Opinion editorial—use and abuse of the latarjet procedure

ABOUT THE EXPERT

Gilles Walch, MD, is an orthopedic surgeon specialized in shoulder surgery. He is a senior partner at the Shoulder Department of Centre Orthopedique Santy and at Hospital Privé Jean Mermoz in Lyon, France. After completing his residency and his fellowship in France with Professors Trillat and Dejour, he visited Dr. Franck Jobe and Dr. Charles Rockwood in the United States. Since his return, Dr. Walch has focused completely on the shoulder, improving the understanding and treatment of various shoulder disorders, including recurrent anterior instability, rotator cuff tears, and primary or secondary osteoarthritis.

History of the latarjet procedure

Michel Latarjet was a general surgeon working at the University Hospital of Lyon next door to Albert Trillat. Professor Albert Trillat was the first orthopedic surgeon in Lyon; between 1950 and December 1953 he operated on 17 cases of recurrent anterior dislocation with his personal procedure inspired by the NOESSKE procedure (a German surgeon working in Dresden who published his technique in 1924). In this procedure an osteotomy is performed at the base of the coracoid process. The entire coracoid process is then moved inferiorly and medially and fixed by a nail or a screw passed through the tip of the coracoid and then into the glenoid neck. A space (“equivalent to the pulp of the index finger”) is left between the coracoid and glenoid to avoid squeezing the subscapularis and limiting external rotation. The goal of this procedure is to diminish the space between the tip of the coracoid process and the anterior part of the glenoid into which the humeral head slips during an anterior dislocation. Because the coracoid tip is fixed to the glenoid neck above the subscapularis, the conjoint tendon serves as a sling keeping the subscapularis in contact with the anterior glenoid rim, closing the Bankart or Brocca-Hartman detachment ( Fig. 44.1 ). Albert Trillat presented his series of 17 cases at the Société Lyonnaise de Chirurgie on March 11, 1954, and published his paper in Lyon Chirurgical journal in November 1954.

One day in 1953 Michel Latarjet ( Fig. 44.2 ) visited Albert Trillat in his operating room to see and learn about his procedure. He tried to reproduce the same operation in a patient of his own but inadvertently broke the coracoid so that it was completely separated and free. Then he fixed the coracoid to the scapular neck through the subscapularis; the patient reportedly did well. Latarjet did a second case with complete osteotomy of the coracoid and reported proudly his “new technique” with a few weeks’ follow-up at the same Société Lyonnaise de Chirurgie in March 1954 ² just 1 week after Albert Trillat’s presentation ( Fig. 44.3 ). That was the beginning of the Latarjet procedure and the beginning of the great animosity between Trillat and Latarjet.

Latarjet reported his technique and results at the Société Lyonnaise de Chirurgie and in the journal “Lyon Chirurgical” again in 1958, 1961, and 1964. The techniques he described in 1954 and then in 1958, 1961, and 1964 were not exactly the same: initially he reported the coracoid process passing through the subscapularis, which was split but not cut. He placed the coracoid lying on the glenoid neck and fixed with one screw. Then in 1958, 1961, and 1964 he totally cut the subscapularis and then repaired it with shortening as in the Putti-Platt procedure ( Fig. 44.4 ). He placed the coracoid in the lying position fixed with one screw very high above the equator and medial “to avoid any contact with the humeral head.” There was no sling effect provided by the conjoint tendon because the full subscapularis was anterior to it.

Latarjet recommended putting the coracoid tip on the periosteum, capsule, and labrum; his goal was clearly not to achieve bone healing between the coracoid and the anterior part of the glenoid but to reattach the anterior ligamentous structures to the glenoid rim as in a Bankart repair.

The Bristow procedure was reported by a South-African surgeon named Helfet in memory of his former boss, Rolley Bristow, from the United Kingdom, who taught him the procedure during the Second World War. In the Bristow procedure, the tip of the coracoid process is detached together with the conjoint tendon insertion and is passed through the subscapularis. It seems that the first surgeon in the United States reporting the use of the screw to fix the coracoid process to the glenoid was Virgil May, who apparently was not aware of the prior publications in French.

