Shoulder Surgery

Latarjet Procedure

Latarjet Procedure

The Latarjet procedure is ideal for those with complex shoulder dislocations with bone loss, failed shoulder stabilisations, and/or high level athletes (particularly collision or overhead contact). The surgery is more involved than a keyhole labral repair; however, post-operative pain and rehabilitation is much the same. Strengthening and training for your sport commences at 3 months and full, unrestricted contact is possible at 6 months after surgery.

A Latarjet procedure involves transferring a piece of bone (coracoid) to the front of your glenoid (socket) to address shoulder instability (dislocations out the front). There are three reasons why this operation works so well: 

  1. Sling effect (from the conjoint tendon)
  2. Capsule/labral repair
  3. Coracoid bone block at the front of the shoulder

2 medical diagrams showing how a Latarjet procedure is performed to treat shoulder instability

This operation works well in the following conditions: 

  1. Excessive glenoid (socket) bone loss – either a large acute bony bankart (glenoid fracture) or chronic bony bankart with gradual glenoid erosion
  2. Large Hill-Sachs lesion (Humeral head bone loss) 
  3. High-level athletes (e.g. rugby, touch rugby, AFL, and other contact sports)
  4. Overhead contact type sportspersons
  5. Revision shoulder stabilisation (failed keyhole procedure)

The unstable shoulder

  • Repeat anterior instability/dislocations can lead to a fear of using the shoulder (not “trusting” it) and reduction in function. Patients may avoid positions of “apprehension”.

Return to sport

  • Active individuals who wish to return to sport should consider surgery to repair torn Labrum. This will allow the ligaments to heal in the correct position. A torn Labrum, without surgery, will not heal itself.
  • The published return to sport rate after shoulder stabilisation surgery (key-hole) is 70-90%. With stabilisation surgery, patients are 5-6 times more likely to return to play than without surgery.

Anterior Tear

  • Patients will have apprehension with the hand in the upper outer quadrant
  • Inability to play overhead contact sports without instability +/- pain

Prevent post-traumatic arthritis

  • Repeat shoulder dislocations may damage the cartilage in the shoulder joint; this, in turn, leads to a higher risk of arthritis
  • The published literature supports that shoulder stabilisation will reduce the risk of post-traumatic arthritis
  • This is especially important in younger patients
  • The procedure is under a General Anaesthetic where you will be positioned on your back
  • The shoulder is then prepared with a special antiseptic solution (dark pink in colour) and the surgical drapes are applied to maintain a sterile field at all times.
  • A 5cm incision is made in the front of the shoulder and the planes are developed to find the subscapularis tendon, the biceps tendon, and the coracoid.
  • The Latarjet procedure involves transferring a piece of bone (coracoid) to the front of your glenoid (socket) to address shoulder instability (dislocations out the front).
  • About 2cm of the coracoid graft is taken and prepared with 2 drill holes
  • The coracoid bone (and attached tendon) is placed through a subscapularis split and fixed to the front of the socket (and held with 2 screws). The capsule and subscapularis tendon is then repaired and the wound is closed.
  • Dressings are applied and a custom sling is used to position the arm correctly (ER Sling).
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Team Doctor/Physiotherapist to maximise your recovery

Medical diagram showing how the Coracoid bone is transferred to the front of the shoulder during the Latarjet procedure

Watch a surgical animation demonstrating how Dr Pant performs a Latarjet Procedure to address recurrent anterior instability in high-level athletes and overhead contact sportspersons. 

https://vimeo.com/654781513 

There are three essential components to a good outcome from surgery

  • Your surgeon
  • You as a patient
  • Your physiotherapist

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement: 

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the Latarjet procedure (coracoid bone graft) to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the bone graft begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post Latarjet surgery. 

Sling

  • A “special” sling is required for the first 6 weeks after your surgery (see below)
  • A “standard” sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery)

The type of sling is selected specific to you and your shoulder surgery

  • Latarjet Procedure: External Rotation Sling (in neutral rotation)

Image of front three quarter and rear view of a External Rotation Sling used following the Latarjet procedure

When can I drive?

