent instability in the high-risk contact athlete, even in the setting of limited osseous deficiency. The following Technical Note provides a diagnostic approach for suspected glenohumeral instability, as well as a detailed description of the congruent-arc Latarjet procedure, performed with a deltoid split, with its postoperative management.

Anterior glenohumeral instability is a common clinical entity, particularly among young athletic patient populations, who have been reported to have shoulder instability at rates up to 2.8% per year.1 Nonoperative management of glenohumeral instability has been associated with high rates of recurrence in multiples studies, with recurrence rates ranging from 37% to 85%.2, 3, 4, 5, 6, 7, 8, 9 Arthroscopic stabilization procedures have been similarly associated with recurrent instability, with recurrence rates ranging from 10.8% to 21.1%.10, 11, 12, 13 As a result, it has become essential for physicians to recognize clinical factors that place patients at increased risk of failed nonoperative or arthroscopic treatment.

Shoulder instability treatment outcomes have been correlated with specific predictive clinical characteristics. Patient demographic factors, including age and involvement in competitive athletics, particularly contact sports, are known to predispose patients to recurrent shoulder instability after nonoperative and arthroscopic management.1, 4, 10, 11 In addition, instability-related intra-articular pathology may increase the risk of inferior outcomes after initial treatment, including labral tears, glenoid bone loss, Hill-Sachs lesions, capsular injuries such as humeral avulsion of the glenohumeral ligament (HAGL) lesions, anterior labral periosteal sleeve avulsion (ALPSA) lesions, and rotator cuff tears.10, 11, 12, 14, 15, 16, 17, 18

Osseous deficiency has been increasingly recognized as a significant risk factor for compromised outcomes after nonoperative and arthroscopic treatment of shoulder instability. Studies have attempted to delineate a degree of “critical” bone loss that predicts failure of soft-tissue stabilization techniques. Cadaveric biomechanical studies have suggested that anterior-inferior glenoid bone loss accounting for 19% to 21% of the glenoid width significantly compromises the stability of soft-tissue repair alone.19, 20 However, lower percentages of “subcritical” bone loss have been correlated with inferior clinical outcomes in the setting of arthroscopic soft-tissue stabilization.14 According to the glenoid track concept, as glenoid bone defect size increases, the glenoid track decreases in width and increases the probability that a Hill-Sachs lesion can engage the glenoid rim.21, 22 As a result, combined glenoid and humeral head bone loss has additive negative effects on glenohumeral joint stability. As little as 2 mm of glenoid bone loss in the setting of a medium Hill-Sachs lesion (1.47 cm3) and 4 mm of glenoid bone loss in the setting of a small Hill-Sachs lesion (0.87 cm3) have been correlated with failed soft-tissue Bankart repairs.23 Because of these findings, coracoid transfer, particularly the Latarjet procedure, has become the treatment of choice for recurrent anterior glenohumeral instability in the setting of osseous deficiencies greater than 20% to 30% of the glenoid surface area and may also be considered for the primary treatment of recurrent instability in the high-risk contact athlete, even in the setting of limited osseous deficiency.

Clinical Evaluation

It is essential to obtain a thorough clinical history and perform a comprehensive physical examination when evaluating a patient with suspected glenohumeral instability. As mentioned previously, multiple patient characteristics are correlated with treatment outcomes, including age and participation in contact sports. The clinician should understand circumstances surrounding both the initial instability event and recurrences, particularly the shoulder positions that provoke instability and the frequency of instability events. When treating an athlete, the physician also should have a solid understanding of the patient's sport, position, time in season, and future career goals to determine an appropriate treatment plan.

A complete physical examination of the bilateral shoulders should be performed in the standard fashion, including inspection, palpation, range-of-motion assessment, and examination of neurovascular status. Particular attention should be directed toward the examination of axillary nerve sensorimotor function and rotator cuff strength because these may be compromised in the setting of glenohumeral instability, particularly in older individuals. Multiple provocative maneuvers have been described for the detection of glenohumeral instability–associated pathology, including the load-and-shift, apprehension, relocation, and release tests. In addition, all patients with a history of instability should be assessed for clinical signs of multidirectional instability, including the sulcus sign, generalized ligamentous laxity, and hypermobility.

