Clinical Faceoff: Latarjet Versus Free Bone Block Procedures for Anterior Shoulder Instability

Our advanced understanding of shoulder instability with bone loss has increased orthopaedic surgeons’ interest in glenoid bone reconstruction procedures, of which the Latarjet procedure is the most well established [10]. While the Latarjet technique (Fig. 1) seems to be more liberally performed in France, where this procedure originated more than 70 years ago, its indications seem to be tighter in the United States, perhaps because of either different preferences in training programs or the complication profile associated with this nonanatomic glenoid bony reconstruction. Numerous reconstruction techniques using free bone blocks have been proposed as theoretically safer alternatives to the gold-standard Latarjet procedure with seemingly similar clinical effectiveness [7]. This raises the question: What is the ideal bony glenoid reconstruction procedure in anterior shoulder instability?

Fig. 1.

An illustration depicting the Latarjet procedure and surrounding neurovascular structures is shown. The figure depicts the subscapularis split approach with fixation of the coracoid graft using two screws. Published with permission from Varsha Sharma.

To take a deeper dive into this treatment dilemma, I am joined by two internationally renowned experts on shoulder instability: John M. Tokish MD and Johannes Barth MD. Dr. Tokish is a Professor of Orthopedic Surgery at the Mayo Clinic Arizona, where he is the Associate Chair for Orthopedic Research and the Director of the Orthopedic Sports Medicine Fellowship. He is currently the First Vice President of The Arthroscopy Association of North America. Dr. Barth completed his shoulder fellowships in the United States and France and is a past-president of the Francophone Arthroscopy Society.

Mariano E. Menendez MD: How have your thoughts about managing shoulder instability with bone loss changed over the past decade?

John M. Tokish MD: The more experience I’ve gained, the more respect I have for the consequences of bone loss in shoulder instability. We now understand that “subcritical” bone loss results in poor Western Ontario Shoulder Instability scores even in patients who do not recur. Additionally, we now consider both sides of the joint to account for bipolar bone loss [15]. I have gained more experience with the remplissage technique [14], which involves “filling” the Hill-Sachs lesion with the posterior capsule, which pulls the head posteriorly preventing engagement of the Hill-Sachs lesion. The results have been promising, but there remains concern for recurrent instability in contact athletes, throwers, and in those patients whose Hill-Sachs lesion is not oriented so as to be amenable for a remplissage.

The Latarjet procedure continues to invite controversy, with strong proponents noting its low risk of recurrent instability in nearly all populations, even with longer term follow-up. Its detractors, however, continue to voice concerns about the complication profile; complications are uncommon, but they can be serious. The inescapable dilemma remains that the Latarjet, when done well, results in excellent outcomes. To do the operation well requires considerable experience to surmount a steep learning curve, and the reality is that most Latarjet procedures are and will continue to be performed by those with less experience and lower surgical volumes.

I have also learned that there may be a middle ground. Bone loss can be addressed with safer approaches that do not put nerve injury in play. Bone graft sources like the distal clavicle autograft, the distal tibia allograft, the iliac crest, and others have evolved into promising surgical approaches [6, 13] that may provide an effective solution with a lower risk of complications for patients with bone loss.

Johannes Barth MD: Bone loss represents more of a concern when performing soft tissue procedures than it is with the Latarjet. Burkhart and De Beer [3] were among the first who pointed out the high risk of recurrence with arthroscopic Bankart procedures in patients with bone loss, especially in contact athletes (in whom they showed that 89% experienced recurrent dislocations). Balg and Boileau [1] developed the Instability Severity Index Score to better anticipate the risk of recurrent instability after an arthroscopic Bankart procedure, and stated that an arthroscopic Bankart should not be performed in patients with an Instability Severity Index Score over 4 points. However, a longer term (9-year follow-up) prospective multicenter study from the Francophone Arthroscopy Society brought that score down to ≤ 2 [17]. Researchers use complex geometric algorithms centered around the concept of engaging the Hill-Sachs lesion and the glenoid track as a way to find a theoretical base for when to recommend different treatment options. These algorithms, however, are difficult to validate in clinical trials [4]. Sure, the remplissage procedure has been associated with low recurrence rates at 2 years that are comparable to that seen with the Latarjet. However, these low recurrence rates come at the expense of decreased external rotation. Longer follow-up is needed to evaluate whether recurrences could occur later and if external rotation stiffness could increase the risk of arthritis progression [9]. My algorithm for when to perform Latarjet is quite straightforward: any patient younger than 60 years old with recurrent instability, regardless of risk factors.

