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Review of Latarjet (1954) on the treatment of recurrent shoulder dislocations

      This classic discusses the original publication ‘Treatment of recurrent dislocation of the shoulder’ on the Latarjet procedure. This surgical technique that has become one of the basics in shoulder-stabilising surgery, introduced by Latarjet in 1954 in the journal Lyon Chirurgical. Inspired by publications of colleagues in the field of shoulder surgery, Latarjet introduced a technique that transfers the coracoid process to the anterior glenoid rim in patients with anterior shoulder instability. Although being outrun in popularity by the Bankart repair for several decades, improved knowledge regarding long-term outcomes, surgical techniques and patient characteristics such as bone loss and participation in contact sports has led to renewed interest in the Latarjet procedure. This especially accounts for patients with significant glenohumeral bone loss or patients with a previously failed soft tissue repairs. Whereas the increase in popularity has led to many studies focussing on various aspects, the 15 basics of the initial procedure have virtually remained unchanged.

      Introduction

      The classic article by Michel Latarjet (1919–1999) was published in 1954 and presents a surgical technique that has evolved to become one of the cornerstones in the treatment of anterior shoulder instability.
      • Latarjet M
      [Treatment of recurrent dislocation of the shoulder].
      With a global incidence varying from 23.1 to 56.3 per 100 000 person-years,
      • Leroux T
      • Wasserstein D
      • Veillette C
      • et al.
      Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada.
      ,
      • Liavaag S
      • Svenningsen S
      • Reikerås O
      • et al.
      The epidemiology of shoulder dislocations in Oslo.
      ,
      • Nordqvist A
      • Petersson CJ
      Incidence and causes of shoulder girdle injuries in an urban population.
      ,
      • Zacchilli MA
      • Owens BD
      Epidemiology of shoulder dislocations presenting to emergency departments in the United States.
      the shoulder is the most frequently dislocated joint. A range of 17%–96% of the patients who are treated non-operative experience recurrent instability,
      • Roberts SB
      • Beattie N
      • McNiven ND
      • et al.
      The natural history of primary anterior dislocation of the glenohumeral joint in adolescence.
      ,
      • Hovelius L
      • Olofsson A
      • Sandström B
      • et al.
      Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up.
      ,
      • Kirkley A
      • Griffin S
      • Richards C
      • et al.
      Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder.
      and surgical treatment is often required. Although still debated, it has even been suggested that surgical treatment should be favoured over non-operative treatment after a first shoulder dislocation in young and high-demand patients.
      • Arciero RA
      • Wheeler JH
      • Ryan JB
      • et al.
      Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations.
      Surgical treatment includes soft tissue repairs and bone block procedures. Based on increased knowledge regarding patient characteristics and bone loss, a recent trend has been reported towards bone block stabilisations.
      • Degen RM
      • Camp CL
      • Werner BC
      • et al.
      Trends in Bone-Block Augmentation Among Recently Trained Orthopaedic Surgeons Treating Anterior Shoulder Instability.
      ,
      • Garcia GH
      • Taylor SA
      • Fabricant PD
      • et al.
      Shoulder Instability Management: A Survey of the American Shoulder and Elbow Surgeons.
      The Latarjet procedure has gained considerable favour, especially in patients with significant bone defects on either side of the glenohumeral joint or in patients with a previously failed Bankart repair.
      • Zhang AL
      • Montgomery SR
      • Ngo SS
      • et al.
      Arthroscopic versus open shoulder stabilization: current practice patterns in the United States.
      ,
      • Schmid SL
      • Farshad M
      • Catanzaro S
      • et al.
      The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair: a retrospective case series of forty-nine consecutive patients.
      Summary of the classic
      In 1954, Michel Latarjet reported on four patients who were treated for recurrent shoulder dislocations over the course of 1 year.
      • Latarjet M
      [Treatment of recurrent dislocation of the shoulder].
      Although he wrote that ‘one may start smiling when considering the small size of this series’ he predicted that ‘the beginning of a new experience could be fruitful’.
      In his small series, Latarjet consistently observed a deficient glenoid bumper and a loose ‘bag of periosteum’ and concluded that this is what needed to be addressed referring to what Eden, Auclaire and Hybinette had reported before.
      Latarjet recognised that the surgical treatment is a challenge, because the scapular neck is hidden behind the humeral head and the coracoid process with its tendons attached.
      Latarjet suggests these issues can be addressed either by placing padding behind the patients' spine while leaving the arm to hang off the table or by removing the overhanging coracoid process, which was previously described by Morsting (1911) and Bazy (1923).
      Latarjet then elaborates on the surgical technique. He releases the fibres of the coraco-acromial ligament and superficial adhesions before he transects the coracoid process with an osteotome between the insertion of the coracobrachialis and the pectoralis minor muscles (figure 4). This allows a good view of the subscapular muscle and tendon. In his more detailed publication in 1958, Latarjet described to release of the pectoralis minor muscle when necessary.
      • Latarjet M
      [Technic of coracoid preglenoid arthroereisis in the treatment of recurrent dislocation of the shoulder].
      Figure thumbnail gr4
      Figure 4Surgical detail from Latarjet's original article, with the coracoid process predrilled and osteomised.
      The subscapularis tendon is then divided, either with a vertical incision of the subscapular tendon that will allow plication or with a horizontal muscle fibre splitting incision.
      This provides an excellent exposure of the glenoid, its loosened bump and loose glenoid rim with the attached periosteal fibres that can easily be removed.
      Positioning of the graft is a delicate matter, because it should be optimally orientated and secured to the scapula. Latarjet uses one screw in the coracoid graft and drills the screw hole before the coracoid process has been osteomised. The capsule and subscapular muscle are subsequently closed around the graft and allow for additional stability (figure 1).
      Figure thumbnail gr1
      Figure 1Surgical detail from Latarjet's original article, with the coracoid graft fixated to the glenoid rim.
      Latarjet observed that two of his patients recovered fast and showed a wide and painless range of motion from the 20th day onwards, without insufficiency of the forearm flexion despite the slightly decreased length of the conjoined tendon.
      Latarjet elaborates on his technique in more detail in his publication in 1958, when he had successfully operated nine patients (figure 2).
      • Latarjet M
      [Technic of coracoid preglenoid arthroereisis in the treatment of recurrent dislocation of the shoulder].
      Figure thumbnail gr2
      Figure 2Surgical detail from Latarjet's article in 1958.