Careful analysis of radiographic and advanced imaging studies can assist in the recognition of clinically significant pathology. Initial evaluation of glenohumeral instability should always begin with the analysis of a standard shoulder radiograph series, including a true anteroposterior (Grashey) view and an axillary lateral view at a minimum. Additional radiographic views may assist in identifying instability-related osseous pathology, including the Velpeau, Stryker notch, West Point axillary, and Garth views.

After the evaluation of plain radiographs, it is prudent to obtain advanced imaging to further assess for both soft-tissue and osseous pathology. Although conventional magnetic resonance imaging has been reported to identify labral pathology with sensitivities of 76% to 93% and specificities of 68% to 87%, magnetic resonance arthrography has been reported to have improved diagnostic results, with sensitivities ranging from 88% to 92% and specificities ranging from 92% to 93%.24, 25, 26, 27, 28, 29 When glenohumeral osseous deficiency is suspected, computed tomography (CT) scans are particularly helpful in determining the extent of glenoid and humeral bone loss in cases of instability. Compared with radiography, conventional CT, and magnetic resonance imaging, 3-dimensional CT has been shown to be the most reliable imaging modality for the quantification of glenoid and humeral bone loss and can be combined with arthrography to allow for simultaneous assessment of soft-tissue structures in addition to the osseous anatomy.30, 31

Surgical Technique

Patient Positioning

After a preoperative ultrasound-guided interscalene block is performed for regional anesthesia, the patient is transported to the operating room (Video 1). General anesthesia is induced, and the patient is placed in the beach-chair position with all bony prominences appropriately well padded. A preoperative physical examination of the shoulder with the patient under anesthesia is then performed to confirm the positions and degree of glenohumeral instability. The shoulder is prepared and draped in the usual sterile fashion. The arm should remain draped free to allow for intraoperative manipulation of the upper extremity. The operative extremity is next secured in a pneumatic limb positioner (Smith & Nephew, Andover, MA) that was previously attached to the surgical table. A padded Mayo stand may also be used to support the arm in the event that a pneumatic limb positioner is unavailable.

Surgical Approach

When indicated, a standard diagnostic arthroscopy may first be performed with the patient in the beach-chair position to confirm the glenohumeral osseous deficiency warranting the Latarjet procedure or to treat concomitant intra-articular glenohumeral pathology (Fig 1). Once the surgeon is ready to proceed with the Latarjet procedure, the coracoid process is palpated and a 5- to 7-cm incision is made from the tip of the coracoid process extending distally along the deltopectoral interval to the superior aspect of the axillary fold (Fig 2). A standard deltopectoral approach is used. The subcutaneous tissue is bluntly dissected, and the clavipectoral fascia is opened in line with the skin incision. The cephalic vein is protected and retracted laterally with the deltoid musculature. Meticulous hemostasis is maintained throughout the approach. Self-retaining Kolbel retractors are inserted to maintain the interval between the deltoid and pectoralis major. In addition, a Hohmann retractor may be inserted superior to the coracoid to improve visualization.

Fig 1.

Fig 1

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Arthroscopic view of glenoid bone loss. After the induction of general anesthesia, the patient is placed in the beach-chair position with all bony prominences appropriately well padded. A routine diagnostic arthroscopy is performed in a right shoulder, showing the anterior glenoid defect and its relation to the humeral head (HH). (G, glenoid.)

Fig 2.

Fig 2

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Surgical approach. The open approach begins after the diagnostic arthroscopy. The coracoid process is palpated under the clavicle in this right shoulder. The coracoid is then marked with a surgical pen (arrow), and a line over the axillary fold is drawn. A 5- to 7-cm incision is marked from the tip of the coracoid process extending distally along the deltopectoral interval.

Coracoid Graft Harvest and Preparation

Obtaining sufficient exposure of the coracoid process is essential to optimize the coracoid graft harvest. During this step, care must be taken to avoid the coracoclavicular (CC) ligaments. Mayo scissors are used to expose the coracoid process from its tip to the insertion of the CC ligaments at its base. The coracoacromial ligament (CAL) is then identified with the aid of shoulder abduction and external rotation, which often improves its visualization. The CAL is transected approximately 1 cm from its insertion on the coracoid process, leaving a cuff of soft tissue (CAL) on the coracoid for later incorporation into the capsular repair. With the shoulder positioned in adduction and internal rotation, the pectoralis minor tendon is next released from its insertion on the medial aspect of the coracoid process sharply with an elevator. Soft tissue from the medial surface of the coracoid must also be released to allow for optimal conformity between this surface and the anterior glenoid margin. The axillary and musculocutaneous nerves should be identified and protected with digital palpation throughout the coracoid exposure. At this point, the coracoid process should be appropriately prepared for the graft harvest.

