Intraoperative and Postoperative Issues With the Latarjet Procedure

Introduction

When Bankart originally described anterior glenohumeral instability, he described the labral tear as the essential lesion which was present in over 90% of cases. More recently, however, we have recognized the increasing role of bony anatomy in shoulder stability. Defects, such as glenoid bone loss or a Hill–Sachs lesion of the humeral head, can significantly compromise stability and may compromise the results of labral repair procedures.

Consequently, there has been recently been renewed interest in glenoid-restoring procedures, such as the Latarjet procedure. Originally described by French thoracic surgeon Michel Latarjet in 1954, this involves transfer of the coracoid process to the anterior margin of the glenoid via screw fixation. Later modified by Didier Patte and Gilles Walch, the modern-day Latarjet procedure consists of a 2-cm long coracoid osteotomy, transfixion of the coracoid to the anteroinferior glenoid with two screws, and subsequent repair of the coracoacromial ligament to the glenohumeral capsulolabral complex. Patte proposed that the mechanism of action of the Latarjet procedure only partially owed its success to the bony augmentation of the anteroinferior glenoid. He termed this the triple effect:

• 1)

  The dynamic sling of the conjoint tendon that acts upon the anteroinferior capsule and subscapularis, particularly in abduction and external rotation

• 2)

  The bony effect of increasing glenoid surface area

• 3)

  The ligamentous effect of the repaired anterior capsule to the stump of the coracoacromial ligament

Yamamoto and colleagues recently confirmed this and found that the dynamic sling is the main stabilizing mechanism of the Latarjet procedure.

Several further variations of this basic technique have been published recently, including rotating the coracoid process onto the glenoid, termed the “congruent-arc” technique, intra- versus extraarticular placement of the coracoid, as well as several arthroscopic techniques. Currently, the Latarjet procedure is being performed for a wide variety of indications, including symptomatic primary instability with or without bone loss, recurrent instability with bone loss, and revision surgery.

Regardless of technique variation, there are several principles to the procedure that, if not followed, may result in complications. This includes poor patient selection with inadequate surgical indication, technique-based complications, and issues with postoperative rehabilitation. Although the Latarjet procedure is usually successful, the overall complication rate based on a recent systematic review is approximately 15%. Reported complications include neurological complications, infection, hematoma formation, fracture or nonunion of the coracoid graft, arthritis, and recurrence of instability.

Of particular note are complications regarding the coracoid bone block, as this can significantly impact the outcome of the surgery. Risk of recurrence and long-term outcomes depend strongly on the correct handling and positioning of the graft. Positioning the graft too medially will result in increased rates of postoperative instability, whilst positioning it too laterally will increase the risk of postoperative osteoarthritis. Intraoperative fracture of the bone block is also a significant concern, as this can jeopardize the ability to complete the procedure.

The purpose of this chapter will be to review the potential complications of the Latarjet procedure, including preoperative and patient factors, intraoperative technical issues, and postoperative events.

Preoperative Factors

The Latarjet procedure is not a panacea for all shoulder instability problems. Careful patient selection is paramount to success, and contraindications to the procedure do exist:

• 1)

  Anterior instability in the setting of a massive irreparable rotator cuff tear

• 2)

  Age greater than 50 years

• 3)

  Voluntary anterior dislocators

• 4)

  Uncontrolled seizure disorder

• 5)

  Chronic locked anterior dislocation

Age Greater Than 50 Years

Age-related bone loss and soft tissue stiffness may contribute to difficulties in performing the Latarjet procedure in patients above 50 years old. Although there is little evidence to support these claims, some authors have observed several types of complications. Primarily, owing to poor bone quality, there may be increased risk of bone block fracture or nonunion. Static anterior instability of the humeral head has been described because of anteroinferior subluxation and progressive osteonecrosis of the head in contact with the graft ( Fig. 26.1 ). Additionally, there may be postoperative irreducible inferior subluxation of the humeral head ( Fig. 26.2 ). This is thought to occur via the nonelastic portion of the subscapularis that is pulled down by the transferred coracoid process and conjoint tendon that results in permanent humeral head subluxation.

Uncontrolled Seizure Disorder

The transferred coracoid process with two screws is insufficiently strong to withstand the strong and violent contraction of the subscapularis during a seizure. Typically, postoperative seizures can result in fracture of the coracoid bone block and 90-degree bending of the screws ( Fig. 26.3 ). Redislocation rates have been reported to be as high as 45%. Revision surgery in these redislocators includes iliac crest bone block transfer. It has been recommended that the primary treatment of instability in these patients is control of their epilepsy. Only once their neurological condition is well controlled should surgery be considered and only in the setting of symptomatic instability with activities of daily living.