      Consideration

      Historic perspective

      Since Hippocrates described surgical treatment for shoulder instability as selectively burning the axilla with a red-hot iron to enhance stabilising scar tissue around 400 BC,
      Hippocrates: work of Hippocrates with an English Translation.
      ,
      • Mosely HF
      Recurrent Dislocations of the Shoulder.
      many surgeons sophisticated treatment strategies and elucidated questions regarding the entity of shoulder instability.
      • Somford MP
      • Van der Linde JA
      • Wiegerinck JI
      • et al.
      Eponymous terms in anterior shoulder stabilization surgery.
      In his initial manuscript, Latarjet refers to a technique, described by Moresting and Bazy in 1911 and 1923, that removed the coracoid process to gain good visibility of the glenohumeral joint in long-standing shoulder dislocations. A similar technique was published by Boicev in 1938, who temporarily removed and then reattached the coracoid process to gain access to perform a soft tissue procedure.
      • Boicev B
      Solla lussazione abituale della spalla.
      In his later work, Latarjet also refers to techniques that were described by Mauclaire, Eden and Hybinette. In 1917, Eden transferred a corticocancellous bone block from the tibia to the scapular neck to act as an extended buttress of the anterior glenoid, a technique that recently has gained renewed interest.
      • Eden R
      Zur Operation der habituellen Schulterluxation unter Mitteilung eines neuen verfahrens bei Abriß am inneren Pfannenrande.
      ,
      • Provencher MT
      • Frank RM
      • Golijanin P
      • et al.
      Distal Tibia Allograft Glenoid Reconstruction in Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes.
      ,
      • Waterman BR
      • Chandler PJ
      • Teague E
      • et al.
      Short-Term Outcomes of Glenoid Bone Block Augmentation for Complex Anterior Shoulder Instability in a High-Risk Population.
      In 1932, Hybinette reported a similar procedure using iliac bone graft.
      • Hybinette S
      De la transplatation d'un fragmant osseux pour remedier aux luxations recivantes de l'epaule; constatations et resultats operatiores.
      Oudard, in 1924, reported a tibial graft interposition to the coracoid process to serve as an anterior strut after plication of the subscapular muscle (figure 3).
      • Oudard P
      La luxation recidivante de l'epaule (variete anter-interne) procede aperatoire.
      Figure thumbnail gr3
      Figure 3Surgical detail from Oudard's technique in 1924, where a soft tissue procedure is performed at the subscapular muscle and an interposition graft at the coracoid process.
      Similar to Latarjet's technique, there are procedures described by Trillat and Helfet. In 1954, in the same journal and just preceding Latartjet's article, Trillat described a very similar technique. He described that the coracoid process is fractured while maintaining the periosteal sleeve, and instead of cutting the subscapularis tendon, it was rather kept out of the way with an elevator.
      • Trillat A
      [Treatment of recurrent dislocation of the shoulder; technical considerations].
      In 1958, Helfet presented a technique that his mentor Bristow taught him.
      • Helfet AJ
      Coracoid transplantation for recurring dislocation of the shoulder.
      In the Bristow procedure, sutures between the conjoined tendon and the subscapular muscle are used to keep the coracoid in place instead of a screw used in the Latarjet procedure. Because the principles of both procedures are nevertheless very similar, they are often referred to as the ‘Bristow-Latarjet procedure’ although they differ in biomechanical entities.
      • Giles JW
      • Degen RM
      • Johnson JA
      • et al.
      The Bristow and Latarjet procedures: why these techniques should not be considered synonymous.
      Moreover, as noted by Hovelius, the several modifications to the Bristow operation have resulted in the same procedure that was first described by Latarjet.
      • Hovelius L
      • Körner L
      • Lundberg B
      • et al.
      The coracoid transfer for recurrent dislocation of the shoulder. Technical aspects of the Bristow-Latarjet procedure.

