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How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
How To Do A Latarjet Procedure
Matthew T. Provencher, MD CDR MC USN
Chief, Sports Surgery
Massachusetts General Hospital
Associate Professor of Surgery, Harvard University
[email protected]
Rachel M. Frank, BS
Northwestern University Feinberg School of Medicine
Chicago, IL USA | [email protected]
Introduction à Potential Pitfalls in Any Shoulder Instability Repair1
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Glenoid bone loss à lots of attention in recent literature
o Over 40 peer-review publications in major journals since 2009 alone (pubmed)
Significant Hill-Sachs lesion
Revision situation – post thermal cases
Revision situation with prior capsular insufficiency
Prior anchor (mal) placement
Error in diagnosis
Rehabilitation issues and compliance
Technical errors
o Correct anchor placement
o Proper capsular mobilization (HAGL)
o RI Closure?
o Prior thermal cases?
o Adequate capsular tensioning – 1cm?
Associated injuries
o SLAP, HAGL, bony deficiencies
o Neurologic injury (winging!)
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Boileau (JBJS 2006)2 – “Risk factors for recurrence of shoulder instability after arthroscopic
Bankart repair”
o 91 patients followed prospectively
o 15.3% recurrence (36 months f/u), at 17 months post-surgery
o Recurrence higher in hyperlaxity, bone loss, and number of anchors
- 4 or more was good prognostic sign
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Tauber3 – “Reasons for failure after surgical repair of anterior shoulder instability”
o 41 patients followed 49 months
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
o At revision surgery – 56% with persistent bony defect, 22% with patulous capsule,
5% with laterally torn capsule
Glenoid Bone Loss à Prevalence, Etiology, Classification, and History
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Burkhart and DeBeer (Arthroscopy 2000)4
o 21 of 194 patients with “significant” glenoid bone loss
o Defined “Inverted Pear” glenoid
o 61 % failure in patients with inverted pear glenoid treated arthroscopically
100 CT scans of shoulder instability patients (Sugaya JBJS 2003)5
o 50% osseous Bankart lesion (1 large -27%, 27 med– 11%, 22 small – 3%)
Location of glenoid defect – mean at 4:17 o’clock (antero-inferior) (Saito AJSM 2005)6
o Parallel to long axis of glenoid
o At higher % defects, the line of bone loss changes somewhat to slightly more oblique
Griffith – AJR 20087
o More bone loss in recurrent instability
o 145 patients with CT scan:
§ 0-10% bone loss – 51%
§ 10-20% bone loss – 37%
§ 20-25% bone loss – 6%
§ >25% bone loss – 6%
Glenoid bone loss higher rate of failure after stabilization procedures (Bigliani AJSM 1998)8
o Amount and type of bone loss quantified and classified into 3 types
o 25 patients with glenoid rim lesions were classified
o 22 / 24 shoulder with good stability at 30 months (88%)
o Type I (16 pts); Type II (5 pts); Type IIIA (3 pts); Type IIIB (1 pt)
o Recommendations from their clinical experience:
Type I
Avulsion fracture
Bone/capsule repair
Type II
Medial fragment
Capsular Repair
Type IIIA
<25% bone loss
Capsular repair
Type IIIB
>25% bone loss
Coracoid transfer
Burkhart and DeBeer, Arthroscopy 20004
o 194 athletes (101 rugby players) with arthroscopic Bankart Repair
o 3 metallic suture anchors on average
o 10.8% recurrence rate (21 total; 14 redislocations, 7 subluxations)
o 173 without bony defects à 4% recurrence
o 21 with bony defects à 67% recurrence
§ Contact athletes with bone defect à 89% recurrence
o Significant bone defect = “Inverted pear glenoid” (not precisely measured, but as
viewed from the anterosuperior portal the inferior diameter of the glenoid was smaller
than the superior diameter”)9
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
o Conclusion: Patients with significant bone defects, especially contact athletes
are not candidates for arthroscopic repair
§ Approximately 11% had significant glenoid bone defects
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Patient History – low threshold for glenoid bone loss suspicion especially if (Piasecki,
Provencher, Romeo et al; JAAOS 2009):
o Long-term instability
o Multiple dislocations
o Mechanical clunk
o Multiple reductions/ER reductions.
o Progressive ease of dislocation and also reduction
o History of self reduction (Not MDI)
o Instability symptoms in mid-ranges of motion
Glenoid Bone Loss - Biomechanics
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Biomechanics: Itoi (JBJS 2000)10 – glenoid defects anteroinferiorly of >21% (mean 6.8
mm) causes persistent instability and limit ER after Bankart repair.
However, he demonstrated stability in ABER position due to competent capsular
constraints. ABD&IR allowed to subluxate.