A 90° oscillating saw is used to harvest the coracoid bone graft by performing a medial-to-lateral osteotomy at a position just anterior to the insertion of the CC ligaments at the coracoid base (Fig 3). Before the osteotomy is performed, a ruler can be used to confirm that an appropriate graft length of 22 to 25 mm from the tip will be harvested. A Chandler elevator or similar instrument is placed beneath the coracoid process to protect the neurovascular structures during the osteotomy. Care should be taken to avoid directly retracting the axillary or musculocutaneous nerves with surgical instruments because this may result in postoperative neurapraxia. In addition, the blood supply to the coracoid process graft, which runs along the medial aspect of the conjoint tendon, should be preserved during the osteotomy. Although an osteotome may be used for completion of the osteotomy after the initial oscillating saw cut is performed, it is recommended to avoid use of an osteotome for the entirety of the osteotomy to decrease the risk of iatrogenic glenoid fracture. After the osteotomy is completed, the coracoid graft is held gently, just at the level of the incision, with grasping forceps, and the coracohumeral ligament is released, concluding the coracoid graft harvest. It is important to release the soft-tissue adhesions on the posterior aspect of the conjoint tendon to allow for ease of transfer. The musculocutaneous nerve is also visualized and gently released until it is free of tension all the way to the insertion site at the muscle.

Fig 3.

Fig 3

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Coracoid osteotomy. Once the coracoid process of the right shoulder is identified and the soft tissue is appropriately released, a 90° oscillating saw (arrow) is used to harvest the coracoid bone graft by performing an osteotomy at a position just anterior to the insertion of the coracoclavicular ligaments at the coracoid base.

The coracoid graft is next prepared for transfer. Any remaining soft tissue is debrided from the medial surface of the coracoid to improve conformity between this surface and the glenoid margin with an oscillating microsagittal saw or high-speed burr. The medial surface is decorticated until a broad, flat, cancellous surface is formed. Ultimately, the original inferior surface of the coracoid will line up with the glenoid face. During graft preparation, care is taken to preserve the CAL stump as well as the conjoint tendon insertion and its adjacent blood supply to the coracoid graft.

Glenoid Exposure and Preparation

After completion of the coracoid graft harvest, attention may be directed toward the glenoid exposure and preparation. The shoulder is placed in external rotation to optimize visualization of the subscapularis. The superior and inferior borders of the subscapularis are identified, and the junction of the superior two-thirds and inferior one-third of the subscapularis is marked with an electrocautery device. The subscapularis is then sharply split in line with its fibers along this junction (Fig 4). Mayo scissors are used to further divide the subscapularis along this longitudinal split and to develop the plane between the subscapularis and the anterior glenohumeral capsule. The subscapularis split is extended laterally to the lesser tuberosity to allow for the visualization of the glenohumeral joint line and capsule. A single-prong self-retaining Gelpi subscapularis retractor can then be inserted to maintain the exposure through the subscapularis split.

Fig 4.

Fig 4

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Subscapularis split. To access the anterior glenoid defect in a right shoulder, the subscapularis is sharply, longitudinally split along the junction of the superior two-thirds and inferior one-third of the muscle (arrow). We suggest an L-shaped capsulotomy. However, if significant scarring is encountered from prior surgical procedures, a T-shaped capsulotomy may also be used to optimize exposure.

An L-shaped capsulotomy is performed—superior first at the superior glenoid and then approximately 1 cm medial to the glenoid rim. If significant scarring is encountered from prior surgical procedures, a T-shaped capsulotomy may also be used to optimize exposure. The corner (superior-medial) of the capsule is then tagged with No. 2 high-strength suture to facilitate identification during subsequent capsular repair. The anterior-inferior glenoid labrum is next subperiosteally dissected off the glenoid neck by electrocautery. Once exposed, the anterior glenoid neck can be abraded with a high-speed burr to prepare the bed for the later coracoid transfer. Care should be taken to avoid removal of excessive bone because significant osseous deficiency may already be present in this region. Most important, a bleeding bed of bone on the anterior glenoid is essential along with preparation of the anterior aspect of the glenoid as perpendicular to the surface as possible.