      Scientific and societal impact

      While in recent decades the Latarjet procedure has gained renewed interest, the Bankart repair in which the detached capsulolabral complex is reattached to the glenoid rim has long been the golden standard.
      • Bankart AS
      Recurrent or habitual dislocation of the shoulder-joint.
      Described by Bankart in 1923, it was originally performed as open surgery, but the technique was popularised with the introduction of arthroscopic surgery from the late 1980s onwards,
      • Morgan CD
      • Bodenstab AB
      Arthroscopic Bankart suture repair: technique and early results.
      ,
      • Grana WA
      • Buckley PD
      • Yates CK
      Arthroscopic Bankart suture repair.
      ,
      • Harryman DT
      • Ballmer FP
      • Harris SL
      • et al.
      Arthroscopic labral repair to the glenoid rim.
      which is a trend that continued over the past decade.
      • Arciero RA
      • Wheeler JH
      • Ryan JB
      • et al.
      Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations.
      ,
      • Zhang AL
      • Montgomery SR
      • Ngo SS
      • et al.
      Arthroscopic versus open shoulder stabilization: current practice patterns in the United States.
      ,
      • Owens BD
      • Harrast JJ
      • Hurwitz SR
      • et al.
      Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination.
      However, several studies reported relatively high recurrence rates varying from 18% to 38% after 10 years
      • van der Linde JA
      • van Kampen DA
      • Terwee CB
      • et al.
      Long-term results after arthroscopic shoulder stabilization using suture anchors: an 8- to 10-year follow-up.
      ,
      • Kartus C
      • Kartus J
      • Matis N
      • et al.
      Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks. Surgical technique.
      ,
      • Nourissat G
      • Neyton L
      • Metais P
      • et al.
      Functional outcomes after open versus arthroscopic Latarjet procedure: A prospective comparative study.
      ,
      • Blonna D
      • Bellato E
      • Caranzano F
      • et al.
      Arthroscopic Bankart Repair Versus Open Bristow-Latarjet for Shoulder Instability: A Matched-Pair Multicenter Study Focused on Return to Sport.
      ,
      • Chapus V
      • Rochcongar G
      • Pineau V
      • et al.
      Ten-year follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocation in young patients.
      following the arthroscopic Bankart repair, while 42% persists to have apprehension.
      • Zimmermann SM
      • Scheyerer MJ
      • Farshad M
      • et al.
      Long-Term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure.
      Improved knowledge regarding patient characteristics, including the assessment of bony defects, has resulted in an increase of Latarjet procedures, while the shift in patient-selection is at the same time likely to result in improved outcomes following the Bankart procedure.
      • Leroux TS
      • Saltzman BM
      • Meyer M
      • et al.
      The Influence of Evidence-Based Surgical Indications and Techniques on Failure Rates After Arthroscopic Shoulder Stabilization in the Contact or Collision Athlete With Anterior Shoulder Instability.
      ,
      • Nakagawa S
      • Mae T
      • Yoneda K
      • et al.
      Influence of Glenoid Defect Size and Bone Fragment Size on the Clinical Outcome After Arthroscopic Bankart Repair in Male Collision/Contact Athletes.
      ,
      • Alkaduhimi H
      • van der Linde JA
      • Willigenburg NW
      • et al.
      Redislocation risk after an arthroscopic Bankart procedure in collision athletes: a systematic review.
      Evidence suggests that the clinical outcome between the arthroscopic Bankart repair and the Latarjet procedure is similar.
      • Blonna D
      • Bellato E
      • Caranzano F
      • et al.
      Arthroscopic Bankart Repair Versus Open Bristow-Latarjet for Shoulder Instability: A Matched-Pair Multicenter Study Focused on Return to Sport.
      A tool that was designed for patient selection is the Instability Severity Index Score (ISIS), that was introduced by Balg and Boileau, where the decision between a soft tissue procedure or bone block procedure is based on potential risk factors for failure.
      • Balg F
      • Boileau P
      The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.
      These factors include patient age under 20 years at the time of surgery, participation in competitive or contact sports and shoulder hyperlaxity and bony defects on radiographs. Patients with a score over 6/10 points had an unacceptable recurrence risk of 70% following an arthroscopic Bankart repair. Later studies suggest that bony procedures should be performed when the ISIS score is ≥4.
      • Phadnis J
      • Arnold C
      • Elmorsy A
      • et al.
      Utility of the Instability Severity Index Score in Predicting Failure After Arthroscopic Anterior Stabilization of the Shoulder.
      ,
      • Rouleau DM
      • Hébert-Davies J
      • Djahangiri A
      • et al.
      Validation of the instability shoulder index score in a multicenter reliability study in 114 consecutive cases.
      Many authors state that bony reconstructions are especially required in the presence of bone loss that is >20%–25% of the glenoid surface.
      • Longo UG
      • Loppini M
      • Rizzello G
      • et al.
      Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.
      ,
      • Provencher MT
      • Bhatia S
      • Ghodadra NS
      • et al.
      Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss.
      ,
      • Warner JJ
      • Gill TJ
      • O'hollerhan JD
      • et al.
      Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft.
      ,
      • Young AA
      • Maia R
      • Berhouet J
      • et al.
      Open Latarjet procedure for management of bone loss in anterior instability of the glenohumeral joint.
      Shin et al
      • Shin SJ
      • Koh YW
      • Bui C
      • et al.
      What Is the Critical Value of Glenoid Bone Loss at Which Soft Tissue Bankart Repair Does Not Restore Glenohumeral Translation, Restricts Range of Motion, and Leads to Abnormal Humeral Head Position?.
      found that glenoid defects of 15% or more of the largest anteroposterior glenoid width should be considered the critical amount of bone loss at which soft tissue repair cannot restore glenohumeral translation, restricts rotational range of motion and leads to abnormal humeral head position. In addition, the smaller defects that engage with a Hill Sachs lesion in external rotation are also considered to be an indication for the Latarjet procedure.
      The presence of bony lesions is underestimated on plain X-rays but can be evaluated reliably on CT and MRI scans.
      • Owens BD
      • Burns TC
      • Campbell SE
      • et al.
      Simple method of glenoid bone loss calculation using ipsilateral magnetic resonance imaging.
      CT scans have also been proven useful when evaluating the risk of engagement in bipolar lesions.
      • Burns DM
      • Chahal J
      • Shahrokhi S
      • et al.
      Diagnosis of Engaging Bipolar Bone Defects in the Shoulder Using 2-Dimensional Computed Tomography: A Cadaveric Study.
      Three dimensional (3D) CT has been reported to be superior to two-dimensional CT or MRI
      • Bishop JY
      • Jones GL
      • Rerko MA
      • et al.
      3-D CT is the most reliable imaging modality when quantifying glenoid bone loss.
      and slightly better than MR arthrography.
      • Markenstein JE
      • Jaspars KC
      • van der Hulst VP
      • et al.
      The quantification of glenoid bone loss in anterior shoulder instability; MR-arthro compared to 3D-CT.
      Newer multidetector CT techniques have even been shown to have better accuracy than MR arthrography in the detection of osseous, cartilage and labroligamentous injuries.
      • Acid S
      • Le Corroller T
      • Aswad R
      • et al.
      Preoperative imaging of anterior shoulder instability: diagnostic effectiveness of MDCT arthrography and comparison with MR arthrography and arthroscopy.
      Recent studies have focused on the development of reliable 3D MR imaging and reported that these are equivalent to 3D CT scans to evaluate bone loss, which could to eliminate the need for CT scans in the future.
      • Yanke AB
      • Shin JJ
      • Pearson I
      • et al.
      Three-Dimensional Magnetic Resonance Imaging Quantification of Glenoid Bone Loss Is Equivalent to 3-Dimensional Computed Tomography Quantification: Cadaveric Study.
      ,
      • Stillwater L
      • Koenig J
      • Maycher B
      • et al.
      3D-MR vs. 3D-CT of the shoulder in patients with glenohumeral instability.
      More recent studies also report on the arthroscopic Latarjet procedure. After the technique was introduced in 2006 by Nourissat,
      • Nourissat G
      • Nedellec G
      • O'Sullivan NA
      • et al.
      Mini-open arthroscopically assisted Bristow-Latarjet procedure for the treatment of patients with anterior shoulder instability: a cadaver study.
      it was popularised by Lafosse.
      • Lafosse L
      • Lejeune E
      • Bouchard A
      • et al.
      The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability.
      ,
      • Rosso C
      • Bongiorno V
      • Samitier G
      • et al.
      Technical guide and tips on the all-arthroscopic Latarjet procedure.
      When considering this technique, good anatomic knowledge, advanced arthroscopic skills and familiarity with the instrumentation are recommended.
      • Lafosse L
      • Boyle S
      Arthroscopic Latarjet procedure.
      Although similar outcomes have been reported after open or arthroscopic Latarjet procedures,
      • Metais P
      • Clavert P
      • Barth J
      • et al.
      Preliminary clinical outcomes of Latarjet-Patte coracoid transfer by arthroscopy vs. open surgery: Prospective multicentre study of 390 cases.
      ,
      • Flinkkilä T
      • Knape R
      • Sirniö K
      • et al.
      Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up.
      arthroscopic procedures improve cosmesis and could be less painful. However, the arthroscopic procedure is associated with a similar
      • Athwal GS
      • Meislin R
      • Getz C
      • et al.
      Short-term Complications of the Arthroscopic Latarjet Procedure: A North American Experience.
      ,
      • Kany J
      • Flamand O
      • Grimberg J
      • et al.
      Arthroscopic Latarjet procedure: is optimal positioning of the bone block and screws possible? A prospective computed tomography scan analysis.
      or higher complication rate compared with the open Latarjet procedure.
      • Marion B
      • Klouche S
      • Deranlot J
      • et al.
      A Prospective Comparative Study of Arthroscopic Versus Mini-Open Latarjet Procedure With a Minimum 2-Year Follow-up.
      ,
      • Cunningham G
      • Benchouk S
      • Kherad O
      • et al.
      Comparison of arthroscopic and open Latarjet with a learning curve analysis.