CONCLUSION: Glenoid Defects >21% (approx 6.8 mm) may cause continued
instability and limit ER after Bankart Repair (especially with capsular repair)
Clinical Applicability: What is also inferred from Itoi’s work is that in up to a 21%
bone defect, the capsular restraints will potentially be enough for stability when
adequately repaired
Biomechanical Implications of Glenoid Bone Loss
↓ glenohumeral stability
↓ articular arc length = ↓ balance stability angle
↓ articular arc depth = ↓ concavity-compression stability
↑ glenohumeral contact pressures
↑ surgical failure rates (if not addressed appropriately)
↑ shear forces seen by isolated soft-tissue repairs = ↑
failure rates
Quantifying Glenoid Bone Loss
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Radiographic:
How to do a Latarjet Procedure
AANA Fall Course 2013
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Provencher MT, Frank RM
MGH Sports Boston MA
o Axillary view and also true AP of the glenohumeral joint may offer “hint” of
subtle bone loss
o Easier to see large losses. Body habitus, radiographic quality (axillary esp.), and
other factors may inhibit determination of amount of glenoid bone loss by plain
radiography
o Special axillary views that are helpful:
§ Apical oblique – Garth JBJS 198411
§ West Point View – Roukis and Feagin CORR 197212
o Itoi AJSM 200313: cadaveric glenoids utilized to create glenoid bone defects, and
West Point and CT scan compared.
§ 21% defect was 18.6% on the West Point
§ 21% defect was 50% of width on single slice (axial)
Saito, Sugaya et al AJSM 20056
o 123 CT scans – patients with anterior shoulder instability
o Defined location of the defect (approximately 3 o’clock centered, extending
inferiorly)
Sugaya et al. JBJS 20035
o 100 instability shoulder with CT scan studied
o Defect measured based on CT scan and digitized the inferior 2/3rds of the glenoid
§ The inferior 2/3rds of glenoid is consistently a “circle”14, 15
§ (Provencher personal images)
Gold Standard to assess bone loss is by 3D CT scan, with humeral head digitally subtracted
o Loss of circle bone comprises amount (percent) of bone loss
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
From Piasecki, Romeo, Provencher et al. JAAOS 2009.
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Bone Loss and size of Fragment (#1 in the right panel) indicates a certain percentage of loss,
in a percent = area Fragment #1 divided by area of circle #1. (From JBJS, 2003)5
MRI or MRA may be helpful: 16 (Provencher images)
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Conclusions – Radiographic Measurements:
o CT scan remains the gold standard for determination of bone loss
o Large Majority of instability patients have some form of bone loss (erosion or
“attritional” versus bony fragment)
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Arthroscopic Measurements
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Lo, Parten & Burkhart, “The inverted pear glenoid: An indicator of significant glenoid
bone loss” Arthroscopy 20049
o Cadaveric study and clinical study (53 patients) to evaluate amount of glenoid
bone loss arthroscopically
o termed “inverted pear glenoid” when viewed from anterosuperior portal.
o Correlated with cadaveric measurements
o Based upon measurements from the glenoid bare spot17
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
Glenoid Bone Loss – Treatment Options
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Based upon preoperative or intraoperative determination of bone loss
Key: How to obtain a successful stabilization procedure with minimal losses of motion
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Nonoperative
o Smaller fragments
o Lower demand individuals:
• Maquieira (JBJS-Br 2007) found no redislocations in 14 patients with
>5 mm bone fracture treated nonoperatively
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Arthroscopic Repair
o Glenoid bone loss less than 20 to 25%
o Can be successful
o Provencher et al (2007)16– results better with incorporation of bony fragment
o Sugaya et al (2006)20, 21 – bony lesion, if repaired with arthroscopic techniques
can heal to more normal/near anatomic position
§ Reconstitutes the bone loss of glenoid
§ Better if more acute injury
§ Less predictable if attritional/erosion loss
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Open Repair without Bony Augmentation
o Described for open capsulolabral repair to address bone loss
§ Probably similar to arthroscopic repairs, potentially higher success?
