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Latarjet Technique and Biomechanics in Shoulder Instability

February 01, 2013

Contributors: Alberto Costantini, MD; Andrea De Vita, MD; Nicola De Gasperis, MD; Giovanni Di Giacomo, MD; Giovanni Di Giacomo, MD

Keywords: Bony Procedure

Peer review has expired on this program. It is the viewer’s responsibility to determine the educational value of this historical content.
Peer review has expired on this program. It is the viewer’s responsibility to determine the educational value of this historical content.

We introduce a new concept, the glenoid track, to evaluate the size of the Hill-Sachs lesion with the size of the glenoid. The glenoid track is a contact zone of the glenoid on the humeral head when the arm is at the end range of motion, i.e. in various degrees of elevation with the arm in maximum external rotation and maximum horizontal extension. This end range of motion is critical to anterior dislocation, because in this position, the anterior soft tissue structures tighten and prevent the anterior translation of the humeral head. In this position, patients with recurrent anterior dislocation of the shoulder tend to feel anterior apprehension. If the Hill-Sachs lesion is always covered by the glenoid at this end range of motion (or in other words, if the Hill-Sachs lesion stays within the glenoid track), the lesion does no harm (because it is covered). On the other hand, if the lesion comes out of the glenoid coverage, it engages with the anterior rim of the glenoid and causes a dislocation. Clarifying the exact location of this contact zone-the glenoid track-enables us to evaluate any Hill-Sachs lesion for its risk of engagement. When the arm is moving along the end range of motion and the glenoid moves on the lesion, any obstacle attached to the lesion prevents the smooth movement of the glenoid. The increasingly popular remplissage technique provides an example: with this procedure, the infraspinatus tendon is fixed into the cavity of the lesion. Obviously, the fixed tendon prevents smooth movement of the glenoid over the lesion, thus creating a limited range of motion. The Latarjet procedure involves using a coracoid transfer to stabilize the shoulder by both the static and dynamic action of the transferred bone block and by the dynamic action of the attached conjoined tendon sling (short head of biceps and coracobrachialis). There are different effects to achieve shoulder stability with the Latarjet procedure: Bone effect: bone graft can prevent engagement of a humeral bone lesion because the graft extends the glenoid arch to such a degree that the shoulder cannot externally rotate far enough to engage the Hill-Sachs lesion over the front of the graft. Muscle effect: transfer of a coracoid graft and conjoined tendon over the top of the lower subscapularis tendon results in increased tension in the inferior fibers of the subscapularis, enhancing anterior stability. Sling effect: the conjoined tendon forms a sling across the anterior-inferior capsule when the shoulder is in 90° abduction and 90° external rotation, providing additional soft tissue restraint anteriorly, all of which act to prevent engagement of the Hill-Sachs lesion even before the anterior capsule is repaired. Capsular effect: follows capsular restorationShoulder instability is one of the most controversial joint diseases in terms of diagnosis and treatment. Several open surgical treatments for primary anterior glenohumeral instability have been published with long-term follow-up. There are reliable and time-tested and can yield excellent clinical results. The use of arthroscopy has improved the recognition of pathologic findings in shoulder instability and led to a better understanding of the anatomopathology of instability and the correlation between symptoms and lesions. The arthroscopic technique allows reparative and reconstructive surgical procedures aimed at selective treatment of the injured structures, obviating tenotomy or splitting of the subscapularis, thus reducing the risk of iatrogenic damage. In international literature of arthroscopic treatment, some studies demonstrate that results include recurrent traumatic anterior instability comparable with those that occur historically with open procedures. Despite these exciting advances, open surgery remains an acceptable method of treatment, particularly when a surgeon lacks the equipment, experience, or technical skills needed to perform an arthroscopic repair. Moreover, open surgery remains the preferred method of treatment in situations-such as anterior instability in the presence of glenoid and/or humeral bony defects or soft tissue deficiencies-in which arthroscopic techniques cannot adequately address the anatomic lesion. There are two basic types of surgical treatment for shoulders with anterior instability: anatomic and nonanatomic. The goals of anatomic repairs (open or arthroscopic) are to restore the labrum to its normal position and to obtain the appropriate tension in the capsule-ligaments complex. The goal of a nonanatomic surgical procedure is to stabilize the shoulder by compensating for the capsule-labral and osseous injury with an osseous graft that blocks excessive translation and restores stability. Several studies have demonstrated excellent outcomes with nonanatomic stabilizations, but there are reports that show complications, such as loss of motion, recurrent instability, and arthritis. The nonanatomic procedures are mostly used by European surgeons. Many North American surgeons avoid nonanatomic procedures as a first approach but use them in the presence of a bony defect >20-23% on the glenoid side. European surgeons generally adopt the principles of the French school and use procedures, such as Latarjet, not only in the presence of bone loss (both glenoid and humeral side, i.e., glenoid track), but also when capsular deficiency is present or after several dislocations, when soft tissue mechanical properties may change and become more pronounced. The negative aspect of these procedures is related to the new anatomy. In these cases, revision surgery can be challenging; however, when these procedures are performed appropriately by well-trained surgeons, good results can generally be obtained.

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