By: Ushala Misra (B.Physio)UKZN – Physiotherapist at BRH Physios.
Shoulder instability, particularly anterior instability affects 24 per 100,000 persons in a population annually, with increased incidences recorded in men, athletes involved in contact sport particularly in the second and third decades of life. The principles of the current Latarjet procedure were described in 1954 by Andre Latarjet in Lyon, France. It is predominantly used in recurrent anterior dislocations.
The anatomy of the shoulder allows for great mobility yet sacrifices stability. The shoulder is one of the most commonly dislocated joints in the body. Shoulder dislocations can occur from trauma or from hyper laxity (genetic or acquired looseness of the capsule and ligaments).
The shoulder joint is a ball and socket joint with the head of the humerus forming the ball and the cupped shaped depression on the shoulder blade, the glenoid fossa forming the socket. The joint is stabilised by the labrum, a cartilaginous rim on the glenoid cavity. The capsule is a series of ligaments that enclose the joint.
Injury or Trauma can stretch or tear the labrum and the ligaments causing dislocation and instability of the joint. The shoulder can dislocate in front (Anterior) more common, downwards (inferior) and behind (posterior). Tearing of the labrum is called a Bankart tear, sometimes there may be a break in the bone along the labrum, this is called a bony bankart. Instability can cause pain and a feeling of giving way. A Latarjet is done when there is recurrent anterior dislocations, a bony bankart or when a surgical repair of the labrum does not correct the damage to the joint.
Studies have shown that traumatic shoulder dislocations result in recurrent instability. The degree of instability is related to the patient’s age, sport or activity level. Studies report recurrence rates from 65-95% for patients less than 20 years of age, 40% for patients who were between 20 and 40 years old and only 4% for patients over the age of 40. It is likely the injury pattern for dislocation changes as people age.
Simonest also compared recurrent dislocations with athletes and non-athletes, with athletes having an 82% recurrence rate and non-athletes having a 30% recurrence rate.
Despite operative treatment instability may recur in 40 % of the patients after a Bankart procedure, a study by Elamo concluded that the open Latarjet procedure yields better results than an arthroscopic Bankart repair in a revision setting after a failed primary arthroscopic Bankart procedure. The redislocation rate and patient reported outcome measures were better after the Latarjet with less risk of osteoarthritis.
The Latarjet is open shoulder surgery, the corcoid process is freed from its attachment, the conjoint tendon is transected from its base. The subscapularis muscle is split in line of its fibres. The capsule of the shoulder is entered and the glenoid is exposed. The transected corocoid with the conjoint tendon is passed through the separated subscapularis muscle and is fixed to the glenoid rim with screws. This increases the glenoid surface and stabilises the joint. The conjoint tendon and the subscapularis muscle provide stability by acting as a sling.
The principle of a Latarjet procedure is to cut and move the coracoid bone with the conjoined tendon (coracobrachialis and short head of biceps) to fill in the bony defect in the glenoid. The repositioning of the conjoined tendon helps to stabilise the shoulder by acting as a sling when the arm is abducted and externally rotated, stopping the humeral head dislocating anteriorly.
Postoperative rehabilitation is essential after a Latarjet. There are specific guidelines to ensure the successful outcome of the procedure and these must be carefully managed by your physiotherapist.
1.Sami Elamo, Liisa Selanne, Kaisa Lehtimaki, Juha Kukkonen, Saija Hurme, Tommi Kauko,Ville Aarimaa. Bankart versus Latarjet operation as a revision procedure after a failed arthroscopic Bankart Repair. https//dol.org/10.1016jjsein2020.01.004
2. Rehabilitation Guidelines for Open Latarjet Anterior Shoulder Stabilisation. University of Wisconsin Sports Medicine.
3. Stephen S. Burkhart, Joe R.De Beer. Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted -Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion. The Journal of Arthroscopic and Related Surgery, Vol16,No 7 (October 2000).
4. Umair Khan, Emma Torrance, Mohammad Hussain, Lenard Funk. Failed Latarjet Surgery :Why, how and what next? https//dol.org/jses.2019.11.006
5. Seper Ekhtiari, Nolan S. Horner, Asheesh Bedi, Olufemi R, Ayeni. The learning Curve for the Latarjet Procedure: A Systemic Review. Orthopaedic Sports Med.2018 July; doi10.1177/232596711886930