§ 0/14 recurrences in open repair procedure22
o Open repairs – screw fixation of acute fractures23
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Bone Augmentation Procedures
o Glenoid bone loss of potentially any amount
o Especially in loss >20-25%
o Variety of options and techniques
o Arthroscopic bone grafts
o Arthroscopic coracoid transfer
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THE LATARJET TECHNIQUE
o – Many ways in which to do a Latarjet Procedure
§ >20 different variations of the original description from 1954
§ All involve – on some level- transfer of the coracoid to the anterior
glenoid
§ Coracoid transfer
§ Bristow – “tip” of coracoids
§ Latarjet – larger piece of coracoids
How to do a Latarjet Procedure
AANA Fall Course 2013
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Provencher MT, Frank RM
MGH Sports Boston MA
Why does a Latarjet work?
o 1. Bone block augmentation of the glenoid
§ reconstitution of glenoid bone stock
o 2. “Sling” effect of the conjoint tendon through a subscapularis split
§ Abduction and ER – sling tightens providing improved anterior
stability
o 3. Anterior capsule repair to bone block, anchors, or CA ligament
§ Capsule repair = anterior restraint
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Technical Issue #1: How much bone to take
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Latarjet typically is about 20-25 mm of bone of anterior tip coracoid to posterior
o Sufficient for two screws
Bristow is smaller amount, about 10-15 mm
o Sufficient for one screw
Measure from anterior tip of coracoid posterior with ruler
Cut with either 90 degree angled sagittal saw or ¼ to ½ inch osteotome.
Protect inferior structures
Dissect off pectoralis minor off medial edge of coracoid
CA Ligament
o – If you want to repair capsule to the CA ligament, keep CA ligament long
and cut 1cm in length laterally off the coracoid
o – Recommend preserving the CA ligament length on the bone in order to sew
in capsule at end of case if desired
Bone for Latarjet should be just long enough to get to the elbow of the coracoid and
have small splinter into the curve of the coracoid
Technical Issue #2: How to manage the subscapularis (SSc)
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Traditionally done with a SSc split
o – The SSc split allows for the conjoint tendon to drape over the SScà allows
for anterior stability improvement via “sling” effect
Split in the SSc is generally halfway as measured from top of rolled edge of SSc to
the bottom (near vessels)
Can make split slightly more superior in patient with anterior instability and
hyperlaxity to help address the inferior laxity
Pitfall: Avoid LHB (laterally) at the groove
Pitfall: Avoid going medial to the level of the coracoid (nerve to SSc penetrates
anteriorly to the SSc muscle about 1 cm medial to the coracoid)
Goal: SSc preservation of insertion site on LT
Alternative: If difficult to see GH joint, one may take down the superior part of the
SSc, but perform meticulous repair, augmented with suture anchors.
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
Technical Issue #3: Rationale and Technique on How to Orient the Bone Block
- Orientation of the coracoid – two ways to orient coracoid
1. Lateral edge (traditional) of coracoid is the glenoid face
a. Preserves CA ligament for repair of anterior capsule
b. Allows for ease of bone fixation
c. Pitfall - Surface is “rougher” than with inferior edge, however, may
not be issue
d. Provides about 7-8 mm of bone stock for glenoid face
2.
Inferior edge (Burkhart/DeBeer) of coracoid is glenoid face
a. Inferior edge as glenoid face by rotating 90 degrees
b. Allows for improved conformity of the glenoid (surface is concave
like the glenoid)
c. Allows for more bone stock and bone length (10-13 mm of bone stock
for glenoid face)
d. Pitfall – more difficult to fix with screws (narrower margine for error
and trajectory)
e. Pitfall- may serve as larger lever arm and bend/fracture
Technical Issue #4: How to Manage the Anterior Glenohumeral Capsule
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Many ways to manage the capsule – provides greatest variation in the case
1. No capsule management
a. Do SSc split and then also cut directly through capsule
b. Bone block is affixed after capsule is taken down off glenoid neck
c. Capsule not repaired at end
2. Capsule dissected medially off glenoid neck
a. L-based incision – start superior in rotator interval and take medial and
horizontal to the glenoid neck
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
b. Dissect off as much capsule anteriorly as possible preserving length of
capsule
c. Dissect off medially from glenoid neck and tag with #2 suture. Can repair
with variety of techniques
3. Capsule off humerus
a. May take off humerus and repair back, however, still need to dissect
capsule off glenoid for bone to bone contact
Technical Issue #5: Bony Fixation Techniques
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Fixation accomplished with screws
Other methods have been described (cortical suture buttons, PEEK or bioabsorbable
screws)
“Gold” standard is two 3.5 mm AO screws, non-cannulated with small washer
Overdrill the anterior aspect of coracoid to obtain compression fixation (lag
technique)
May use 4.0mm cancellous screws (again overdrill with lag technique) if need better
fixation bite
Cannulated systems are described
Pitfall: cannulated screws <3.5mm may be prone to failure and bending
Generally two screws to fix bone graft
Pitfall: Length of screws is between 32-38 mm. Longer screws indicate either too
long in the back or trajectory (angle relative to face of glenoid) is too divergent
Goal: to have screw trajectory be within 10-15 degrees of the face of the glenoid
Technical Issue #6: Capsule Closure Management
- If choose to repair capsule – multiple ways
1. Repair to native CA ligament that comes off the coracoid (traditional Latarjer)
a. Utilized #2 suture to repair capsule to CA ligament.