Coracoid Process Transfer

Optimizing the position of the coracoid transfer is essential for a successful outcome after the Latarjet procedure. The objective of coracoid graft positioning is for the graft to be placed flush with the glenoid articular surface to allow for an extension of the glenoid articular arc. Excessive lateralization of the coracoid graft can result in an increased rate of postoperative degenerative changes about the glenohumeral joint. If the graft is excessively medialized, it may be subject to increased resorption and may fail to improve glenohumeral stability. The medial aspect of the coracoid graft conforms nicely to the anterior-inferior glenoid margin, and the prior decortication of the opposing surfaces creates a broad surface for osseous healing.

After a Fukuda retractor is placed in the glenohumeral joint to provide visualization of the anterior-inferior glenoid articular surface, the longitudinal axis of the coracoid graft is positioned superoinferiorly along the glenoid neck flush with the articular surface. The optimal position is between the 3- and 5-o'clock position on the glenoid. Two Kirschner wires may be placed into the coracoid graft to assist with positioning and later advanced into the glenoid neck for provisional fixation (Fig 5). Definitive screw fixation is then performed with a lag technique to optimize fixation stability and strength. A 2.5-mm drill is used to create 2 bicortical anteroposterior holes, approximately 1 cm apart, perpendicular to the longitudinal axis of the coracoid graft and parallel to the glenoid surface. The near cortex of the coracoid graft is then over-drilled with a 3.2-mm (or larger) drill according to the standard lag technique. A depth gauge is used to confirm screw length, typically 34 to 36 mm, and definitive graft fixation is achieved with the placement of two 3.5-mm cortical or 4.0-mm malleolar screws and washers with preloaded suture washers (Arthrex, Naples, FL) (Fig 6). After graft fixation, the glenoid articular surface should be reassessed to ensure proper graft position. At this point, a high-speed burr may be used to smooth any lateral prominence of the coracoid graft.

Fig 5.

Fig 5

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Positioning coracoid graft. Once the coracoid process of the right shoulder has been sufficiently cut and any remaining soft tissue is debrided from the medial surface of the coracoid to improve conformity between this surface and the glenoid margin, 2 Kirschner wires (white arrows) are placed into the coracoid graft (yellow arrow) to assist with positioning and are later advanced into the glenoid neck for provisional fixation.

Fig 6.

Fig 6

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Coracoid graft fixation. The 2 Kirschner wires previously introduced into the graft are used to transport and provisionally fixate the graft to the anterior aspect of the glenoid, which has been previously prepared. Once optimal leveling between the graft and native bone is verified, definitive fixation is performed with 2 anteroposterior 4.0-mm malleolar screws and suture washers (arrow), approximately 1 cm apart.

Capsule and Subscapularis Repair

With the arm adducted to the side and placed in approximately 45° of external rotation, the capsular repair is performed with No. 2 FiberWires preloaded in the suture washers (Arthrex), as well as with additional free high-strength No. 2 sutures and the CAL. The sutures are placed in a figure-of-8 style to allow for the imbrication of the capsular tissue (Fig 7). The CAL remnant on the coracoid graft is incorporated into the capsular repair for additional strength. The subscapularis split is next repaired with high-strength No. 2 suture. Careful attention is directed toward avoiding the long head of the biceps tendon when repairing the lateral-most extent of the subscapularis split. At the completion of the repair of the capsule and subscapularis, the conjoint tendon will exit medially and anteriorly through the previously divided segments of the subscapularis (Fig 8).

Fig 7.

Fig 7

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Fastening of preloaded suture washers. After placement of two 3.5-mm cortical or 4.0-mm malleolar screws and washers, preloaded suture washers (Arthrex) (Fig 6) are fastened for coracoid graft fixation in the right shoulder.

Fig 8.

Fig 8

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Completion of Latarjet procedure. The right arm is adducted to the side and placed in approximately 45° of external rotation to perform the capsular repair, utilizing the No. 2 FiberWires preloaded in the suture washers (Arthrex), as well as additional free high-strength No. 2 sutures and the coracoacromial ligament. At the completion of the repair of the capsule and subscapularis, the conjoint tendon will exit anteriorly through the previously divided segments of the subscapularis.

