Latarjet Shoulder Procedure: Understanding, Indications, and Recovery

What is the Latarjet Shoulder Procedure?

The Latarjet procedure is a highly specialized surgical technique used to treat recurrent anterior shoulder instability, particularly when there is significant bone loss from the glenoid (shoulder socket) or when previous soft tissue repairs have failed.

Understanding Shoulder Instability

The shoulder is a highly mobile ball-and-socket joint, formed by the head of the humerus (arm bone) and the glenoid fossa of the scapula (shoulder blade). Its stability relies on a complex interplay of static and dynamic stabilizers:

• Static Stabilizers: These include the glenoid labrum (a rim of cartilage deepening the socket), the joint capsule, and the glenohumeral ligaments.
• Dynamic Stabilizers: These are the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis) and the periscapular muscles, which actively control joint movement and position.

Shoulder instability occurs when these stabilizers are compromised, allowing the humeral head to excessively translate or dislocate from the glenoid. While often traumatic in origin (e.g., a fall or direct impact), it can also result from repetitive microtrauma or underlying ligamentous laxity. Recurrent anterior (forward) dislocations are the most common type, often leading to damage to the anterior labrum (Bankart lesion) and, critically, bone loss from the anterior rim of the glenoid (bony Bankart lesion) or an indentation fracture on the posterior humeral head (Hill-Sachs lesion).

When is the Latarjet Procedure Indicated?

The Latarjet procedure is not typically the first-line treatment for all shoulder instabilities. It is specifically indicated in cases where soft tissue repairs alone are insufficient to restore stability, primarily due to:

• Significant Anterior Glenoid Bone Loss: This is the primary indication. When a substantial portion (typically >20-25%) of the anterior glenoid rim has eroded or fractured, a soft tissue repair (like an arthroscopic Bankart repair) may not provide enough structural support, leading to high failure rates.
• Failed Previous Stabilization Surgery: Patients who have undergone one or more failed arthroscopic Bankart repairs, especially if bone loss was an unrecognized or untreated factor.
• Engaging Hill-Sachs Lesion: A large Hill-Sachs lesion on the humeral head that "engages" (articulates) with the anterior glenoid rim during abduction and external rotation, increasing the risk of dislocation.
• High-Risk Individuals: Athletes involved in overhead or contact sports (e.g., rugby, football, wrestling) who experience recurrent dislocations and require a highly robust and durable repair.
• Generalized Ligamentous Laxity: While less common, some surgeons consider Latarjet for individuals with hyperlaxity who have failed other treatments.

The Latarjet Procedure Explained

Named after French surgeon Michel Latarjet, this procedure is a reconstructive technique that involves the transfer of a piece of bone to augment the anterior glenoid. The key steps are:

1. Coracoid Osteotomy: The coracoid process, a small, hook-like projection of the scapula, is carefully cut (osteotomized) along with its attached muscles and tendons – specifically, the conjoined tendon (biceps short head and coracobrachialis) and often a portion of the pectoralis minor insertion.
2. Bone Graft Transfer: The detached coracoid process, complete with its muscular attachments, is then rotated and meticulously positioned onto the anterior rim of the glenoid.
3. Fixation: The coracoid bone block is secured to the glenoid using two screws, effectively extending the glenoid articular surface and creating a bony buttress.
4. The "Double-Block" Effect: The Latarjet procedure provides stability through two primary mechanisms:
   • Bone Block Effect: The transferred coracoid process acts as a physical barrier, preventing the humeral head from dislocating anteriorly.
   • Sling Effect: The conjoined tendon, now positioned over the anterior shoulder capsule, provides a dynamic sling that reinforces the anterior capsule and tightens when the arm is abducted and externally rotated – positions where the shoulder is most vulnerable to dislocation.

The procedure can be performed via an open incision or, increasingly, arthroscopically, depending on surgeon preference and complexity.

Surgical Outcomes and Efficacy

The Latarjet procedure boasts a high success rate in preventing recurrent shoulder dislocations, with reported rates of re-dislocation significantly lower than those following isolated soft tissue repairs in patients with bone loss. Studies consistently demonstrate:

• Excellent Stability: Markedly reduced rates of re-dislocation.
• High Return-to-Sport Rates: Especially for athletes in contact or overhead sports.
• Improved Quality of Life: Reduction in pain and apprehension associated with instability.

While effective, it's important to note that the Latarjet can sometimes result in a slight, often clinically insignificant, loss of external rotation range of motion due to the sling effect of the transferred conjoined tendon.

Potential Risks and Complications

As with any surgical procedure, the Latarjet carries potential risks, including:

• General Surgical Risks: Infection, bleeding, adverse reaction to anesthesia, nerve damage (e.g., to the musculocutaneous nerve, which innervates the conjoined tendon).
• Non-Union or Mal-Union: The transferred coracoid process may fail to heal to the glenoid, or heal in an improper position.
• Hardware Complications: Screw loosening, breakage, or impingement, potentially requiring removal.
• Stiffness: Post-operative stiffness or loss of range of motion, particularly external rotation.
• Coracoid Fracture: Fracture of the transferred bone block.
• Persistent Pain: Though rare, some patients may experience ongoing pain.

Post-Operative Rehabilitation and Recovery

Rehabilitation after a Latarjet procedure is a critical component of successful recovery and typically follows a structured, progressive protocol:

1. Immobilization (0-4 weeks): The arm is typically immobilized in a sling to protect the surgical site and allow initial healing. Passive range of motion exercises may begin under therapist guidance.
2. Early Mobility (4-8 weeks): Gradual progression to active-assisted and then active range of motion exercises, focusing on restoring mobility without stressing the repair. Scapular stability exercises are often introduced.
3. Strengthening (8-16 weeks): Introduction of light isometric and progressive resistance exercises for the rotator cuff, deltoid, and periscapular muscles. Neuromuscular control and proprioception drills begin.
4. Advanced Strengthening and Return to Activity (16+ weeks): Sport-specific drills, plyometrics, and functional training are incorporated. Gradual return to light activities and then full sports participation, typically not before 6-9 months, and only after achieving specific strength and functional milestones.

Adherence to a physical therapy program is paramount to optimize outcomes, restore strength and mobility, and minimize the risk of re-injury.

Comparing Latarjet to Other Shoulder Procedures

The Latarjet procedure stands in contrast to soft tissue-only repairs, such as the arthroscopic Bankart repair. While a Bankart repair addresses a torn labrum and tightens the capsule, it does not directly augment the bony glenoid. Therefore:

• Bankart Repair: Ideal for patients with recurrent instability primarily due to soft tissue damage (labral tear) and minimal to no bone loss.
• Latarjet Procedure: The preferred choice when significant bone loss is present, when a large engaging Hill-Sachs lesion exists, or after failed previous soft tissue repairs, as it directly addresses the bony deficiency and provides a more robust mechanical block.

The decision between these procedures is complex and depends on a thorough clinical assessment, imaging studies (especially CT scans to quantify bone loss), and the patient's activity level and goals.

Conclusion

The Latarjet shoulder procedure is a powerful and effective surgical option for individuals suffering from recurrent anterior shoulder instability, particularly those with significant glenoid bone loss or who have failed prior stabilization attempts. By providing a bony buttress and dynamic sling effect, it offers a high success rate in restoring stability and enabling a return to high-level activities. However, it is a specialized procedure with specific indications, and a structured, disciplined rehabilitation program is essential for optimal recovery and long-term success.