Treatment of Shoulder Instability - Latarjet Procedure

Frédéric Balg, M.D., FRCSC
Orthopaedic Surgeon, Centre Hospitalier Universitaire de Sherbrooke
Associate Professor, University of Sherbrooke
Sherbrooke, QC

Numerous surgical options have been proposed to treat anterior shoulder instability. With increased understanding of the underlying primary lesion, Bankart repair gained popularity, especially with the advent of arthroscopic surgery. In North America, arthroscopic Bankart repair is the surgeon's preferred treatment for most patients. According to recent studies, the recurrence rate is believed to stand between 5 to 15%, yet some patients remain less satisfied with this soft tissue procedure.

 

In a study by Burkhart and De Beer1, the recurrence rate of arthroscopic Bankart repair increased to 67% when a significant bone lesion was present, and up to 87% in contact athletes with bone lesions. When treated by a modified Latarjet open procedure, the same population experienced a recurrence rate of 4.9%2. Therefore, patient selection in these procedures is important. The Instability Severity Index Score3 (ISIS) allows a preoperative evaluation of this risk based on patient history (i.e. age, type of sport), physical exam (shoulder hyperlaxity), and shoulder X-ray (Hill-Sachs and glenoid lesion). This consultation tool was validated and a score of ≥4 suggests that a Bankart repair alone would not be adequate4, 5.

If a Hill-Sachs bone lesion is present, an arthroscopic Bankart repair associated with a "remplissage"(filling of the bone defect) may be a solution6. But for glenoid lesions, no arthroscopic option exists. If the osseous defect is ≥6mm (≥19% glenoid length), a biomechanical study showed that Bankart repair alone could not restore adequate stability, but the addition of a glenoid bone graft restored adequate stability7. The numerous methods that exist to calculate this bone lesion were reviewed by Piasecki et al.8, and Latarjet procedures or Iliac bone grafts were recommended for certain defects between 15-25%, and for all defects >25%.

BALG_FIG_1
Figure 1: In abduction-external rotation, the humeral head can easily dislocate (A). After the Latarjet procedure (B) the coracobiceps tendon maintains the lower third of the subscapularis inferior and prevents the anterior dislocation.
 

A bone block procedure was created by Latarjet in 1954 in a paper in which he described a coracoid bone block that passes through the fibers of the subscapularis and secures flush to the anteroinferior glenoid using a screw9. The Bristow procedure was later described using only the tip of the coracoid10. In theory, the bone effect of this procedure is less than that of the Latarjet, but it was explained that the efficiency was attributable to the bracing role played by the coracobiceps tendon and the subscapularis fibers in abduction-external rotation rather than by the bone block itself11. Patte12 proposed the term "triple block" to best explain the Latarjet effect: (1) stable screw fixation, (2) preservation of the subscapularis, (3) and capsular repair to the coracoid.

The technique is well described by Walch et al.13. The coracoid is exposed through a small deltopectoral approach. The coracoacromial ligament (CAL) is incised 1cm from its coracoid attachment, the pectoralis minor is released from the coracoid, and a 2.5 to 3cm fragment of the coracoid is harvested to be used as a graft. With an oscillating saw, the inferior coracoid surface is decorticated up to the cancellous bone and two holes are drilled. The glenoid is exposed by splitting the fibers of the subscapularis at the junction of its inferior third, and the capsule is incised at the joint line. An osteotome is used to decorticate the anteroinferior glenoid surface. The coracoid graft is then secured to the anteroinferior glenoid with two screws. The anterior capsule is repaired to the stump of CAL.

A paper by Young et al.14 presented some technical pearls of wisdom in avoiding complications. Of the most important: (1) avoid coracoid fracture by "2-finger" screw tightening technique; (2) decrease degenerative joint disease by insuring the coracoid is not lateralised nor overhanging; (3) prevent non-union by compressing the two cancellous bone surfaces with two screws and maximizing contact surface using the inferior surface of the coracoid; (4) avoid stiffness by using subscapularis split approach and suturing the capsule with the arm in external rotation; and (5) avoid subscapularis fatty infiltration by using the splitting approach.