At this point, the wound is copiously irrigated and closed in a standard layered fashion. The deltopectoral interval is approximated in an interrupted fashion with No. 0 Vicryl (Ethicon, Somerville, NJ), and the cephalic vein is evaluated to ensure that it was not damaged. The subcutaneous dermal layer is then closed with interrupted No. 2-0 Monocryl (Ethicon) followed by a running subcuticular stitch with No. 3-0 Monocryl (Ethicon) to allow for improved cosmesis. Dermal skin glue and Steri-Strips (3M, St Paul, MN) are also applied to the skin closure to further reduce wound drainage. A postoperative dressing is applied in a sterile fashion followed by the application of a well-padded abduction sling. Pearls and pitfalls of our procedure are summarized in Table 1, whereas advantages and disadvantages are summarized in Table 2.

Table 1.

Pearls and Pitfalls of Our Technique

Pearls
 Place a Chandler elevator beneath the coracoid process to protect the neurovascular structures during the coracoid osteotomy.
 Preserve the blood supply to the coracoid process graft, which runs along the medial aspect of the conjoint tendon.
 Position the long axis of the coracoid graft in a superior-to-inferior orientation along the glenoid neck flush with the articular surface to allow for an extension of the glenoid articular arc.
 To optimize definitive graft fixation strength, use the lag technique to place 2 bicortical anteroposterior 3.5- to 4.0-mm screws perpendicular to the longitudinal axis of the coracoid graft and within 10% to 15% of the glenoid surface.
 In addition to incorporating the coracoacromial ligament stump into the capsular repair, use suture washers preloaded with No. 2 FiberWire sutures for additional capsular repair strength.
Pitfalls
 Direct retraction of the axillary or musculocutaneous nerves with surgical instruments, instead of digital palpation, may result in postoperative neurapraxia.
 Use of an osteotome to perform the entirety of the coracoid osteotomy, instead of a 90° oscillating saw, may increase the risk of iatrogenic glenoid fracture.
 Excessive medialization of the coracoid graft may fail to improve glenohumeral stability, whereas excessive lateralization of the coracoid graft can result in an increased rate of postoperative degenerative changes about the glenohumeral joint.
 Performing the capsular repair with the arm positioned in neutral or internal rotation, instead of 45° of external rotation, increases the risk of postoperative loss of external rotation.
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Table 2.

Advantages and Disadvantages of Our Technique

Advantages
 Adequate exposure of coracoid and glenoid defect
 Successful and reliable technique to avoid coracoclavicular ligaments and neurovascular structures during osteotomy of coracoid
 No arthroscopic proficiency needed
 No need for allograft, which decreases costs and heightens potential for bony union with native bone
 Use of screws with suture washers provides adequate fixation of graft to native bone
Disadvantages
 Technically demanding
 Open procedure, which leads to greater blood loss compared with arthroscopic procedure
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Postoperative Management

The goals of postoperative management are to optimize osseous healing at the coracoid transfer site and to protect the subscapularis repair. Typically, a sling is used for the first 3 to 4 weeks after surgery. However, during this initial period, the patient is permitted to perform gentle passive, active, and active-assisted shoulder range of motion in the scapular plane. In addition, no resisted elbow flexion is permitted for at least the first 6 weeks postoperatively. Anti-inflammatory pain medications are avoided in the early postoperative period to optimize osseous healing. Radiographs are obtained at clinical follow-up appointments (Fig 9). Once osseous healing is visualized, active strengthening is permitted. Return to contact sports or heavy labor activities is typically prohibited until approximately 4 months postoperatively.

Fig 9.

Fig 9

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Postoperative radiograph. A radiographic study in the axillary view of the right shoulder at 3 months after the Latarjet procedure shows coracoid graft fixation with 2 screws (arrow) inserted in an anteroposterior direction. One should note the restoration of the anterior defect, preventing recurrent anterior instability.