In the 1950s, 1960s, and 1970s the influence of Professor Trillat in France was such that the only procedure to compete with the Bankart operation was the Trillat procedure. ^, However, several publications showed that the humeral head was still able to dislocate under the medialized coracoid process (14% recurrence rate in a series of 250 procedures done by Trillat himself). ^, In the 1970s another French orthopedic surgeon, Didier Patte, from Paris, revisited and popularized the Latarjet procedure, describing its “triple blocking” effect ( Fig. 44.5 ). Patte recommended cutting the superior two-thirds of the subscapularis and maintaining the integrity of the inferior third to create the sling effect of subscapularis under the coracoid process and the conjoint tendon creating the first blocking effect. The second blocking effect was the glenoplasty obtained by the increase in the glenoid anteroposterior diameter. The third blocking effect was the ligamentous effect obtained by suturing the stump of the coracoacromial ligament to the capsule. Nobu Yamamoto nicely demonstrated that the muscular effect of the subscapularis sling is the most important mechanism for providing stability of the humeral head after Latarjet procedure. In the cadaver the bony effect and the ligamentous effect were less effective.

The Latarjet procedure was thereafter modified many times by other surgeons. These included: ( Fig. 44.6 )

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Variations in the management of the subscapularis: cut, no cut, split, window
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Variations in the position of the coracoid: lying position, standing position, or “on the side” like reported by de Beer and Burkhart
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Variations in type of screw fixation: one or two screws, 3.5- or 4.5-mm diameter, cannulated or not, absorbable or not, with or without washer
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Variations in the management of the capsule: no repair, repair to the stump of the coracoacromial ligament, repair to the anterior glenoid rim with transosseous sutures or anchors.

More recently, techniques have been developed for performing the Latarjet arthroscopically with minor or major variations on the open procedure.

These variations in surgical technique make analysis of the outcomes of the Latarjet procedure very difficult because each change may have an important influence on the results, and it is difficult to conclude which modifications were beneficial or and which were not. Moreover, the Latarjet procedure is technically demanding. There is a steep learning curve to master this operation: it is difficult to quantitate the effect of surgeon experience on patient outcomes.

My experience of the latarjet procedure

After visiting Franck Jobe in Los Angeles in 1983 and Didier Patte in Paris in 1985, I gradually switched from the Trillat procedure (I was working in Trillat’s department) to the modified Latarjet-Patte procedure after the retirement of Professor Trillat, who was still extremely upset about Latarjet.

The surgical technique I currently use became gradually standardized and has not changed since 1989 ( Fig. 44.7 ). As I pointed out, there is a long learning curve to master the different steps. Here is my technique for the Latarjet:

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Beach chair positioning with a small pillow under the scapula to keep it flat and to help the surgeon feel the tip of the coracoid under the skin.
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Small deltopectoral approach starting under the coracoid tip and keeping the cephalic vein lateral with the deltoid.
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Osteotomy of the coracoid process with an angulated saw from medial to lateral at the junction between the vertical and horizontal parts just in front of the intact coracoclavicular ligaments. The length of the detached coracoid must be at least 2.0 cm.
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Abrasion of the cortical bone on the posterior part of the coracoid to achieve a flat cancellous surface, ensuring proper contact with the anterior glenoid rim and minimizing the risk of nonunion.
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Drilling of two holes in the coracoid 1 cm apart, perpendicular to the decorticated posterior surface. I use a 3.2 mm drill bit, rather than a 4.5 mm to avoid fracture or weakening of the coracoid process.
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Split in the subscapularis in its lateral part avoiding damage to the tendon insertion or the capsule
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A 1- or 2-cm vertical opening in the capsule at the level of the anterior glenoid rim allowing the introduction of a humeral head retractor into the joint.
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Correct exposure of the anteroinferior part of the glenoid that need to be cleaned and decorticated to offer a bleeding surface to apply the flat cancellous surface of the prepared coracoid. Types and positions of the four retractors necessary to expose the anteroinferior part of the glenoid are crucial to have a perfect exposure.
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Positioning the inferior screw at 5 o’clock for a right shoulder and the second screw at 4 o’clock. Both screws must be bicortical; no washer is used.
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“Two-finger technique” to tight the screws, especially in adults older than 35 years, for whom bone is weaker.
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The lateral part of the coracoid process must be flush or slightly medial with respect to the glenoid articular surface, never lateral and no overhanging, to avoid contact with the cartilage of the humeral head cause of secondary osteoarthritis.
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The repair of the capsule with the stump of the coracoacromial ligament is performed with two absorbable sutures with the arm is external rotation. No repair of the subscapularis is necessary.