The recurrence rate of the Latarjet procedure is reported to be between 0% and 5%, with a mean loss of 0° to 10° of external rotation13-16. Subscapularis split leads to a less fatty infiltration and better functional results17. The occurrence of arthropathy at 15 years is 14%, which is similar to Bankart repair16.

In conclusion, the Latarjet procedure is a reliable technique to treat anterior instability in patients with risk factors, especially those with glenoid bone defects or combined glenoid and humeral head bone defects. Excellent results and patient satisfaction is achievable while minimizing complication rates by following the technique and heeding certain technical notes.


References

  1. Burkhart S.S., De Beer J.F. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy : the journal of arthroscopic & related surgery. 2000;16(7):677-94.
  2. Burkhart S.S., de Beer J.F., Barth J.R.H, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy : the journal of arthroscopic & related surgery. 2007;23(10):1033-41.
  3. Balg F., Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. Journal of Bone and Joint Surgery British Volume. 2007;89(11):1470-7.
  4. Rouleau D.M., Hébert-Davies J., Djahangiri A., Godbout V., Pelet S., Balg F. Validation of the Instability Shoulder Index Score in a Multicenter Reliability Study in 114 Consecutive Cases. American Journal of Sports Medicine. 2013;41(2):278-82.
  5. Thomazeau H., Courage O., Barth J., et al. Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score. Orthopaedics & traumatology, surgery & research. 2010;96(8 Suppl):S77-83.
  6. Purchase R.J., Wolf E.M., Hobgood E.R., Pollock M.E., Smalley C.C. Hill-sachs "remplissage": an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy : the journal of arthroscopic & related surgery. 2008;24(6):723-6.
  7. Yamamoto N., Muraki T., Sperling J.W., et al. Stabilizing mechanism in bone-grafting of a large glenoid defect. Journal of Bone and Joint Surgery American Volume. 2010;92(11):2059-66.
  8. Piasecki D.P., Verma N.N., Romeo A.A., Levine W.N., Bach B.R., Provencher M.T. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. Journal of the American Academy of Orthopaedic Surgeons. 2009;17(8):482-93.
  9. Latarjet M. Treatment of recurrent dislocation of the shoulder. Lyon chirurgical. 1954;49(8):994-7.
  10. Helfet A.J. Coracoid transplantation for recurring dislocation of the shoulder. Journal of Bone and Joint Surgery British Volume. 1958;40-B(2):198-202.
  11. May V.R. A modified Bristow operation for anterior recurrent dislocation of the shoulder. Journal of Bone and Joint Surgery American Volume. 1970;52(5):1010-6.
  12. Patte D., Debeyre J. Luxation récidivantes de l'épaule. Encyclopédie Médico-chirurgicale. Paris1980. p. 4.-02.
  13. Walch G., Boileau P. Latarjet-Bristow Procedure for Recurrent Anterior Instability. Tech Shoulder Elbow Surg. 2000;1(4):256-61.
  14. Young A.A., Maia R., Berhouet J., Walch G.. Open Latarjet procedure for management of bone loss in anterior instability of the glenohumeral joint. Journal of Shoulder and Elbow Surgery. 2011;20(2 Suppl):S61-9.
  15. Matthes G., Horvath V., Seifert J., et al. Oldie but goldie: Bristow-Latarjet procedure for anterior shoulder instability. Journal of orthopaedic surgery (Hong Kong). 2007;15(1):4-8.
  16. Hovelius L., Sandström B.C., Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. Journal of Shoulder and Elbow Surgery. 2006;15(3):279-89.
  17. Maynou C., Cassagnaud X., Mestdagh H. Function of subscapularis after surgical treatment for recurrent instability of the shoulder using a bone-block procedure. Journal of Bone and Joint Surgery British Volume. 2005;87(8):1096-101.

 

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