Discussion

The Latarjet procedure has been shown to consistently restore glenohumeral stability when used to treat instability-related glenoid soft-tissue and osseous pathology in both cadaveric biomechanical studies and clinical outcome studies. Three distinct mechanisms have been described that contribute to the stability of the Latarjet procedure.32 The primary stabilizing mechanism, known as the “sling effect,” is provided by the conjoint tendon's reinforcement of the dynamic stabilization offered by the lower subscapularis in the midrange and end range of shoulder abduction and external rotation. This sling effect has been reported to provide greater than 75% of the resistance to glenohumeral dislocation at the extremes of the apprehension position.32 The capsular repair with augmentation from the CAL, the second stabilizing mechanism of the Latarjet procedure, accounts for the additional stability at the end range of abduction and external rotation.32 However, the significance of the stabilizing mechanism has been questioned, given that capsular repair has been associated with decreased glenohumeral external rotation without providing additional stability compared with the Latarjet procedure performed without capsular repair in one cadaveric biomechanical study.33 The final stabilizing mechanism of the Latarjet procedure is provided by the reconstruction of the glenoid concavity by the coracoid transfer, which contributes a significant portion of glenohumeral stability in the midranges of motion.32, 34

Multiple clinical outcome studies have further confirmed the efficacy of the Latarjet procedure's ability to restore glenohumeral stability. Hovelius et al.35 reported a 3.4% recurrence rate after the Bristow-Latarjet procedure performed in 118 patients at 15-year follow-up, with a 98% satisfaction rate in their cohort. Mizuno et al.36 reported a postoperative recurrence rate of 5.9% at a mean of 20 years after 68 Latarjet procedures. Bhatia et al.37 reported the results of 10 clinical studies on the Latarjet procedure in their systematic review and showed postoperative recurrent instability rates ranging from 0% to 8%, with the duration of follow-up ranging from 6 months to 14.3 years. In a meta-analysis of 8 clinical studies comparing 416 shoulders treated with the Bankart repair versus 379 shoulders treated with the Latarjet procedure for instability, An et al.13 reported a significantly lower postoperative recurrent instability rate in the Latarjet cohort (11.6%) compared with the Bankart cohort (21.1%).

Although the Latarjet procedure has been shown to reliably restore glenohumeral joint stability, this procedure has been associated with postoperative complication rates up to 25%.38 Reported short-term complications after the Latarjet procedure include infection, hematoma, intraoperative graft fracture, graft malposition or malunion, nonunion, hardware complications including screw breakage, and neurovascular injury.38 Iatrogenic neurologic injuries are possibly the most concerning, given that clinically detectable transient axillary or musculocutaneous nerve deficits have been reported postoperatively in up to 20.6% of Latarjet procedures with intraoperative nerve monitoring alert episodes occurring in 76.5% of cases.39 Late coracoid graft resorption after Latarjet procedures is also increasingly recognized. Zhu et al.40 reported that some degree of coracoid graft resorption occurs after greater than 90% of Latarjet procedures; however, the clinical significance of this finding remains unclear because graft resorption did not correlate with functional outcomes or recurrent instability. In addition, long-term outcome studies have reported significant rates of glenohumeral arthropathy after Latarjet procedures. Hovelius et al.41 reported their radiographic outcomes of 115 shoulders treated with a Bristow-Latarjet procedure; they showed moderate to severe dislocation arthropathy in 14% of shoulders and an additional 35% with mild arthropathy at 15 years' follow-up. Cadaveric biomechanical studies have shown that excessive lateralization of the coracoid graft with prominence beyond the glenoid margin results in abnormal glenohumeral contact pressures and may contribute to the progression of glenohumeral arthropathy.42 However, the development of dislocation arthropathy after the Latarjet procedure appears to be consistent with the natural history of glenohumeral instability,43 as well as comparable to the results of soft-tissue Bankart repairs.44

In conclusion, the Latarjet procedure is a reliable option for the surgical management of recurrent anterior glenohumeral instability in the setting of osseous deficiencies greater than 20% to 30% of the glenoid surface area and may also be considered for the primary treatment of recurrent instability in the high-risk contact athlete, even in the setting of limited osseous deficiency. Surgeons must be aware of the complications related to this surgical procedure to take appropriate intraoperative precautions to limit patient risk, as well as to provide proper preoperative and postoperative patient education. This Technical Note should assist with performing the Latarjet procedure in an effective and safe manner.

Footnotes

The authors report the following potential conflict of interest or source of funding: M.T.P. receives support from Arthrex, JRF Ortho. Consultant. Patent numbers (issued): 9226743, 20150164498, 20150150594, 20110040339. Arthrex, SLACK. Publishing royalties.

