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J Shoulder Elbow Surg (2013) -, 1-6

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Contribution of osseous and muscular stabilizing effects


with the Latarjet procedure for anterior instability
without glenoid bone loss
Joshua S. Dines, MDa,*, Christopher C. Dodson, MDa, Michelle H. McGarry, MSb,
Joo Han Oh, MD, PhDb, David W. Altchek, MDa, Thay Q. Lee, PhDb

a
Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
b
Orthopedics Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, CA, USA

Background: The Latarjet procedure is used to treat anterior shoulder instability. Authors contend that the
main concept of the operation is using the conjoined tendon as a sling to lower the subscapularis, reinforc-
ing the anteroinferior capsule. The effects of the ‘‘sling,’’ as well as stability and range of motion (ROM),
after the Latarjet procedure have not been documented. In this study, we test the Latarjet procedure,
attempting to account for the effect of the conjoined tendon. We also use the model to characterize the
kinematic effects and stabilizing mechanism of the Latarjet procedure.
Materials and methods: Six cadaveric shoulders were tested in the intact state, after anterior capsulotomy,
and after the Latarjet procedure. An apparatus was designed that allowed for loading of the conjoined
tendon. ROM and translation were quantified. After conclusion of testing in the Latarjet group, the
conjoined tendon was released and specimens were retested to determine stability attributable to the
sling effect versus the osseous effect alone.
Results: We found no statistically significant differences with regard to ROM after the Latarjet procedure.
The Latarjet procedure did significantly decrease anteroinferior translation. However, when the conjoined
tendon was unloaded, there was a significantly decreased resistance to anterior translation. After conjoined
tendon release, there was no effect on inferior translation.
Conclusion: This study confirmed that the Latarjet procedure successfully decreases anteroinferior trans-
lation while maintaining ROM. It did not support the belief that inferior stability is provided by the sling
effect. The model developed can serve as the basis for future testing.
Level of evidence: Basic Science Study, Biomechanics.
Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Latarjet procedure; biomechanics; conjoined tendon; anterior instability of shoulder

The Latarjet-Bristow procedure is being used more outcomes for patients treated with the procedure for insta-
frequently given its success treating recurrent anterior bility due to both bony defects on the glenoid and soft-
shoulder instability.9 Authors have reported successful tissue (ie, capsular) insufficiency. Unlike the traditional
Bristow procedure, which only describes a transfer of the
Institutional review board approval: not applicable (cadaveric study). tip of the coracoid, the Latarjet-Bristow procedure transfers
*Reprint requests: Joshua S. Dines, MD, Hospital for Special Surgery,
935 Northern Blvd, Ste 303, Great Neck, NY 11021, USA.
the coracoid along with the attached conjoined tendon
E-mail address: jdinesmd@gmail.com (J.S. Dines). through the subscapularis muscle. In addition, part of the

1058-2746/$ - see front matter Ó 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2013.02.014
2 J.S. Dines et al.

Figure 2 Conjoined tendon spring loaded after completion of


Latarjet procedure.

Figure 1 A custom testing system was used in which the


shoulder was secured with a scapula-mounting bracket in 30 of
Table I Range of motion
abduction.
Group Internal External Total
rotation ( ) rotation ( ) ROM ( )
coracoacromial ligament is maintained on the coracoid and Intact 71.8 69.7 141
used to reinforce the anterior capsule.3,9 It has been Capsulolabral tear 74.1 73.8 148
hypothesized that the procedure works because of its Latarjet procedure 75.2 72.3 147
‘‘triple effect’’: (1) osseous, by coracoid fixation to the Latarjet procedure 74.9 76.1 151
glenoid neck; (2) ligamentous, by coracoacromial ligament with conjoined
reinforcement of the inferior glenohumeral ligament; and tendon unloaded
(3) muscular, through conjoined tendon transfer lowering
the inferior portion of the subscapularis.9
Many authors contend that the main concept of the coracoacromial ligament, and conjoined tendon intact. Three
operation is to use the conjoined tendon as a sling to lower sutures were attached to the anterior, middle, and inferior insertion
the subscapularis to reinforce the anteroinferior capsule.3,9 sites of the subscapularis and infraspinatus, and 2 sutures were
Unfortunately, given the difficulty associated with attached to the anterior and posterior supraspinatus. The local
modeling of the conjoined tendon and subscapularis in coordinate systems of the glenoid and the humerus were defined
by 6 small screws that were inserted into the acromion and on the
cadaveric models, the biomechanical effects of the ‘‘sling,’’
proximal humerus. The systems were used to calculate the
as well as stability and range of motion (ROM), after the humeral head apex position, the most prominent point on the
Latarjet procedure have not been accurately documented. articular surface, relative to the geometric center of the glenoid.4
Another issue that arises when trying to characterize the The scapula was mounted onto a mounting plate with the
stabilizing mechanisms of the Latarjet procedure is that it medial border parallel to the mounting bracket, and an aluminum
may work differently in different situations (ie, bone loss vs rod was secured into the humeral medullary canal.
no bone loss). To date, there is only one biomechanical A custom testing system was used in which the shoulder was
study of the effectiveness of the Latarjet procedure.10 The secured with a scapula-mounting bracket in 30 of abduction5-7
authors found that the procedure significantly decreased (Fig. 1). The humerus was fixed in 90 of abduction in the scap-
translation at both 30 and 60 of abduction. ular plane but allowed for rotation, as well as translational degrees
In this study, we describe a novel biomechanical model of freedom. A square mounting bracket also allowed the humerus
to be locked in rotation while still allowing 3 degrees of trans-
to test the Latarjet procedure and the effect of the conjoined
lational freedom. On the basis of previous studies, a goniometer
tendon. We then use the model to characterize the stabi- was attached to the distal end of the humeral rod, and rotational
lizing mechanism of the Latarjet procedure in the setting of position was defined by aligning the bicipital groove with the
soft-tissue insufficiency, hypothesizing that the sling effect anterior edge of the acromion to simulate 20 of external rota-
is the main stabilizing component of the procedure. tion.11 Rotational ROM was measured with a goniometer at the
distal end of the humerus with 2.2 Nm of torque applied.
Through the use of additional sutures, rotator cuff musculature
Materials and methods was loaded based on physiological cross-sectional area ratios: 9 N on
the subscapularis and infraspinatus and 6 N on the supraspinatus.8
We tested 6 matched pairs of cadaveric shoulders (2 female and 4 The conjoined tendon was sutured and attached to a spring that
male cadavers). The mean age was 53.2 years (range, 40-68 was attached to the mounting track at the distal humerus. When
years). The specimens were dissected of all soft tissue, leaving engaged, the spring applied 6 N of tension across the conjoined
the subscapularis, infraspinatus, supraspinatus, joint capsule, tendon, which was based on the physiological cross-sectional area.
Stabilizing effects of Latarjet procedure 3