b. Ensure there is good ER at side and equal to opposite side when tensioned
c. Two to 3 figure of 8 sutures are sufficient
2. Repair capsule to anterior construct
a. Repair to sutures placed under washers
b. Sutures tensioned and capsule tied to anterior aspect of bone (this is way to do
fixation for ICBG and allograft – i.e. distal tibia)
3. Suture anchors to native glenoid
a. Suture anchors (usually two) are placed after bone graft affixed in native
glenoid
b. Sutures are utilized to tie down the capsule
c. Pitfall: the capsule may be “posteriorized” by this procedure – meaning the
capsule is moved posteriorly esp with a case in which there is bone loss of the
glenoid
i. May result in significant losses of ER
How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
Glenoid Bone Loss – Selected Results
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Previously discussed Burkhart and De Beer (Arthroscopy 2000)
o Very high recurrence (67%) with “inverted pear glenoid”
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Sugaya et al. (JBJS 2005)20 – “Arthroscopic osseous Bankart repair for chronic recurrent
traumatic anterior glenohumeral instability”
o 42 patients followed 34 months with mean loss of 24.8% anterior glenoid.
§ All had osseous fragment that was incorporated into the Bankart Repair
(anchors)
§ 39/42 G/E result at final f/u – 2 with reinjury
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Provencher, Mologne et al AJSM 200716
o 23 patients (mean age 25 years, San Diego military population)
o 93% follow-up at mean of 37 months
o Mean of 25% anterior glenoid bone loss
o All treated with arthroscopic repair (3 to 4 bioabsorbable anchors)
o 11 patients had “Attritional loss” (no bony Bankart); 10 patients had Bony Bankart
o 3 Failures à all in the “attritional” group (2 sublux, 1 dislocated)
§ Mean loss ABER = 8 degrees
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Porcellini et al AJSM 200728
o 215 arthroscopic repairs over 6 years
o 31.5% had bony Bankart; operated on early versus late
o Review of results showed chronic (61 Rowe score) had less favorable outcomes than
acute (92 Rowe score)
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Rhee et al Int Orthop 200729
o Open Bankart repair those with glenoid bone loss (20 pts) and those without (20 pts)
o Less favorable scores with larger glenoid bone loss
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Burkhart et al Arthrosc 200730
o 102 patients treated with a Modified Latarjet with glenoid bone loss
o All had “inverted pear” Glenoid (arthroscopically measured)
o 5 of 102 patients à recurrence (4.9%)
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Boileau et al Arthrosc 200731
o Arthroscopic Bristow procedure; transfer of coracoid with conjoint and a repair of the
capsulolabral structures
o 8% failures of 36 patients total
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Provencher et al Arthrosc 2008
o Anatomic osteochondral allograft reconstruction for glenoid bone deficiency using
distal tibia allograft
o Basic science work has demonstrated excellent congruence and similar radius of
curvature across numerous specimens
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How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
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AANA Fall Course 2013
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Provencher MT, Frank RM
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How to do a Latarjet Procedure
AANA Fall Course 2013
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Provencher MT, Frank RM
MGH Sports Boston MA
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Additional Reading and Resources
1. Piasecki D, Ghodadra N, Bach BR, Romeo AA, Provencher MT. The diagnosis and
management of glenoid bone loss in recurrent anterior shoulder instability. Journal of the
American Academy of Orthopaedic Surgeons 2009; 17(8):482-493.
2. Seroyer S, Nho S, Provencher MT, Romeo AA. Four-Quadrant Approach to Capsulolabral
Repair: An Arthroscopic Roadmap to The Glenoid. Arthroscopy (In Press).
3. Detterline AJ, Provencher MT, Ghodadra N, Bach BR, Verma N, Romeo AA. A novel
measurement of anterior glenoid bone loss; correlation measurements of the inverted pear
glenoid. Arthroscopy 2009. In print.
4. Grumet R, Ghodadra N, Romeo AA, Bach BR Jr., Provencher MT. Recurrent shoulder
instability with glenoid bone loss. Orthopaedic Knowledge Update, Online 7(9);
http://www5.aaos.org/oko/description.cfm?topic=SHO032. Accessed September 2, 2009.
5. Provencher MT, Ghodadra N, LeClere L, Bach BR, Solomon DJ, Romeo AA. Anatomical
osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid
deficiency using a distal tibia allograft. Arthroscopy 2009;25(4)446-452
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How to do a Latarjet Procedure
AANA Fall Course 2013
Provencher MT, Frank RM
MGH Sports Boston MA
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