      Current evidence as related to the original article

      The Latarjet procedure is a very reliable treatment for patients with recurrent instability with good to excellent results in 80%–92.3% of the patients.
      • Bhatia S
      • Frank RM
      • Ghodadra NS
      • et al.
      The outcomes and surgical techniques of the latarjet procedure.
      Biomechanical studies have shown that its stabilising effect is based on restoration of the glenoid contour, as well as the sling effect from the conjoined tendon that will form a ‘hammock’ on the anterior glenoid rim when the arm is abducted.
      • Giles JW
      • Boons HW
      • Elkinson I
      • et al.
      Does the dynamic sling effect of the Latarjet procedure improve shoulder stability? A biomechanical evaluation.
      ,
      • Yamamoto N
      • Muraki T
      • An KN
      • et al.
      The stabilizing mechanism of the Latarjet procedure: a cadaveric study.
      For surgeons, the Latarjet procedure can be challenging and has a learning curve. Regarding the open procedure, a surgeon's experience significantly affects the surgery duration and the occurrence of early complications, whereas coracoid harvesting time and bone block positioning are not related to surgical experience.
      • Dauzère F
      • Faraud A
      • Lebon J
      • et al.
      Is the Latarjet procedure risky? Analysis of complications and learning curve.
      Regarding the arthroscopic Latarjet, increased surgical experience also decreases operating time.
      • Marion B
      • Klouche S
      • Deranlot J
      • et al.
      A Prospective Comparative Study of Arthroscopic Versus Mini-Open Latarjet Procedure With a Minimum 2-Year Follow-up.
      ,
      • Bhatia S
      • Frank RM
      • Ghodadra NS
      • et al.
      The outcomes and surgical techniques of the latarjet procedure.
      It has been reported that about 10 procedures are required to overcome the need for conversion and 20 procedures to achieve equal operating time to the open technique.
      • Cunningham G
      • Benchouk S
      • Kherad O
      • et al.
      Comparison of arthroscopic and open Latarjet with a learning curve analysis.
      Despite the excellent results, complication rates associated with the Latarjet procedure has been reported to 15% and 30% in reviews that include 1018 and 1904 shoulders.
      • Longo UG
      • Loppini M
      • Rizzello G
      • et al.
      Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.
      ,
      • Griesser MJ
      • Harris JD
      • McCoy BW
      • et al.
      Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review.
      Risk factors for suboptimal outcome following the Latarjet procedure include patients with revision surgery and patients with voluntary instability.
      Degenerative arthropathy is most frequently reported, although it is a risk in any patient who has a traumatic anterior shoulder dislocation also without operative treatment. Overall, 24% of the patients that were either treated surgically (irrespective to the technique) or non-operative develop moderate/severe arthropathy, with the risk of the arthritis increasing with an increasing number of instability episodes, and decreasing if a shoulder has been surgically stabilised.
      • Hovelius L
      • Rahme H
      Primary anterior dislocation of the shoulder: long-term prognosis at the age of 40 years or younger.
      ,
      • Hovelius L
      • Saeboe M
      Neer Award 2008: Arthropathy after primary anterior shoulder dislocation–223 shoulders prospectively followed up for twenty-five years.
      Incorrect coracoid placement (too lateral) can potentially lead to humeral head abutment and degenerative changes, whereas position of the coracoid 1 cm or more medial to the rim can lead to more recurrences.
      • Hovelius L
      • Sandström B
      • Olofsson A
      • et al.
      The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders.
      Correct bone block positioning is a delicate matter. While a biomechanical study suggests that graft fixation at the 4 o'clock position could decrease anterior displacement of the humeral head and inferior glenohumeral translation,
      • Nourissat G
      • Delaroche C
      • Bouillet B
      • et al.
      Optimization of bone-block positioning in the Bristow-Latarjet procedure: a biomechanical study.
      a clinical study demonstrated that graft placement inferior to the 5 o'clock position leads to recurrent instability.
      • Gasbarro G
      • Giugale JM
      • Walch G
      • et al.
      Predictive Surgical Reasons for Failure After Coracoid Process Transfers.
      In the original technique, the coracoid graft is positioned with the inferior surface against the anterior surface of the glenoid neck. De Beer has introduced the congruent-arc technique in 2009, where he advocates to rotate the coracoid process 90°, such that the medial surface of the coracoid graft is positioned against the anterior surface of the glenoid neck.
      • de Beer J
      • Burkhart SS
      • Roberts CP
      • et al.
      The Congruent-Arc Latarjet.
      The advantage of the congruent-arc procedure is that the radius of curvature of the inferior coracoid surface matches the radius of curvature of the glenoid rim.
      • Boons HW
      • Giles JW
      • Elkinson I
      • et al.
      Classic versus congruent coracoid positioning during the Latarjet procedure: an in vitro biomechanical comparison.
      Additionally, this method potentially allows treatment of a significantly greater glenoid bone deficiency, as the coracoid is often wider than it is thick and glenoid articular surface contact pressures are better restored. By cutting the medial side of the coracoid process slightly obliquely instead of exactly parallel to the medial axis, a greater surface area of coracoid can be attached to the scapular neck.
      • de Beer J
      • Burkhart SS
      • Roberts CP
      • et al.
      The Congruent-Arc Latarjet.
      Nerve injuries are a potentially catastrophic complication in any shoulder operation. This includes the musculocutaneous nerve in the Latarjet procedure, as the distance between the inferior tip of the coracoid process and the entry into the muscle is about 5.5 cm. Recent studies have investigated the use of nerve monitoring during Latarjet procedures.
      • Delaney RA
      • Freehill MT
      • Janfaza DR
      • et al.
      2014 Neer Award Paper: neuromonitoring the Latarjet procedure.
      Apart from other general complications such as wound infections and superficial haematoma, hardware-related complications predominate. These include screw bending or breakage and prominent sitting screws secondary to graft osteolysis.
      • Longo UG
      • Loppini M
      • Rizzello G
      • et al.
      Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature.
