Review Question - QID 216803

Given the degree of anterior glenoid bone loss, a Latarjet procedure is likely to be necessary. It functions by increasing the bony glenoid arc, creating a sling effect, and providing capsular reinforcement.

Anterior shoulder instability is a common shoulder issue, more so in young male athletes participating in contact sports. Surgical options include arthroscopic vs. open bankart repair +/- remplissage, Latarjet-Bristow bone transfers, iliac crest autograft and distal tibial allograft. With increasing degrees of bone loss, bone augmentation procedures have become more popular, with studies demonstrating low rates of recurrence and high rates of satisfaction. Some even suggest that bony procedures like the Latarjet should be performed primarily in cases with bone loss present at the index event. The Latarjet procedure functions by increasing the glenoid track (to a greater degree with congruent arc than traditional), reinforcing the anterior capsule, and creating a sling effect with the conjoint tendon over the subscapularis.

Burkhart et al. looked at risk factors for recurrent instability with arthroscopic labral repair. There was no difference in failure in arthroscopic repairs compared to open repairs in patients which didn't have significant bone loss. However, failure rates were up to 67% in the group who had large bone defects and the authors recommended Latarjet in this cohort.

Piasecki et al. reported on management strategies in recurrent anterior shoulder instability. They noted that while recurrence was multifactorial, the degree of anterior bone loss was an important factor. Up to 90% of the patients studied with recurrent instability had anterior bone loss, which they reiterate is important to completely evaluate before choosing the appropriate stabilization procedure.

Schmid et al. retrospectively evaluated a case series of patients for which Latarjet was used for recurrence of instability. There were no redislocations in the study and no revision surgery was needed, with patients reporting high degrees of satisfaction. They concluded that Latarjet was effective in restoring glenohumeral stability and preventing recurrence of dislocation.

Illustration A demonstrates the appearance of the shoulder status post Latarjet procedure with a split in the subscapularis performed for placement of the coracoid graft. Illustration B shows the two types of Latarjet procedures, with a/b representing the traditional version and c/d representing the congruent arc technique.

Incorrect Answers:
Answer 1: The subscapularis is not routinely detached during Latarjet procedures. Instead, it is split and the coracoid graft is passed through this split.
Answer 2: The musculocutaneous nerve, not axillary, injury occurs with excessive retraction. Axillary nerve injury can occur during instrumentation if not careful.
Answer 3: More lateral placement of the graft with overhang into the joint is thought to increase the degree of early glenohumeral arthritis progression.
Answer 4: Glenoid track is increased more with the congruent arc technique as the undersurface of the coracoid is rotated to abut the anterior glenoid and provides increased surface area compared to the traditional Latarjet technique.