Recurrent anterior shoulder instability is common in contact athletes and the high-energy injuries seen in this group make them more prone to bone loss. Athletes with recurrent instability and associated bone loss have high failure rates when treated with a soft tissue reconstruction procedure. Therefore it is preferred to manage recurrent instability in contact athletes with the Latarjet-Patte procedure. In this article, the authors describe their technique. They have found this procedure to be safe and effective, with very low recurrence and early return to sport. A meticulous surgical technique is important to avoid intraoperative and postoperative complications.
Key points
- •
Bone loss is common with recurrent anterior shoulder instability in contact athletes.
- •
The failure rate in these situations with a soft tissue procedure alone is high.
- •
The Latarjet-Patte procedure addresses both bony and soft tissue deficiencies with its “triple-blocking” effect.
- •
The Latarjet-Patte procedure has few complications and allows early return to contact sports without recurrence.
- •
The Latarjet-Patte technique is the authors’ preferred management for recurrent instability in contact athletes.
Recurrent anterior shoulder instability in contact athletes
Contact Athletes Are a High-risk Group
Glenohumeral dislocation and anterior shoulder instability are most common in young athletes involved in contact sports. Ongoing sports participation in this population is associated with a high recurrence rate. Recurrent instability has physical and psychological consequences for the athlete, with more severe soft tissue and bony pathologic abnormality, greater time away from sports participation, and a negative impact on quality of life. Surgery is therefore generally recommended in contact athletes experiencing recurrent anterior shoulder instability.
Open or Arthroscopic Techniques for Soft Tissue Pathology
The operative management of recurrent instability has evolved since its first description by Bankart in 1923. Following the introduction of arthroscopic surgery, debate centered over whether open or arthroscopic repairs best addressed the Bankart lesion, a soft tissue pathologic abnormality characterized by capsulolabral detachment from the anteroinferior aspect of the glenoid. Open Bankart stabilization has traditionally been considered the gold standard with early studies demonstrating better outcomes compared with arthroscopic stabilization. Arthroscopic techniques and equipment have however continued to evolve and arthroscopic repairs using suture anchors now achieve similar results to open surgery in the treatment of such soft tissue lesions.
Soft Tissue or Bony Procedures for Recurrent Instability
With improved understanding of the pathoanatomic changes associated with recurrent instability, more recently debate has shifted focus to soft tissue versus bony surgical stabilization procedures. Shoulders with recurrent instability are associated with a high incidence of bone loss. Glenoid and/or humeral bone lesions have been shown to be present in 90% to 95% of shoulders with recurrent instability. Failure to address these bone defects can result in a poor outcome. A glenoid defect approaching 21% of its length has been shown to compromise shoulder stability. Burkhart and De Beer observed a 67% recurrence rate in patients with an “inverted pear” glenoid configuration if they only underwent a soft tissue procedure. The recurrence rate was 4.9% in these patients with an open Latarjet technique. This evidence has led some authors to favor a bony procedure for recurrent anterior shoulder instability associated with bone loss.
Open Bony Procedures Best for Contact Athletes
Contact athletes are more prone to bone loss because of the high-energy injuries they sustain. Successful treatment in this group must provide a stable reconstruction with a pain-free, mobile, and strong shoulder, thereby allowing early return to sports participation without recurrence. Higher failure rates have been reported in contact athletes with recurrent instability following arthroscopic soft tissue stabilization. An open bony procedure seems to give better results in this group. Balg and Boileau have proposed the Instability Severity Index Score to determine which patients would in fact benefit from an open bony reconstruction. Contact athletes by definition have many of their proposed risk factors and would score high on the Instability Severity Index Score, resulting in the Latarjet procedure being recommended.
For all of the reasons mentioned above, the authors’ preferred management of the contact athlete is therefore the Latarjet procedure.
Recurrent anterior shoulder instability in contact athletes
Contact Athletes Are a High-risk Group
Glenohumeral dislocation and anterior shoulder instability are most common in young athletes involved in contact sports. Ongoing sports participation in this population is associated with a high recurrence rate. Recurrent instability has physical and psychological consequences for the athlete, with more severe soft tissue and bony pathologic abnormality, greater time away from sports participation, and a negative impact on quality of life. Surgery is therefore generally recommended in contact athletes experiencing recurrent anterior shoulder instability.
Open or Arthroscopic Techniques for Soft Tissue Pathology
The operative management of recurrent instability has evolved since its first description by Bankart in 1923. Following the introduction of arthroscopic surgery, debate centered over whether open or arthroscopic repairs best addressed the Bankart lesion, a soft tissue pathologic abnormality characterized by capsulolabral detachment from the anteroinferior aspect of the glenoid. Open Bankart stabilization has traditionally been considered the gold standard with early studies demonstrating better outcomes compared with arthroscopic stabilization. Arthroscopic techniques and equipment have however continued to evolve and arthroscopic repairs using suture anchors now achieve similar results to open surgery in the treatment of such soft tissue lesions.
Soft Tissue or Bony Procedures for Recurrent Instability
With improved understanding of the pathoanatomic changes associated with recurrent instability, more recently debate has shifted focus to soft tissue versus bony surgical stabilization procedures. Shoulders with recurrent instability are associated with a high incidence of bone loss. Glenoid and/or humeral bone lesions have been shown to be present in 90% to 95% of shoulders with recurrent instability. Failure to address these bone defects can result in a poor outcome. A glenoid defect approaching 21% of its length has been shown to compromise shoulder stability. Burkhart and De Beer observed a 67% recurrence rate in patients with an “inverted pear” glenoid configuration if they only underwent a soft tissue procedure. The recurrence rate was 4.9% in these patients with an open Latarjet technique. This evidence has led some authors to favor a bony procedure for recurrent anterior shoulder instability associated with bone loss.