Supplementary Data

Video 1

Latarjet technique. As evident by the clearly visible scar, this patient presents as a revision case for a prior intervention. The operative shoulder is examined preoperatively to assess the degree of instability. In this case, instability events can be readily induced multiple times. For exposure, an incision is made from the tip of the coracoid process extending inferiorly along the axillary fold for approximately 7 cm. At the completion of this incision, a self-retaining Kolbel retractor is placed between the pectoralis major and deltoid to maintain exposure. Mayo scissors are then used to further expose the coracoid. To harvest the coracoid graft, an osteotomy of the coracoid is performed with an oscillating saw blade just anterior to the coracoclavicular ligament insertion at the coracoid base. Next, the osteotome is used to complete the osteotomy with care taken to not split the fragment or extend the osteotomy to the glenoid articular surface. The coracoid fragment is now free and ready for preparation. The stump of incised coracoacromial ligament seen here will later be incorporated into the capsular repair. To aid and enhance graft union, the oscillating saw is used to decorticate the fragment. Then, after the shoulder is placed in external rotation, the superior and inferior borders of the subscapularis are identified, and the junction of the superior two-thirds and inferior one-third of the subscapularis is marked with an electrocautery device. The subscapularis is sharply split in line with its fibers along this junction. After this, a Gelpi retractor is used to open the subscapularis split. Once the subscapularis is split, a No. 2 high-strength suture is used to tag the corner of the capsule for later repair. A high-speed burr is then used to lightly decorticate the anterior glenoid neck. Two K-wires are placed temporarily in the graft to aid in manipulation and placement, as well as for provisional fixation of the graft. The screws that will be used for fixation are preloaded with suture washers. A cannulated drill is then used over the K-wires, through the previously drilled 4.0-mm holes in the graft, into the near cortex of the native glenoid, which will allow for lag screw compression. Two non-cannulated, fully threaded screws with suture washers are inserted. Next, in adduction and 45° of external rotation, the capsular repair is performed. At the completion of the repair, we see the conjoint tendon, necessary for reinforcement of dynamic stabilization during midrange and end-range shoulder abduction and external rotation. The conjoint tendon helps create the sling effect, which ultimately contributes to the stability of the Latarjet technique.

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References

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Supplementary Materials

Video 1

Latarjet technique. As evident by the clearly visible scar, this patient presents as a revision case for a prior intervention. The operative shoulder is examined preoperatively to assess the degree of instability. In this case, instability events can be readily induced multiple times. For exposure, an incision is made from the tip of the coracoid process extending inferiorly along the axillary fold for approximately 7 cm. At the completion of this incision, a self-retaining Kolbel retractor is placed between the pectoralis major and deltoid to maintain exposure. Mayo scissors are then used to further expose the coracoid. To harvest the coracoid graft, an osteotomy of the coracoid is performed with an oscillating saw blade just anterior to the coracoclavicular ligament insertion at the coracoid base. Next, the osteotome is used to complete the osteotomy with care taken to not split the fragment or extend the osteotomy to the glenoid articular surface. The coracoid fragment is now free and ready for preparation. The stump of incised coracoacromial ligament seen here will later be incorporated into the capsular repair. To aid and enhance graft union, the oscillating saw is used to decorticate the fragment. Then, after the shoulder is placed in external rotation, the superior and inferior borders of the subscapularis are identified, and the junction of the superior two-thirds and inferior one-third of the subscapularis is marked with an electrocautery device. The subscapularis is sharply split in line with its fibers along this junction. After this, a Gelpi retractor is used to open the subscapularis split. Once the subscapularis is split, a No. 2 high-strength suture is used to tag the corner of the capsule for later repair. A high-speed burr is then used to lightly decorticate the anterior glenoid neck. Two K-wires are placed temporarily in the graft to aid in manipulation and placement, as well as for provisional fixation of the graft. The screws that will be used for fixation are preloaded with suture washers. A cannulated drill is then used over the K-wires, through the previously drilled 4.0-mm holes in the graft, into the near cortex of the native glenoid, which will allow for lag screw compression. Two non-cannulated, fully threaded screws with suture washers are inserted. Next, in adduction and 45° of external rotation, the capsular repair is performed. At the completion of the repair, we see the conjoint tendon, necessary for reinforcement of dynamic stabilization during midrange and end-range shoulder abduction and external rotation. The conjoint tendon helps create the sling effect, which ultimately contributes to the stability of the Latarjet technique.

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