The Latarjet procedure is a surgical technique for treating shoulder instability, specifically for cases involving an anterior glenoid bone defect, an engaging Hill-Sachs injury, or both. It includes transferring the coracoid process to the anterior glenoid through the subscapularis and fixing it to the anterior glenoid to provide stability. The technique, as recognized by most surgeons today, was described by Gilles Walch and involves harvesting the coracoid along with the attached conjoined tendon through a small deltopectoral approach. The inferior surface of the coracoid and the anterior glenoid face are prepared to achieve a flat cancellous bleeding surface via a subscapularis split. Fixation is achieved using two bicortical 4.0 mm malleolar screws placed at the 4- and 5-o’clock positions, flush with the anterior glenoid surface and below the equator. Additionally, the stump of the coracoacromial (CA) ligament is repaired to the capsule with the arm in 30° of external rotation. This technique is an evolution of Didier Patte’s technique, who described the triple blocking effect and was Walch’s boss at Lyon.

The original Latarjet procedure was first described by French surgeon Dr. Michel Latarjet in 1954. During an unsuccessful Trillat procedure involving a subtraction osteotomy of the coracoid with fixation of the coracoid tip to the glenoid, the coracoid broke and was subsequently fixed to the anterior glenoid neck with a screw. Over time, modifications have been made to the procedure, including changes in the subscapularis split, graft position and fixation, type of fixation, and capsule management. However, more data must be provided to analyze the impact of these variations on clinical outcomes.

A significant development is the introduction of arthroscopic Latarjet, pioneered by Laurent Laffose, which aims to replicate the technique described by Gilles Walch using arthroscopic methods. Arthroscopic Latarjet has been shown to have comparable outcomes to the open approach, along with the advantages of reduced pain, faster recovery, and fewer complications (Table 38-1).¹ Modifications to the arthroscopic technique have mainly focused on technical aspects of the procedure, such as performing the subscapularis split and drilling the coracoid to the anterior glenoid.^{2, 3 and 4} Challenges remain in achieving the correct height of the subscapularis split and guaranteeing protection to the brachial plexus and nerves. Developing new glenoid aiming guides and dedicated instruments has facilitated the procedure, but its technical demands and steep learning curve have limited its wider application.⁵

Fixation of the coracoid using suture material is safe and effective, although it may not decrease the graft’s proximal bony resorption rate.^{5, 6, 7, 8 and 9} However, it can limit damage to surrounding structures in case of proximal resorption. Interconnected double cerclage tape sutures have recently been introduced for coracoid graft fixation, eliminating the need for buttons, and reproducing the compression effect of screws more closely.⁹

The preoperative evaluation consists of assessing the past medical history, a physical exam, and proper shoulder imaging. The medical history should include information about the number of episodes of dislocation, subluxation, or instability reported by the patient; the amount of trauma related to each episode; the position of the arm at the time of the episode; the time required for reduction; the use of anesthesia for reduction; and the length and type of immobilization.

The medical history should include clearance of neurologic causes, mostly seizures, and current medical status and medications. Patients should be asked about other signs of instability or pain in other joints, assessing for generalized joint laxity. While patients with hyperlaxity are not a contraindication for the Latarjet procedure, many of these patients will not have significant bone defects and may deter certain surgeons from using this technique.

The physical exam should assess for skin stigmas of poor collagen quality (striae in the axillary fold, abdomen, thighs, prior widened skin incisions), proper scapula positioning and function, proper range of motion, and rotator cuff function. A complete bilateral neurovascular exam of the upper limb should be performed.

Assessment of joint laxity should be registered and compared bilaterally. We prefer the HERI test to assess the anterior (hyperextension with the arm in internal rotation).¹³ The sulcus test in neutral and external rotation investigates the rotator interval area. External rotation in adduction and abduction is registered.

Provocative maneuvers are performed at mid-arc and end-range motion of the shoulder. Mid-arc maneuvers take away the stabilization component of taut ligaments and are an excellent way to judge anterior bony instability due to bone loss, and we typically perform it with the arm in 30° flexion and 30° of external rotation. A classic provocative Neer test with the patient standing or sitting will generate apprehension in the unstable patient. However, many patients dislike it, and we prefer performing the apprehension test and relocation test in the supine position.

It is advisable to gather imaging studies of documented shoulder dislocations when available. In young patients with traumatic injuries or recurrent instability, the preferred imaging study is a computed tomography (CT) exam to assess for the presence of bone loss. New sequences can improve the diagnosis of bone loss in MRI and are advisable in patients over 40 years of age or when an associated rotator cuff injury is suspected.

We use 3D CT surface reconstructions of the glenoid with subtraction of the humeral head, placing the glenoid in an “en face” sagittal oblique view of the glenoid. The glenoid morphology is assessed, and quantitative assessment of glenoid bone loss as a percentage of either total surface area or diameter is assessed after the following formula: Percent bone loss = (Defect width/Diameter of the inferior glenoid circle) × 100%. Percent bone loss = (Defect surface area/Surface area of inferior glenoid circle) × 100% (Figure 38-1).¹⁴

The glenoid track concept has gained traction recently, and it involves calculating the width of the glenoid track, which is the area of the glenoid that articulates with the humeral head throughout the range of motion. 83% of the original glenoid width is subtracted from the actual glenoid width of the inferior glenoid (glenoid track = 0,83D-d). On the other hand, the width of the HSL is calculated by adding the distance of a bony bridge if there is one-up to the insertion of the rotator cuff. The injury is off-track or engaging if the humeral distance exceeds the glenoid distance. CT scans are typically used, but MRI can also calculate the glenoid track preoperatively. If the HSL < glenoid track, the lesion is on-track, the humeral head will not engage, and the risk of instability decreases compared to off-track injuries. Off-track lesions are an indication of reconstructing the anterior glenoid bone loss, while on-track injuries could potentially be effective without anterior glenoid bone reconstruction. Still, even if there is not an increased rate of instability, on-track peripheral lesions—those that are close to engagement—show worse clinical outcomes than central on-track lesions and could be an additional indication to perform the Latarjet technique.¹⁵

Some surgeons use the ISIS (Instability Severity Index Score) to assess the severity of shoulder instability and predict the risk of recurrent instability after surgery, thus requiring a Latarjet procedure.¹⁶ The score is based on factors such as age, sex, activity level, and bone loss or previous surgery (Table 38-4), with an ISIS higher than three having a high risk of failure after a Bankart repair.

The surgical technique was described in 2021.^7,8 A few modifications have been introduced, as demonstrated in the supplementary video (Video 41.1). The technique involves a stepwise approach, including preparing the glenoid and the coracoid, performing the subscapularis split, and transferring and fixing the transfer using a double FiberTape circular cerclage system (Arthrex) (Figure 38-2). Matching the coracoid and glenoid surfaces and the offset of the tunnels is of utmost importance in this technique, as well as orderly suture tape management. If this is done correctly, transferring the coracoid becomes straightforward.