  • After Latarjet surgery you will be in a sling and you may be unable to drive for at least 6-8 weeks

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually, before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection – Do not be concerned just yet; please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery (especially after rotator cuff repair)
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep.

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling
  • The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications. 

The risk of complications after Latarjet surgery are less than 1% in the Sydney Shoulder Unit experience. General risks include: 

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to Latarjet surgery

Neurovascular injury during surgery

  • There are many nerves at risk during the procedure and care is taken during surgery to keep them safe. 
  • Frozen shoulder (5% risk) improves over 3-6 months and will generally not affect your outcome or need further surgery.

Reoperation and failure of surgery

  • When performing a shoulder reconstruction, your surgeon is using your own tissue to repair what is damaged. The weakest point in the repair is your own tissue. 
  • The longer the history of damage and frequency of dislocations/instability prior to surgery, the more likely the tissue quality is poor.

Bone healing – Latarjet Procedure (coracoid to glenoid graft)

  • In a small number of cases there is non-union (failure of bone to heal) at the Latarjet graft site
  • The non-union rate is very low
  • In cases of non-union it may be okay to leave things alone or you may need a revision surgical procedure (uncommon)
  • Patients who smoke, use tobacco products, have diabetes, or elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing. 

Dr Pant is a Sports Orthopaedic Shoulder Surgeon and with his involvement at Sydney Sports Medicine Centre at Olympic Park he treats both elite and amateur sports persons with shoulder instability. When done well, the Latarjet procedure provides patients with the lowest risk of recurrent instability.

Return to sport

  • The published return to play rate after shoulder stabilisation surgery with a Latarjet procedure overall is 85-90%; with 70-80% returning to the same level of play. 
  • The overall risk of re-dislocation after a Latarjet procedure is between 3-5% (depending on a number of factors).

Patients commence a strengthening program at 3 months and generally return to full unrestricted overhead contact and collision sport at 6 months post-operatively (after bone healing has been confirmed).

Patient results

Shoulder Dislocation – Surfer

The gentleman is a keen surfer and dislocated his shoulder. He presented with instability symptoms and an X-ray that showed a bony bankart (fractured glenoid). He was unstable on examination and wished to return to his previous level of function overhead. 

The MRI scan confirmed an anterior labral tear with a bony bankart; in addition he had a posterior (back of the shoulder) labral tear and a SLAP tear. He had a corresponding Hill-Sachs lesion (fracture at the back of the Humeral head). 

He underwent an Arthroscopic bony bankart and labral repair as pictured below. We were able to repair the tissues back to their anatomical (original) position using suture anchors and achieved a nice “bumper” at the front of the shoulder. We also repaired the posterior labrum and the unstable SLAP lesion – all keyhole – a total of 3 small 1cm incisions around the shoulder. 

He commenced JPL therapy at two weeks and went on to strengthen his shoulder at 3 months. He is back surfing at six months post-surgery and happy with his outcome.

Shoulder Dislocation – Latarjet

After a shoulder dislocation some patients may be a candidate for a “bone transfer” procedure: a Latarjet. This is a good procedure for high level athletes, those who participate in overhead contact type sport, those with significant bone loss, and revision cases of failed previous “key-hole” stabilisation surgery.

This 16 year old high level wakeboarder dislocated his shoulder and sustained both a rotator cuff tear and an anterior labral tear. This is an uncommon injury pattern and presents unique decision making and surgical challenges.

Given his high level sporting ambitions and demands we repaired the Rotator Cuff and did a Latarjet procedure to treat his instability. He was in a sling for six weeks and commenced JPL rehabilitation at two weeks post surgery. He commenced formal Physiotherapy at 3 months, eventually regaining full ROM and function with his shoulder. He is back to his active lifestyle and riding waves around the waterways of Australia.

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