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, and military personnel, 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 when recurrent anterior instability is associated with osseous glenoid defects.
The effectiveness of this procedure is largely attributed to a triad of:
The conjoint tendon acting as a sling on the inferior subscapularis and capsule.
Increased anteroposteriorglenoid diameter
The effect of repairing the capsule stump to the conjoint tendon.
This procedure has been modified several times over the years.
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).
Traumatic anterior shoulder dislocation occurs when significant force is placed on the anterior shoulder, in severe cases there may be an avulsion fracture of the glenoid, this is referred to as a bony Bankart.
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. Simonest reviewed 128 patients who suffered a shoulder dislocation and found that two years after the initial dislocation, 66% of the patients who were less than 20 years old suffered a second dislocation, while 40% of the patients who were between 20 and 40 years old suffered a second dislocation. None of the patients older than 40 years old suffered subsequent dislocations. Penvy studied 125 patients with shoulder dislocations over the age of 40 and found only 4% of these patients had recurrent instability, 35% of the patients had a rotator cuff tear. 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. The athletic group also has different recurrent risk based on the type of sport, with overhead and contact sports being more likely to have recurrent dislocations.
Anteroinferior shoulder instability is a frequent disorder among young adults, it poses severe limitations on daily activities and quality of life. Moreover, it wears out the glenohumeral cartilage and predisposes to later osteoarthritis. An arthroscopic Bankart procedure is the most common surgical intervention to treat this disorder. In this operation the torn labrum and inferior glenohumeral ligaments are anatomically reattached to the glenoid rim with suture anchors to re-establish anatomy and stability of the joint.
When the shoulder dislocates anteriorly the capsule, ligaments and labrumare often torn. The anterior inferior part of the labarum (located between 3 o clock and 6 o clock on the glenoid) are torn.
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 are poor after an arthroscopic revision Bankart operation compared to an open Latarjet, furthermore later osteoarthritis is more common after an arthroscopic Bankart repair. Similarly in the shoulder if more than 20% of the anteroinferiorglenoid is fractured then a standard labral repair will not give a stable shoulder.The failure rate following an arthroscopic Bankart repair has been shown to dramatically increase from 4% to 67% in patients with significant bone loss. These injuries require a Latarjet procedure.
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. The rehabilitation guidelines below may differ depending on your surgeon’s protocols.
PHASE 1 (0-6 weeks)
Wear sling day and night to protect the shoulder.
Remove sling when showering, stoop forward and hang arm on the side of the body. Do not move the shoulder joint.
Do not sleep on operated shoulder.
Avoid bracing strategies to protect the operated shoulder.
Maintain good Posture.
Ice the shoulder every 2 to 4 hours for 20 minutes if painful.
Cervical Rom exercises.
Hand gripping exercises
Walking with a sling on, avoid swimming, running and jumping due to distractive forces.
Phase 2 (6-12 weeks)
Goals: Full Active Range of Shoulder Movements in all cardinal planes.Progress External rotation range of movement gradually to prevent overstressing therepaired anterior shoulder structures.
Strengthen shoulder and scapular stabilisers in a protected position (0-45 degrees abduction)
Begin proprioceptive and dynamic neuromuscular training.
Active assisted range of movement in all cardinal planes
ActiveScapular and Rotator cuff strengthening in non-provocative positions (0-45 abduction)
ActiveStrengthening and dynamic neuromuscular control.
ActiveCervical and scapular active range of motion
ActiveWalking and stationary bike
Phase 3 (12-16 weeks)
Goals: Full Active Range of Movement with normal scapulohumeral movement.
Improve Rotator cuff and scapular strength.
Precautions: Avoid swimming, throwing or sports.
Diagonals in standing, full can exercises.
Theraband or light weight IR in 90 degrees of abduction.
Balance board in push up position.
Closed chain stabilisation with narrow base of support.
Walking, stair master and running.
Phase 4 (16-18 weeks)
Goals: Full multiplane shoulder active range of movement.
Rotator cuff strengthening.
Demonstrate stability with velocity movements and change of direction of movement.
Dumbbell and medicine ball exercises that incorporate trunk rotation and control with rotator cuff strengthening at 90 degrees of abduction. Begin working towards more functional activities engaging core and hip strength with good shoulder control.
Theraband/Dumbbell IR and ER in 90 abduction
Higher velocity strengthening and control such as plyometrics
Begin education on sport specific biomechanics for throwing,overhead racquet sports
Phase 5 (Usually 24 weeks after meeting phase 4 criteria)
Goals: Stability with higher velocity movements that replicate sport specific patterns.
Sami Elamo, Liisa Selanne, Kaisa Lehtimaki, Juha Kukkonen, SaijaHurme, TommiKauko, VilleAarimaa. Bankart versus Latarjet operationas a revision procedure after a failed arthroscopic Bankart Repair. https//dol.org/10.1016jjsein2020.01.004
Rehabilitation Guidelines for Open Latarjet Anterior Shoulder Stabilisation. University of Wiconsin Sports Medicine.
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).
Umair Khan, Emma Torrance, Mohammad Hussain, Lenard Funk. Failed Latarjet Surgery :Why, how and what next? https//dol.org/jses.2019.11.006
Seper Ekhtiari, Nolan S. Horner, Asheesh Bedi, Olufemi R, Ayeni. The learning Curve for the Latarjet Procedure: A Systemic Review. OrthoJ Sports Med.2018 July; doi10.1177/232596711886930