Shoulder Instability Update: Latarjet
Shoulder instability can be a source of significant pain and disability with progressive damage to cartilage and an increased risk of arthritis and destruction of the bone on the socket (glenoid) and ball (humeral head) of the shoulder joint. Treatment of shoulder instability has evolved considerably over the past 15 years with research to better understand which patients would benefit from surgery, technological advances in arthroscopic techniques, and refinement of the open Latarjet procedure for cases that involve bone loss and greater complexity.
The Latarjet Procedure, developed in France in 1954, restores anterior stability to the shoulder by transferring a piece of bone from the scapula called the coracoid to the front of the socket (glenoid) and stabilizing it with screws. This bone graft or transfer is placed between a split in the Subscapularis tendon of the rotator cuff to enhance stability when the shoulder comes up and out into the position of potential anterior instability (like coming back to throw a ball). In addition, the capsule of the shoulder is reinforced by taking a ligament from the coracoid and suturing it to the capsule and ligament at the front of the shoulder.
Latarjet: Pros & Cons
The Latarjet is an excellent procedure for recurrent instability in the setting of bone loss which is measured as the total of socket (glenoid) bone loss and ball (humeral head) bone loss. Together, this total is referred to as articular arc compromise meaning that the significance of bone loss is determined by the sum of each side of the ball-and-socket joint. In addition, tissue quality and activity-level will further influence surgical decision-making. While some surgeons may speak in absolutes, the reality is that there are multiple options to successfully treat shoulder instability. The location and orientation of the Hill-Sachs lesion or defect on the humeral head has been shown in several studies by Itoi and others to potentially influence the success of an arthroscopic procedure and need to consider Latarjet. Several studies have continued to evaluate the best way to measure bone loss and controversy persists as how to best measure these factors. We believe it is also important to minimize radiation exposure and the use of CT scans unless clearly necessary.
However, Latarjet is not necessary for every patient with shoulder instability. The literature clearly demonstrates a higher risk of complications and the procedure distorts the native or “normal” anatomy of the shoulder. As a result, patients may have a higher risk of complications with additional procedures in the future should there shoulder become arthritic.
The Latarjet has been a successful procedure for over 60 years to restore stability to an unstable shoulder with excellent results. While more invasive than an arthroscopic stabilization and carrying additional risks, it is a highly effective method of providing stability with the “triple blocking effect”: increasing the size of the socket with the coracoid bone graft, placing a sling effect with the Subscapularis tendon to restrain the shoulder, and reinforcing the capsule of the shoulder. Careful thought into each patient’s specific history, physical exam, diagnostic imaging and goals is essential to define the optimal approach for each individual.