Latarjet and Labral Repair

The Latarjet procedure is an operation for a shoulder that repeatedly dislocates at the front. A small block of bone called the coracoid process, a bony projection at the front of the shoulder blade, is moved onto the front rim of the glenoid (the shoulder socket), together with the tendons attached to it. This replaces bone that has been lost from the socket and adds a further restraint across the front of the joint.

It is used for people with recurrent anterior (front) shoulder instability who have bone loss from the glenoid and who play contact sport, and for people whose shoulder has become unstable again after earlier stabilisation surgery. Dr Cutbush performs the procedure arthroscopically (through keyhole incisions) and repairs the labrum at the same time.

The procedure

The coracoid process is taken from the front of the shoulder blade and transferred to the front of the glenoid, where it is fixed in place with screws. The transferred bone restores the width of the socket, and the tendons still attached to it pass across the front of the joint and act as a sling. The aim is to stabilise the shoulder and reduce the risk of further dislocations.

To reach the socket, the subscapularis muscle, which crosses the front of the shoulder, is split so that the bone block can pass through it and be fixed to the glenoid.

Traditional Latarjet techniques remove the anterior capsule and leave the anterior labrum, the ring of cartilage around the rim of the socket, unrepaired. Dr Cutbush uses a modified technique in which the labrum is preserved and repaired as part of the same operation.

Risks and complications

General surgical risks

• Bruising and haematoma. The amount of bruising varies from person to person. It is a normal part of healing and usually settles quickly.
• Infection. Uncommon, and usually treated with antibiotics.
• Deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots in the leg or the lung. These can be serious, but the risk of harm is significantly reduced when they are treated promptly.
• Anaesthetic risk. This is discussed in detail with your anaesthetist before surgery. The risk of death under a general anaesthetic in Australia is approximately 1 in 100,000.
• Wound problems. Superficial wound problems can occur. Most need only a small intervention.

Risks specific to this procedure

• Recurrent instability. Approximately 2 to 4% of patients continue to feel that the shoulder is unstable. A further dislocation after surgery is uncommon.
• Stiffness. This can be caused by scar tissue or by a residual frozen shoulder. Approximately 2% of patients need an arthroscopic release at 12 months to restore their range of motion.
• Hardware problems. The screws or other implants used to hold the bone block can cause problems.
• Nerve injury. Severe nerve injury occurs in approximately 1 in 200 cases, and may require nerve repair or a nerve transfer.
• Bone and graft problems. The bone block may fail to unite with the glenoid, and fracture of the block or the socket can occur.
• Frozen shoulder. Causes pain and stiffness, and settles on its own over time.

Before surgery

There are a number of things to organise while you are waiting for surgery. You will also be given detailed written instructions.

1. Confirm with your health fund that the hospital fee is covered by your policy.
2. Confirm the anaesthetist's fees.
3. Register your details with the hospital.
4. Read, complete and return the paperwork to Dr Cutbush's office.
5. Plan your transport to and from hospital. You will not be able to drive yourself home.
6. Arrange any pre-operative physiotherapy that has been recommended.
7. Complete any pre-operative pathology that is required, such as blood tests.
8. Benzoyl peroxide 5% wash. Five applications to the shoulder in total, to reduce the risk of Cutibacterium acnes infection. Apply it twice daily for two days, then once more on the morning of surgery.
9. Hospital bag. Pack your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. If you have sleep apnoea, bring your CPAP machine.
10. Blood thinners. Phone Dr Cutbush's office to confirm when to stop them.
11. Diabetic tablets. Phone your anaesthetist to confirm whether to stop them before surgery.
12. Confirm your admission details with the office one to two business days before surgery.