      ,
      • Griesser MJ
      • Harris JD
      • McCoy BW
      • et al.
      Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review.
      Osteolysis most often affects the superficial and medial portions of the proximal end of the graft and occurs after 6 months–1 year after surgery.
      • Haeni DL
      • Opsomer G
      • Sood A
      • et al.
      Three-dimensional volume measurement of coracoid graft osteolysis after arthroscopic Latarjet procedure.
      ,
      • Di Giacomo G
      • Costantini A
      • de Gasperis N
      • et al.
      Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients.
      ,
      • Zhu YM
      • Jiang CY
      • Lu Y
      • et al.
      Coracoid bone graft resorption after Latarjet procedure is underestimated: a new classification system and a clinical review with computed tomography evaluation.
      One of the reasons could be Wolff's law, which tells that bone constantly adapts itself to external forces, gaining mass in areas of stress and undergoing osteolysis in areas of less stress. The inferior half of the coracoid graft is exposed to higher stresses by the humeral head compared with the superior half, thus resulting in resorption of the superior part of the bone graft.
      • Haeni DL
      • Opsomer G
      • Sood A
      • et al.
      Three-dimensional volume measurement of coracoid graft osteolysis after arthroscopic Latarjet procedure.
      When osteolysis results in prominent screws, these might cause pain due to irritation of the subscapularis muscle and cartilaginous damage to the humeral head due to abutment.
      • Haeni DL
      • Opsomer G
      • Sood A
      • et al.
      Three-dimensional volume measurement of coracoid graft osteolysis after arthroscopic Latarjet procedure.
      Alternative techniques to fixate the graft include the use of a mini plate,
      • Giacomo GD
      • Costantini A
      • de Gasperis N
      • et al.
      Coracoid bone graft osteolysis after Latarjet procedure: A comparison study between two screws standard technique vs mini-plate fixation.
      suture buttons
      • Boileau P
      • Gendre P
      • Baba M
      • et al.
      A guided surgical approach and novel fixation method for arthroscopic Latarjet.
      ,
      • Tytherleigh-Strong GM
      • Morrissey DI
      Failed Latarjet procedure treated with a revision bone block stabilization using a suture-button fixation.
      and bioabsorbable screws.
      • Balestro JC
      • Young A
      • Maccioni C
      • et al.
      Graft osteolysis and recurrent instability after the Latarjet procedure performed with bioabsorbable screw fixation.
      However, the mini plate does not decrease osteolysis on the superficial and proximal end of the graft, the suture button technique requires either an arthroscopic procedure or an additional posterior approach
      • Boileau P
      • Gendre P
      • Baba M
      • et al.
      A guided surgical approach and novel fixation method for arthroscopic Latarjet.
      ,
      • Tytherleigh-Strong GM
      • Morrissey DI
      Failed Latarjet procedure treated with a revision bone block stabilization using a suture-button fixation.
      and bioabsorbable screws increase graft osteolysis.
      • Balestro JC
      • Young A
      • Maccioni C
      • et al.
      Graft osteolysis and recurrent instability after the Latarjet procedure performed with bioabsorbable screw fixation.
      In his original publication, Latarjet used one bicortical screw to fixate the graft and suggests that a vertical incision of the subscapular tendon can be used to enable plication. It has however been demonstrated that the subscapular muscle loses its strength and thickness after a vertical incision,
      • Picard F
      • Saragaglia D
      • Montbarbon E
      • et al.
      [Anatomo-clinical consequences of the vertical sectioning of the subscapular muscle in Latarjet intervention].
      while single-screw fixation was identified as an important risk factor for recurrent instability.
      • Gasbarro G
      • Giugale JM
      • Walch G
      • et al.
      Predictive Surgical Reasons for Failure After Coracoid Process Transfers.
      Two screws are nowadays widely accepted. Whereas some evidence suggests that biomechanical performance does not depend on their type (cannulated vs cancellous and partially threaded vs fully threaded) or fixation (unicortical vs bicortical),
      • Shin JJ
      • Hamamoto JT
      • Leroux TS
      • et al.
      Biomechanical Analysis of Latarjet Screw Fixation: Comparison of Screw Types and Fixation Methods.
      another study found significant graft displacement with 3.75 mm unicortical screws compared with the same size bicortical screws, when tested in a polyurethane foam model up to 200 N.
      • Willemot LB
      • Wodicka R
      • Bosworth A
      • et al.
      Influence of screw type and length on fixation of anterior glenoid bone grafts.
      After fixation of the graft, the capsule can be repaired either to the glenoid rim or to the coracoid graft. One cadaver study demonstrated that capsular repair does not improve stability,
      • Kleiner MT
      • Payne WB
      • McGarry MH
      • et al.
      Biomechanical Comparison of the Latarjet Procedure with and without Capsular Repair.
      while another cadaver study found that only midrange stability (with the arm in 60° of abduction) is improved.
      • Itoigawa Y
      • Hooke AW
      • Sperling JW
      • et al.
      Repairing the Capsule to the Transferred Coracoid Preserves External Rotation in the Modified Latarjet Procedure.
      Both studies however report that a capsular repair limits external rotation. Reattachment of the capsule to the coracoid graft results in less limitation but could potentially increase the risk of humeral head abutment and subsequent osteoarthritis.
      • Itoigawa Y
      • Hooke AW
      • Sperling JW
      • et al.
      Repairing the Capsule to the Transferred Coracoid Preserves External Rotation in the Modified Latarjet Procedure.
      Clinical studies have however demonstrated that external rotation is maintained after the Latarjet procedure.
      • Neviaser RJ
      • Benke MT
      • Neviaser AS
      Mid-term to long-term outcome of the open Bankart repair for recurrent traumatic anterior dislocation of the shoulder.
      ,
      • An VV
      • Sivakumar BS
      • Phan K
      • et al.
      A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair.
      Moreover, the Latarjet procedure has been clearly demonstrated in the literature
      • An VV
      • Sivakumar BS
      • Phan K
      • et al.
      A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair.
      to maintain a better range of external rotation of the shoulder joint when compared with soft tissue procedures, which has many clinical and theoretical advantages.