Regarding the high complication rates associated with Latarjet reported by some groups, I agree that this procedure is technically demanding and difficult to teach. Alternative open and arthroscopic techniques using free bone blocks are seeing wider use, but only time and further research will tell if these promising techniques avoid Scott’s parabola, a model to illustrate the cyclical rise and fall of a surgical technique [11]. I believe that the Latarjet procedure is and will remain the gold standard for anterior shoulder instability.

Dr. Menendez: The Latarjet procedure was first described in France in the 1950s. Seventy years later, what role does it play in your surgical armamentarium?

Dr. Barth: Currently, in my personal registry of anterior shoulder instability surgeries that I started in 2005, I have performed 710 open Latarjet procedures, 120 arthroscopic Bankarts, and 20 arthroscopic Latarjet techniques. Interestingly, when I returned to France after my fellowship in the United States with Dr. Stephen Burkhart, I was performing as many Latarjet as Bankart procedures (Fig. 2), and I also followed the trends of arthroscopic Latarjet. But I am currently back to doing open Latarjet in 90% of my patients with shoulder instability. I use the same technique as popularized by Gilles Walch, with the exception of a drill guide that improves the reliability of the coracoid graft placement [2]. This is unique, as most of our techniques have evolved substantially over time. Why is this not the case for open Latarjet? Because nothing outperforms the open Latarjet: early return to daily activities at 2 weeks and return to sport at 3 months with 2% recurrent rate in long-term follow-up [5].

Fig. 2.

Dr. Barth’s annual number of surgical procedures for anterior shoulder instability is shown. A color image accompanies the online version of this article.

Dr. Tokish: The Latarjet has its fierce proponents, who often are excellent surgeons who have seen a well done arthroscopic Bankart result in recurrent instability. Perhaps the best argument for the Latarjet is Dr. Burkhart himself, the most staunch advocate of arthroscopic shoulder surgery, who abandoned it in the setting of bone loss and who taught us all the limits of the arthroscopic Bankart [3]. Anyone experienced with arthroscopic Bankart surgery has experienced this frustration. And it is understandable that a conscientious surgeon may abandon the arthroscopic Bankart for the Latarjet. But I would caution against throwing the baby out with the bathwater. There are, I believe, three reasons for a more nuanced approach: First, patients with anterior instability often have additional pathology, especially posteriorly, that cannot be addressed with an isolated open Latarjet. In our series of young active instability patients, nearly 20% of anterior instability patients had a posterior component that we were able to treat arthroscopically by just extending the labral reconstruction [16]. A “Latarjet-only” approach either neglects this pathology or requires a second approach. Further, there are some bone loss situations that are not converted back to an “on-track” situation after Latarjet. Mook et al. [12] demonstrated that such patients have high recurrence and worse results.

Second, the risk of complication for the Latarjet approach is not ideal. The worst, of course, is the permanent nerve motor injury, which has been estimated to be between 2% and 5% [19]. Even if it is at the low end of this range, if one does even a modest 50 Latarjets/year, that equates to about one devastating complication per year. Now, many proponents would say they have never had a major nerve injury under their watch; I haven’t either, but I sure worry about it. I have seen too many good surgeons send patients to me with this problem. And it isn’t just the nerve injury: Screw problems, graft malposition, and resorption are all common reasons to revise a Latarjet.

Finally, we need to commit to a reproducible, simple, and safe approach. We all owe Drs. Walch and Burkhart a debt of gratitude for teaching us that an isolated arthroscopic Bankart in the setting of bone loss will not work, and for teaching us the Latarjet, which does. But these are steps on the path to an ideal approach. I think most would agree that ideally, we would like to have a surgical approach to instability that is effective, minimally invasive, reproducible, simple, and anatomic. It is exciting to see innovative surgeons around the world pursue this goal. With newer free bone block techniques and advances such as the remplissage procedure, I believe we will achieve this balance of stability and simplicity in the course of our lifetimes.