The day of surgery

• Your admission details are confirmed one to two business days before surgery. Make a note of your admission time and your fasting time.
• Admission can be as early as 6am. If you live outside Brisbane, it is usually recommended that you stay in Brisbane the night before.
• After admissions you wait in the surgical waiting area. The anaesthetist consults with you before you go through to theatre.
• Dr Cutbush greets you in the anaesthetic bay and marks the operation site with you.
• The usual hospital stay is one night. An X-ray of the shoulder is taken the next morning and the nurses change your dressings.
• Discharge is usually around 10am, after Dr Cutbush has reviewed you.
• You are given a folder containing your post-operative pack. It includes a letter describing what was found and what was done during surgery, along with rehabilitation and aftercare information.
• Arrange for someone to take you home.

Recovery and healing

For the first six weeks after a Latarjet procedure, rest matters more than exercise. The bone block needs to unite with the glenoid before the shoulder can be loaded.

• Avoid active use of the biceps. Lifting an object towards your head by bending the elbow contracts the biceps. Because the biceps tendon is attached to the transferred bone block, this can interrupt healing or dislodge the block.
• Sling. Worn full time for six weeks.
• Restrictions. No driving, no work and no normal physical activity during this period. It is worth planning for this when you schedule your surgery.
• The morning after surgery. A physiotherapist shows you how to manage daily tasks in the sling, including putting the sling on, dressing and showering.
• Six-week CT scan. This confirms that the bone has healed. If it has, your rehabilitation can be advanced and a return to work and sport can be considered.

Rehabilitation

The aims of rehabilitation are to protect the healing bone block, strengthen the rotator cuff and restore proprioception (your sense of where the shoulder is in space) to its pre-surgery level. The shoulder is immobilised in a sling for six weeks. Strength and conditioning work done before surgery makes rehabilitation afterwards easier.

Day one

The goals on day one are to protect bone healing by limiting active use of the biceps and keeping the sling on for six weeks, while maintaining glenohumeral range of motion.

• Sling. Worn full time for six weeks, except when showering or doing your prescribed exercises. The fit is checked and you practise daily tasks such as showering and dressing.
• Phase I precaution. Avoid all active elbow flexion. Contraction of the short head of the biceps loads the coracoid and may affect healing.
• The sling is fitted correctly and you learn to put it on and take it off independently, with the hand aligned to the midline of the body (fingertips to belly button).
• Posture in the sling and scapular awareness are addressed.
• Passive glenohumeral range of motion: external rotation to 30 degrees and flexion to 120 degrees.
• Adjacent joints are maintained: full active cervical spine range; no active elbow flexion (active extension and passive flexion, active pronation and passive supination); and full active range at the hand.
• Scapular postural patterning through shoulder range of motion.
• You are taught not to contract the biceps during passive elbow flexion, supination or forceful gripping.
• The sling is used in the shower for two weeks, with a collar and cuff.
• Core and lower limb strengthening is allowed, provided there is no load on the biceps and you remain in the sling.

Exercises and progression

• The biceps must stay inactive. Bending of the elbow is done passively.
• Early exercises focus on external rotation and forward flexion, to prevent tightness and maintain movement. Gentle walking can usually start at three to four weeks.
• Six weeks. The sling is usually no longer needed and strengthening begins. Some muscle deconditioning is expected, so a range of strengthening exercises is encouraged.
• Twelve weeks. Range of motion is assessed. Strengthening and confidence-building continue, working towards your maximum range of motion.

Follow-up

After the twelve-week review, the next routine follow-up is at twelve months.

Results after surgery

Published series report good to excellent results for stability and movement in most patients after a Latarjet procedure, with recurrent dislocation reported in under 1% of patients. Most people return to their pre-injury activity level and range of motion. Individual results vary.

• Approximately 2 to 3% of patients develop tightness in external rotation.
• Approximately 2% report that the shoulder feels slightly loose.
• Some patients may develop arthritis in the shoulder in the long term.
• In a small number of cases, a Remplissage procedure may also be needed.

Next steps

• Anterior shoulder instability
• Shoulder instability
• Shoulder anatomy
• Surgery FAQs
• Book a consultation

This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.