It is important to respect each step and to avoid bleeding to ensure perfect vision of what I am doing. Postoperative course has also been standardized:

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Simple sling for 2 weeks with immediate passive range of motion (self-assisted exercises).
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Resume activities of daily living after 2 weeks with continuous stretching. Active rehabilitation with elastic bands or weights is not necessary for noncompetitive athletes; repetitive stretching and activities of daily living are sufficient to recover full function. Because no stiffness occurs, there is no muscular atrophy and no need for strengthening exercises. Otherwise in the athletes, strengthening exercises are started and progressively developed during the second postoperative month and adapted to each type of sports to allow a return to play at the end of the third month.

Some “academic” remarks or comments coming from a long experience about the Latarjet procedure, even if all of them have not been scientifically proven:

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There is no need to repair a superior labrum anterior and posterior (SLAP) lesion because I have never done it at the time of open procedure. I have had to perform several arthroscopic second looks for persisting pain or for removing the screws, and I have never found a SLAP lesion as potential cause of pain or instability.
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There is no need to close the rotator interval even in the patient with multidirectional hyperlaxity (positive sulcus sign).
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There is no need to put one or two anchors at the posteroinferior part of the capsule and labrum to achieve correct stability.
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There is no need to perform a remplissage procedure of the Hill-Sachs lesion to achieve a correct stability.
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Secondary osteolysis, especially of the superior part of the transferred coracoid, is extremely frequent (if not constant). The cause is probably vascular and does not influence the stability or the functional results.

It seems that healing of a small part of the tip is enough to restore the stability as the main mechanism of stability is the transfer of the conjoint tendon to the anterior part of the glenoid.

In 2% to 5% of cases the patients present with persisting pain at the anterior part of the joint, which is increased during the belly-press test. In those cases, I wait for 1 year postoperation and then remove the screws after an arthroscopic inspection to make sure that there is no intra-articular cause. Although it is possible to remove the screws under arthroscopy, I do not recommend it anymore because it is a long and tenuous procedure that is much easier with a standard open approach after the arthroscopy.

Indications and use of the latarjet procedure

The Latarjet procedure has been used in our practice since 1985 to treat recurrent anterior subluxation or dislocation and primary dislocation in professional contact athletes; close to 3000 cases have been performed. Latarjet is effective for treating anterior instability (dislocation or subluxation) even if the patient presents with multidirectional hyperlaxity (also known as multidirectional instability described by Neer and Foster). However, the Latarjet procedure, even when combined with capsular plication or capsular shift, is not sufficient to decrease constitutional anterior or inferior laxity of the glenohumeral joint: the patient must be aware that the operation will prevent dislocation and subluxation, but the constitutional laxity will stay the same after recovering full range of motion.

In cases with a huge anterior glenoid rim fracture involving more than one-third of the anterior posterior diameter of the glenoid, I may combine an iliac crest bone graft with the coracoid transfer to restore the anteroposterior diameter of the glenoid. This is extremely rare and has been necessary in a few cases.

Humeral avulsion of the glenohumeral ligament lesions described by Russ Warren are usually discovered intraoperatively during the Latarjet procedure after osteotomy of the coracoid: consequently, I treat them by reinserting the capsule to the anatomic neck of the humerus using suture anchors combined with the classic coracoid transfer; I have had no failures to date.

Preoperative glenohumeral arthritis in the young contact athlete is not rare, especially in cases of severe glenoid rim fracture: arthritis is mainly represented by humeral inferior osteophyte without joint narrowing (i.e., the radiographic joint space is intact). The Latarjet procedure has been efficient in treating those patients with near normal return of range of motion despite the sometimes-important inferior osteophyte ( Fig. 44.8 ).