Comprehensive Modified Latarjet Technique: What the Masters Taught Us.

UNLABELLED

The Latarjet surgical technique is one of the most effective and well-known techniques in the treatment of anterior shoulder instability. The modified Latarjet technique is a history book of surgical details demonstrated by renowned masters of shoulder surgery. The procedure includes soft-tissue repair and osseous reconstruction to stabilize the glenohumeral joint in recurrent anterior instability. The procedure has been shown to have reliable success in reducing recurrent instability and minimizing risk of dislocation arthropathy.

DESCRIPTION

The Latarjet technique can be performed via a cosmetic axillary-based approach. The subscapularis is split horizontally without detachment as described by Neer. The capsule is released like in a medially based T-plasty as described by Altchek et al.. The coracoid osteotomy is performed with a 90° oscillating saw and prepared for en-face implantation as described by Edwards and Walch. The inferior surface of the coracoid is decorticated and prepared per Molé. Coracoid fixation is performed with two 3.5-mm cortical screws. The soft-tissue reconstruction is selectively tensioned per Warner et al.. The capsular shift is augmented with a pants-over-vest repair per Kim et al..

ALTERNATIVES

Nonoperative treatment in young patients with glenohumeral instability and bone loss can lead to recurrence rates as high as 87%. Arthroscopic management with anterior capsulolabral repair and a remplissage procedure can be beneficial for patients with instability. In the setting of bone loss, arthroscopic repair is associated with failure rates as high as 75%.

RATIONALE

In the setting of glenoid and/or humeral bone loss, there is a loss of native osseous anatomy, leading to a higher risk of instability. Gerber and Nyffeler reported a >30% loss of compressive force when the vertical edge of the glenoid defect is greater than one-half of the glenoid diameter. The Latarjet procedure is a reliable procedure that reconstructs the anterior osseous anatomy as well as the capsular laxity, restoring glenohumeral stability. When compared with arthroscopic labral repair, the Latarjet procedure is superior with more consistent improvements in functional outcomes with low risk of recurrence, even in high-risk populations of young, active athletes in contact sports.

EXPECTED OUTCOMES

At our institution, a total of 34 patients underwent Latarjet reconstruction as described in the present article and videos from 2013 to 2018, with a minimum follow-up of 1 year. Among these patients, the mean Single Assessment Numeric Evaluation score was 90.7 (range, 70 to 100). There were 4 cases of recurrent instability with graft fracture or resorption (11.8%). Zimmermann et al. presented a series of Latarjet reconstructions with similar functional outcomes and a recurrence rate of 11%. Meta-analysis of long-term Latarjet studies show high rates of return to sports and successful outcomes in 86% of cases, with an 8.5% recurrence rate.

IMPORTANT TIPS

The Latarjet procedure can be consistently performed with a subscapularis-sparing approach, which minimizes adverse comorbidities.Splitting the subscapularis at the inferior one-third junction will position the surgical window directly over the bottom half of the glenoid, which optimizes coracoid implantation.A medially based T-plasty will maximize the glenoid exposure for direct coracoid implantation. Subsequently, the capsule may be shifted for capsular imbrication.Low-profile, non-bulky retractors will help to improve visualization.Adjusting the arm is a key technique in performing this surgical procedure. This adjustment will help to shift the surgical window, expose key anatomic structures, and allow a capsular shift without overtensioning. This cannot be overstated.