What is Arthroscopic Latarjet for Shoulder Instability?
Arthroscopic latarjet for shoulder instability is a novel minimally invasive surgical procedure to treat chronic shoulder instability or anterior shoulder dislocation, usually caused by bone loss or a fracture of the glenoid. The procedure is performed using small incisions, an arthroscope - a small flexible tube with a light and tiny camera at its end - and thin surgical instruments to treat shoulder instability by relocating a piece of bone with an attached tendon to the shoulder joint.
The shoulder joint is a ball and socket joint with the head of the humerus (long arm bone) forming the ball, and a cup-shaped depression on the shoulder blade (glenoid fossa) forming the socket. The joint is stabilized by the labrum, a cartilaginous rim of the glenoid cavity, and the capsule, a series of ligaments that enclose the joint. Injury and trauma can tear or stretch the labrum and/or ligaments, causing instability and dislocation of the joint. The shoulder can dislocate in front (anterior), down (inferior), or behind (posterior), but anterior dislocation is the most common.
Arthroscopic latarjet surgery is performed in cases where a labral repair has a high risk of re-dislocation or is not feasible. Hence, during the procedure, rather than repairing the torn labrum, a bone graft (the coracoid process) is placed onto the front of the glenoid and fixed in position using two screws. The bone graft and its attached tendon prevent the shoulder from dislocating, thereby replacing the function of the labrum.
Indications for Arthroscopic Latarjet Surgery for Shoulder Instability
Shoulder instability is a chronic condition that causes frequent dislocations of the shoulder joint. A dislocation occurs when the end of the humerus (the ball portion) partially or completely dislocates from the glenoid (the socket portion) of the shoulder. A partial dislocation is referred to as a subluxation, whereas a complete separation is referred to as a dislocation. Arthroscopic latarjet procedure is indicated for shoulder dislocation associated with:
- Significant glenoid bone loss/fracture
- Failed shoulder reconstruction, labral repair, or stabilization surgery
- Generalized ligamentous laxity
- An engaging Hill Sach’s fracture
- A large Hill Sach’s humeral head fracture
- Recurrent or chronic shoulder instability
- Participation in contact sports
- Certain forms of capsular avulsions, such as HAGL lesion
Preparation for Arthroscopic Latarjet Surgery for Shoulder Instability
Preparation for arthroscopic latarjet surgery for shoulder instability may involve the following steps:
- A review of your medical history and a physical examination to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications or supplements you are taking or any conditions you have such as heart or lung disease.
- You may be asked to stop taking blood-thinners, anti-inflammatories, aspirin, or other supplements for a week or two.
- You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.
Procedure for Arthroscopic Latarjet Surgery for Shoulder Instability
Latarjet surgery involves cutting the coracoid process (a small hook-like process of the shoulder bone) and transferring it to the inferior/anterior portion of the glenoid through a split in the subscapularis muscle. The extra boney surface area, together with the “sling” effect of the conjoined tendon, offers great stability to the glenohumeral joint.
In general, arthroscopic latarjet surgery will involve the following steps:
- The procedure is performed under general anesthesia with you lying in a semi-reclined or beach-chair position.
- Your surgeon makes a few small incisions (arthroscopic portals), about half-inch in length, over your shoulder joint.
- An arthroscope, a slender tubular device attached with a light and a small video camera at the end is inserted through one of the incisions into your shoulder joint.
- The video camera transmits the image of the inside of your shoulder joint onto a television monitor for your surgeon to view.
- Your surgeon then uses small surgical instruments through the other tiny incisions to expose the coracoid process and its attached tendons.
- The coracoid process is freed of its attachments and along with the conjoined tendon is transected from its base.
- Holes are drilled into the transected coracoid process.
- The subscapularis muscle, which passes in front of the shoulder joint is split in line with its fibers.
- The capsule of the shoulder joint is entered and the glenoid is exposed and prepared to receive the coracoid.
- The transected coracoid with the conjoined tendon is passed through the separated subscapularis muscle and fixed to the glenoid rim with screws through the previously drilled holes. This increases the glenoid surface and stabilizes the joint. The conjoined tendon and subscapularis muscle provide additional stability by acting as a sling.
- Upon completion, the scope and the instruments are withdrawn, and the incisions are closed and covered with a sterile bandage.
Postoperative Care and Recovery
In general, postoperative care and recovery after arthroscopic latarjet procedure will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs.
- Following the surgery, your arm will be placed in a shoulder sling for 2 to 4 weeks to rest the shoulder and promote healing.
- You may experience pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed to address these.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- You may also apply ice packs on the shoulder area to help reduce swelling and pain.
- You are encouraged to move around in bed and walk as frequently as possible to prevent the risk of blood clots.
- Instructions on incision site care and bathing will be provided to keep the wound clean and dry.
- Refrain from strenuous activities and lifting heavy weights for at least a couple of months. A gradual increase in activities is recommended.
- An individualized physical therapy protocol is designed to help strengthen your shoulder muscles and optimize shoulder function.
- You will be able to resume your normal daily activities in 3 to 4 weeks, but with certain activity restrictions. Return to sports may take 6 months or longer.
- Refrain from driving until you are fully fit and receive your doctor’s consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Benefits of Arthroscopic Latarjet Surgery for Shoulder Instability
The newly developed arthroscopic technique offers several benefits over traditional latarjet procedure, including:
- Smaller incisions
- Minimal muscle trauma
- Smaller scars
- Minimal blood loss
- Lower risk of infection
- Less post-operative pain
- Shorter hospital stay
- Quicker recovery
- Higher accuracy with graft positioning
Risks and Complications
Arthroscopic latarjet procedure is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Postoperative pain
- Damage to surrounding structures
- Stiffness or restricted motion
- Thromboembolism or blood clots
- Anesthetic/allergic reactions
- Recurrence of instability
- Fracture or failure of union of the coracoid