      The lessons learnt

      The Latarjet procedure can be used in patients as a primary or revision procedure to restore stability, especially in case of significant bone loss on both sides of the glenohumeral joint. Glenoid defects that measure approximately 25% of the intact glenoid surface can be restored to nearly normal.
      • Moon SC
      • Cho NS
      • Rhee YG
      Quantitative assessment of the latarjet procedure for large glenoid defects by computed tomography: a coracoid graft can sufficiently restore the glenoid arc.
      Although the surgical technique has been modified several times over the past decades,
      • Cowling PD
      • Akhtar MA
      • Liow RYL
      What is a Bristow-Latarjet procedure?: A review of the described operative techniques and outcomes.
      ,
      • van der Linde JA
      • van Wijngaarden R
      • Somford MP
      • et al.
      The Bristow-Latarjet procedure, a historical note on a technique in comeback.
      the essentials remain very similar to the way Latarjet has described his initial procedure 63 years ago.
      Additional expert opinion by Laurent Lafosse
      The open Latarjet procedure has proven to be an effective and efficient technique for shoulder stabilisations. So why perform it arthroscopically? Mini-invasive surgery is getting more and more popular, and the Bankart repair, acromioplasty and rotator cuff repairs are currently managed arthroscopically; there are some specific arguments to perform the Latarjet procedure under arthroscopic control. While the glenoid and humeral bone can be evaluated with three-dimensional (3D) CT and 3D MRI, and while soft tissue detachment can be anticipated with CT and MRI arthro, only arthroscopy can evaluate the thickness, the elasticity, the strength of the IGHL and the continuity of the labral ring, which are important prognostic factors when considering a soft tissue repair. Although the technique is nowadays perfectly codified, every step remains difficult and tricky. Perfect visualisation by meticulous haemostasis is required, but the swelling due to fluid extravasation can be dangerous and the procedure should not take longer than 2 hours. Collaboration with the anaesthesist is crucial to maintain ideal surgical conditions. Coracoid preparation and osteotomy, nerve visualisation, subscapularis split and coracoid placement and fixation are difficult steps. The 30° scope angulation makes the graft positioning look different according to the portal that is used for visualisation. The graft should be flush to the glenoid bone—a too medial position will lead to recurrent instability and graft resorption, and a proud graft will rapidly create osteoarthritis. The screws must be as parallel as possible to the glenoid surface, which is a very difficult step due to the fact that the scapula is mobile around the thorax and the fact that the plexus crosses the medial portal used for instrumentation. Today, we have performed more than 700 arthroscopic Latarjet procedures with a very low complication rate and very good results. Nevertheless, in our hands, each arthroscopic Latarjet remains a challenging procedure. It is always possible at any stage to convert arthroscopy to an open procedure. A good open Latarjet is much better than a bad arthroscopic Latarjet.
      Additional expert opinion by Matthew T Provencher
      It is interesting to note that over 60 years later, the Latarjet procedure is one that still has international widespread use but with some variations. In the original publication, Latarjet used some of the techniques that most surgeons use today but varied in subscapularis management (a vertical incision) and use of only one bicortical screw.
      • Joshi MA
      • Young AA
      • Balestro JC
      • et al.
      The Latarjet-Patte procedure for recurrent anterior shoulder instability in contact athletes.
      ,
      • Ruci V
      • Duni A
      • Cake A
      • et al.
      Bristow-Latarjet Technique: Still a Very Successful Surgery for Anterior Glenohumeral Instability - A Forty Year One Clinic Experience.
      Regardless, the Latarjet concept, in principle, is one that has clearly stood the test of time and is likely here to stay.
      There are many variations to the Latarjet procedure and can be briefly divided into:
      • Arthroscopic versus open: gold standard remains an open procedure, however, arthroscopic is certainly gaining momentum given the improvements in technology and retractors to protect the anterior neurovascular structures.
      • Subscapularis management: whether to perform a split or takedown of the superior half.
      • Location of the subscapularis split: some advocate for a split directly in half, some advocate doing 2/3 superior, 1/3 inferior, while some advocate for a higher split with 1/3 superior and 2/3 superior. Latarjet performed a vertical split, which is generally not done today so as to preserve the sling effect.
      • Capsule management: there are a variety of techniques, from maintaining the coracoacromial ligament and sewing in the native capsule, to repair with anchors to the native glenoid, to repairing all in one with the subscapularis as the glenoid face.