Open Bony Procedures Best for Contact Athletes
Contact athletes are more prone to bone loss because of the high-energy injuries they sustain. Successful treatment in this group must provide a stable reconstruction with a pain-free, mobile, and strong shoulder, thereby allowing early return to sports participation without recurrence. Higher failure rates have been reported in contact athletes with recurrent instability following arthroscopic soft tissue stabilization. An open bony procedure seems to give better results in this group. Balg and Boileau have proposed the Instability Severity Index Score to determine which patients would in fact benefit from an open bony reconstruction. Contact athletes by definition have many of their proposed risk factors and would score high on the Instability Severity Index Score, resulting in the Latarjet procedure being recommended.
For all of the reasons mentioned above, the authors’ preferred management of the contact athlete is therefore the Latarjet procedure.
The Latarjet-Patte procedure
Michel Latarjet described his technique for shoulder stabilization in 1954, whereby the horizontal limb of the coracoid process was transposed to the anteroinferior glenoid rim through a window in the subscapularis and fixed with a single screw. The Latarjet-Patte procedure is a modification of this involving the use of 2 screws and including repair of the anterior capsule to the stump of the coracoacromial ligament.
Proposed Mechanism of Action
The Latarjet-Patte procedure has been proposed to address both bony and soft tissue deficiencies with a “triple-blocking” effect ( Fig. 1 ). The coracoid graft provides a “bony effect” by restoring the anteroposterior diameter of the glenoid, thereby increasing stability and preventing an otherwise engaging Hill-Sachs lesion from levering on a deficient anteroinferior glenoid rim. The most important stabilizing mechanism of the Latarjet-Patte procedure is however the interaction between the conjoint tendon and lower subscapularis with the arm in abduction and external rotation. In this position, the conjoint tendon reinforces the inferior subscapularis fibers and anteroinferior joint capsule to provide a so-called ”sling effect.” It also counteracts the ligament laxity seen with recurrent instability through a tensioning effect on the lower subscapularis as it passes through a split in the muscle. Essentially, the lower subscapularis fills the potential space into where the humeral head would otherwise dislocate. The further the arm moves into the at-risk position of abduction and external rotation, the tighter the sling effect becomes. Finally, repair of the anterior capsule to the stump of the coracoacromial ligament completes the triple-blocking effect. This mechanism is most important in abduction and neutral rotation.
Technique
Patient position
The patient is placed in a beach chair position with the lateral most aspect of the acromion level with the edge of the operating table. A small towel is placed between the scapula and table to stabilize and flatten the scapula. The arm is draped free to allow intraoperative abduction and external rotation.
Surgical approach
A limited deltopectoral approach is used. The skin incision is 4 to 5 cm long and extends vertically downward from the coracoid tip. Branching vessels from the cephalic vein are ligated. A self-retaining retractor between the deltoid and pectoralis major is used to maintain exposure. A Hohmann retractor is placed over the top of the coracoid.
Coracoid harvesting
The coracoacromial ligament (CAL) is incised 1 cm lateral to its coracoid attachment. The CAL is released. The pectoralis minor tendon is released from the coracoid. Care should be taken not to release past the coracoid tip because the blood supply to the graft enters just medial to the conjoint tendon insertion. The inferior aspect of the “knee” of the coracoid (ie, the junction between its horizontal and vertical parts) is now exposed and is the site of the osteotomy. A coracoid graft greater than 25 mm in length can routinely be harvested without damaging the coracoclavicular ligaments using this technique. The inferior coracoid surface is decorticated. Two central drill holes are made in the coracoid about 1 cm apart.
Glenoid exposure and preparation
The subscapularis is split at the junction of its superior two-thirds and inferior one-third. The underlying capsule is exposed and a vertical incision is made at the level of the joint line. An intra-articular retractor is placed. The anterior labrum and periosteum are excised. An osteotome is used to decorticate the anterior glenoid surface with the aim of creating a flat surface of bleeding cancellous bone. The inferior hole in the glenoid is drilled at a position between 4 and 5 o’clock in the right shoulder. The hole must be sufficiently medial to avoid lateral coracoid overhang from the glenoid and the recommended distance is typically 7 mm from the glenoid margin. Drilling is parallel to the glenoid articular surface and passes through the posterior glenoid cortex.
Graft fixation
The coracoid graft is fixed with a 35-mm-long 4.5-mm partially threaded malleolar screw. The screw is fully inserted into the inferior hole of the graft (ie, the conjoint tendon end). Although this is typically the correct length, it can later be exchanged after placement of the superior screw. The screw is placed in the already drilled hole in the glenoid and tightened, correcting rotation of the graft to ensure the lateral margin of the coracoid is flush with the glenoid articular margin ( Fig. 2 ). Although this is the ideal position for the graft, a slightly medial position (1–2 mm) is acceptable. The drill is used to create a second hole in the glenoid through the superior hole in the graft. A depth gauge is used to measure the length of the malleolar screw (typically 35 mm, usual range 30–40 mm). Both screws are tightened using a 2-finger technique. Aggressive over-tightening should be avoided to prevent fracture of the graft. The position of the coracoid is rechecked. If any lateral overhang is noticed, it should be removed with bone rongeurs or a high-speed burr. Alternatively, the graft can be repositioned and the glenoid drilled in a slightly different direction by removing one screw and loosening the other.
