Shoulder instability and dislocation: arthroscopic coracoid process transfer (latarjet procedure)

Definition and indication of Latarjet procedure:

If proper shoulder rehabilitation is not sufficient and recurrent shoulder dislocation episodes or relocation apprehension (cocking position, external rotation position 2) causing incapacitating discomfort persist, arthroscopic stabilization surgery on the shoulder must be considered.

When there is an osseous lesion to the glenoid (Bony Bankart) and/or when the patient practises contact sports (rugby, judo, handball, volleyball, basketball) with a high risk of shoulder dislocation, shoulder stabilization surgery must be considered. Surgery consists in bone blocks positioned anterior to the glenoid. To build these bone blocks, a transfer of a section of the coracoid process is performed; this is known as the arthroscopic Latarjet procedure (@Latarjet) or Bristow-Latarjet procedure.

This procedure, which improves shoulder stability by means of additional bone and tendon (conjoint tendon) material, is non-anatomic stabilization surgery for reinforcement. It is the opposite of anatomic bipolar fixation repair surgery. It is the procedure that is typically suggested to young adults who play rugby in our region.

Video of arthroscopic Latarjet procedure:

Video of arthroscopic shoulder surgery showing Latarjet procedure / Toulouse specialist

Benefit of arthroscopy in Latarjet procedures:

The advantage of this arthroscopic Latarjet procedure over traditional open surgery is that it allows a complete diagnostic assessment to be carried out: the posterior capsule, the superior labrum (SLAP lesion) can be evaluated and repaired on an individual basis.

Traditional open Latarjet surgery is confined to the anterior (frontal) approach portal, forbidding 360° access to repair all shoulder dislocation lesions.

Only arthroscopy makes it possible to combine procedures and address all shoulder instability lesions: posterior fixation and Latarjet, SLAP treatment and Latarjet, bipolar fixation and Latarjet

Principle and benefit of arthroscopic Latarjet

 

Shoulder surgery technique: Latarjet procedure

The Latarjet procedure is performed on an outpatient basis, under regional and general anaesthesia. The patient is in the beach chair position.

For the first operative stage, the optics (camera) are introduced through the posterior portal, allowing exploration of the shoulder joint and assessment of instability factors to be carried out: labral lesions, tear of the inferior gleno-humeral ligament, osseous and ligamentous lesions of the glenoid, posterior humeral dent, SLAP lesion.

The Latarjet procedure makes it possible to treat the posterior humeral dentHill-Sachs lesion exposed at arthroscopy

 

 

Surgery begins by posterior fixation, then attention is turned to the anterior instability lesions. The surgeon starts by debriding the anterior aspect of the glenoid and releasing the subscapularis; the anterior aspect of the glenoid is then freshened at the site of the transfer.
The rotator interval is then opened to expose the coracoid process which is released; only the conjoint tendon is kept. This tendon will contribute to shoulder stability, particularly for external abduction-rotation.

Bony Bankart, glenoid fracture with blunting, CT arthroscopyAnterior glenoid fracture, Bony Bankart, shoulder arthroscopy

 

The subscapularis is then split in line with its fibers at its deep aspect, where the 2/3-1/3 junction is. Once this surgical procedure is performed, a guide is positioned at this deep split so that it can be located from the anterior extra-articular portal.

In the second stage of the procedure, the optics are introduced through the anterior portal, the surgeon locates the guide transfixing the subscapularis and can then complete muscle splitting to expose the glenoid.

When this surgical stage is finished, the coracoid process is prepared and a guide placed to help the positioning of the top hats that will accommodate the screws of the future block.  Osteotomy of the coracoid process is then prepared with a burr and finalized with the osteotome.

 

Positioning of bone block opposite Bony BankartVerification of coracoid block protrusion, shoulder arthroscopy

 

Using the guide handle it is possible to retrieve the transfer unit and manipulate it. The inferior aspect of the block is then burred to bleeding bone to promote consolidation. The coracoid block can then be positioned onto the anterior part of the glenoid where bleeding bone is exposed. Two screws are used to maximize fixation and contact.

At the end of surgery the surgeon confirms that there is no muscle interference and that external shoulder rotation is unimpeded. At the end of the procedure, the surgical incisions are closed with absorbable sutures.

 

Post-operative scanner of Latarjet with remplissageScar 2 months after arthroscopic Latarjet

 

Shoulder recovery and recuperation after arthroscopic Latarjet

After surgery, the shoulder must be immobilized for 1 week. Specialized shoulder rehabilitation must be started immediately after surgery, and follow a specific protocol. Active shoulder rehabilitation only starts the 4th week after surgery. Driving often resumes after 6 to 8 weeks.

Normal recovery spreads over 4 to 6 months, with maximal recovery of active articular range of motion toward the end of the 6th post-operative month, and maximal shoulder strength recovery toward the end of the 9th month after surgery. Contact sports such as rugby do not resume before the 4th month.

Arthroscopic Latarjet, rugby resumes after 3 to 4 months.