      • Coracoid osteotomy: whether to use the lateral edge or the inferior aspect of the coracoid as the glenoid face.
      • Length of coracoid osteotomy: whether to use one versus two screws.
      • Location of bone graft placement on glenoid: there is no clear consensus on exactly where to place the graft, but most surgeons would advocate between the 3 o'clock to 5 o'clock position.
      • Fixation: including cortical screws, cancellous screws, cannulated screws, J bone grafting and dovetail osteotomy techniques.
      • Postoperative rehabilitation timeline: ranges from 2 weeks to 6 weeks in a sling, and return to full activities from 4 weeks to 24 weeks with some authors (especially with an arthroscopic approach) advocating for earlier return to play.
      This article by van der Linde et al nicely demonstrates the variations and evolution in the last 60 years of Latarjet bone grafting procedure. It is clear that this procedure is here to stay, but we will continue to see technological as well as surgical advancements to help us define the above variations in technique for an optimal outcome.
      Additional expert opinion by Joe F de Beer
      During the 1980s, we spent energy at developing from open stabilisation procedures (Bankart and capsular shift) to the arthroscopic stabilisation procedure. A lot of detail was attended to, including knot tying techniques, suture passing, new anchors, patient positioning and visualisation, to name a few. Procedures developed in this field from simple tacks to anchors and sutures. During this process, we did encounter a fairly large number of failed stabilisation operations. After critically looking at the glenoids, we observed the resemblance of an ‘upside-down’ pear due to the anteroinferior loss of bone. We then coined the phrase ‘inverted pear’, which became a well-recognised entity. It dawned on us that the presence of glenoid bone loss was associated with failed arthroscopic stabilisations and especially in contact athletes.
      During this time I met Dr Gilles Walch, who demonstrated the Latarjet procedure to me and pointed out that in France they had realised this principle for many years. We then performed the open Latarjet procedure according to the French method.
      In dealing with large numbers of rugby players, it was soon apparent that the failure rate decreased significantly, and overall results were excellent. The next step was to critically study the anatomy of the coracoid. We found that the radius of curvature of the coracoid was identical to that of the glenoid surface. We transferred the coracoid to the neck of the scapula by turning it so that the medial surface, where the pec minor had been attached, was apposed to the neck of the glenoid. This led to the term congruent arc Latarjet, implying that the arc of the coracoid was similar to that of the glenoid.
      Dr Steve Burkhart and I met and concurred on these principles and collaborated to pool results and research.
      Unlike the French method, we detached the coracoacromial ligament when harvesting the coracoid and repaired the capsule to the native edge of the glenoid. This placed the transferred coracoid ‘extra-articular’ with the theoretical aim of decreasing the potential for the development of osteoarthritis in the joint.
      Initially, we reattached the pec minor to the coracoid stump, using a bone anchor. The theory was that these contact rugby players needed strong protraction of the scapula in scrums. After measuring the protraction strength during follow-up, this did not seem to be necessary and we abandoned that.
      For contact athletes, we have a low tolerance to perform a Latarjet due to the excellent results. One does have to remember that complications do occur and our most frequent one, although relatively rare, has been resorption of the graft. In many of them the shoulder remains stable and at times only the screws can then be removed.
      So our most common indication of the Latarjet is for a contact player with instability.
      We would therefore caution to still consider arthroscopic procedures and take the principles of the glenoid track and performing remplissage when possible.
      The congruent arc Latarjet has served us well to have our contact sports players to return to the same level sports at an average of 10 weeks. Attention to the correct indications and technique leads to excellent results, and it remains the procedure of choice for specific indications.

      Conclusion

      The technique that Latarjet described in his original article in 1954 and elaborated on in subsequent publications in 1958 and 1965 has evolved to become one of the cornerstones in the treatment of anterior shoulder instability.
      However, despite its satisfying results and its ever increasing popularity, the potential complications should be considered and discussed when counselling patients.

      Acknowledgments

      The authors acknowledge and thank Dr Laurent Lafosse, Dr Matthew Provencher and Dr Joe de Beer for providing their expert opinions and insightful comments.

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