Dr. Menendez: The Latarjet procedure may have a higher complication profile compared to free bone block techniques, but it has the theoretical benefit of the sling effect. How should surgeons consider this trade-off?

Dr. Barth: Yamamoto showed that the sling effect was the main stabilizing effect of the procedure [20]. The beauty of this technique is the triple stabilizing effect described by Patte [2]: (1) the capsular retention with the coracoacromial stump, (2) the bone augmentation, and (3) the sling effect to counterbalance the distention/deterioration of the anterior capsule. I do not believe in the durability of capsular retention. I think this is why recurrences occur over time with isolated soft tissue procedures. Furthermore, the sling effect is unique to the Latarjet procedure and does not occur during free bone block techniques.

The risk of complications varies substantially among surgeons. This is likely reflective of the fact that this technique is demanding and needs to be well transmitted as it is in France, so as to minimize the risk of complications, especially neurological complications. Godenèche et al. [8] have reported that about 6% of patients will experience a complication following this procedure, but half of those are hardware-related and resolve with simple screw removal. In my opinion, the reliably low rates of recurrent dislocation associated with Latarjet offset the small risk of complications in our hands.

Dr. Tokish: The sling effect undoubtedly plays a role in the setting of instability. For proponents of the Latarjet procedure, it forms one of the three pillars of the “triple blocking effect.” I do not dispute that it can have an important role. But there is room for discussion here. While most laboratory studies have shown an important effect, the role of the sling effect may not be as important clinically when bone loss itself is corrected. For instance, consider the study that compared iliac crest bone graft to the Latarjet [13], or the series that compared distal tibial allograft versus Latarjet [6]. Both studies showed comparable restoration of stability, and in each study, half of the patients had no sling effect yet achieved similar results. This leads us to question whether the sling effect is important at all, or if it is merely the restoration of bone loss that restores stability. Indeed, my bony glenoid reconstruction procedure of choice currently consists of a free bone block technique using either distal clavicle autograft (in cases of subcritical bone loss) or distal tibia allograft (for larger defects), done arthroscopically with suture anchor fixation [18].

Dr. Menendez: What are some of the gaps in knowledge in the treatment of shoulder instability, and how do you counsel your patients considering these gaps?

Dr. Tokish: There remain many gaps in the treatment of shoulder instability with bone loss. We still do not know the limits of the arthroscopic Bankart in the setting of the active athlete, and we do not know the limits of bone loss in its treatment.

The role of the sling effect in the Latarjet has long been touted as one of its most critical components. This would imply that bone transfers without the associated soft tissue of the conjoined tendon should be at risk for failure. While this has been shown in the lab, several studies to date have shown no difference in the in vivo setting, but longer term follow-up is required [7].

In the clinical setting, it is important to counsel patients that shoulder instability is a serious threat to their future participation in sports, and that even the best of operations may result in the risk of not returning to play. It is important to ensure that the patient and their support system (parents, therapists, trainers, and coaches) are aware of the entire recovery period and the importance of postoperative protection and rehabilitation.

Treating shoulder instability calls for the use of a complex algorithm. The surgeon must be adept at many approaches, both arthroscopic and open, and have a thorough understanding of each patient’s future goals, as well as the strengths and limitations of all of the tools in the toolbox.

Dr. Barth: I completely agree with Dr. Tokish, except for the last paragraph because I like simple things. If the algorithm is complex, it will not be embraced by our community, and I truly believe that it may just be a way to find an excuse not to perform Latarjet for everyone. I rarely perform arthroscopic Bankart repairs in my practice, only in certain elderly patients with concomitant rotator cuff tears or a painful unstable shoulder; otherwise, Latarjet for everyone else, which makes my algorithm very straightforward.

We have to remember our mission: These young patients ask us to address the problem of recurrent anterior instability, and they want to be back to their sports as soon as possible. With the Latarjet, I can offer them full return to sport at 3 months with a very low recurrence rate. The price is the small risk of an additional surgery to remove the screws in 4% of patients, but that procedure will not limit them more than a couple of weeks. Most of the complications associated with Latarjet can be avoided by learning its well-identified technical errors, which is a good reason to do a great fellowship in France for our young, open-minded colleagues.