Figure 3 Rotational ROM in each of 4 testing states.

positions; the specimens were preconditioned before each measure-


Table II Translation
ment, and the forces applied were non-destructive.
Group Translation (mm) Rotational ROM, the position of the humeral head relative to
Anterior) Inferior) Posteriory Superiory the glenoid, and translation of the humerus with an anterior and
posterior force applied were measured for the intact glenohumeral
Intact 7.4 1.7 13.4 0.7 joint, after creation of a capsulolabral tear (simulating soft-tissue
Capsulolabral tear 9.7 3.0 14.4 0.6 insufficiency) from the 3- to 6-o’clock position on the glenoid for
Latarjet procedure 6.2 0.5 13.8 0.6 right shoulders with corresponding positions for the left shoulders,
Latarjet procedure 9.3 1.3 14.4 0.4 and after the Latarjet procedure. The capsulolabral tear was
with conjoined created through a subscapularis split.
tendon unloaded The Latarjet procedure was performed as described by Walch and
) As a result of anterior translational force. Boileau.9 The coracoacromial ligament was incised 1 cm from its
y
As a result of posterior translational force. attachment on the coracoid. Next, the base of the coracoid was
exposed, and a small oscillating saw was used to perform an osteotomy
of the coracoid process at the junction of the vertical and horizontal
parts. Two 3.2-mm drill holes were made in the bone graft. The sub-
Testing protocol scapularis was divided in line with its fibers at the junction of the
superior two-thirds and inferior one-third of the muscle. The bone
Rotational ROM was measured with 2.2 Nm of torque after pre- block was placed through the soft tissue and positioned with the
conditioning with the same amount of torque for 10 cycles. The inferior surface of the coracoid flush with the anteroinferior margin of
position of the humerus relative to the glenoid was measured by the glenoid. Two 3.5-mm malleolar screws were used to secure the
digitizing the scapular position and the humeral position throughout bone block to the glenoid. The coracoacromial ligament was used to
the rotational ROM, specifically at maximum internal rotation, 30 of reinforce the anterior capsule. After the Latarjet procedure, the
internal rotation, 0 of rotation, 30 of external rotation, and conjoined tendon was reloaded with 6 N, the vector of which was in
maximum external rotation. This was done by digitizing the 6 refer- line with the humerus directed toward the short head of the distal biceps
ence screws, 3 on the scapula and 3 on the humerus, with a Micro- attachment (Fig. 2). Data were recorded after the Latarjet procedure
Scribe G2LX (Revware, Raleigh, NC, USA). Humeral translation that with the conjoined tendon loaded and after conjoined tendon release.
occurred with an anterior and posterior load was measured with the At the completion of testing, the specimens were disarticulated
humerus locked at 0 of rotation and 20 N and 30 N of translational to digitize the geometry of the glenoid and the humeral head
force applied in both the anterior and posterior directions. Trans- articular surfaces relative to the local coordinate systems. The
lational force was applied by attaching 2 sutures at the distal portion of position of the humeral head apex relative to the geometric center
the pectoralis major insertion. These sutures were then directed to 2 of the glenoid was then calculated at each rotational ROM posi-
pulleys directly anterior and posterior from where the translational tion. Two trials of each data point were recorded, and the mean
load could be administered. The position of the humerus was digitized was used for comparison. A Wilcoxon matched-pairs test was used
with the MicroScribe G2LX when it was centered in the glenoid and for statistical analysis with a significance level of .05.
after the application of the translational force. Before testing, the
specimens were preconditioned with 20 N in both directions for 10
cycles. When the translational force was applied, the humerus was Results
free to translate in the anteroposterior, superoinferior, and medio-
lateral directions.1 Translation was measured from the MicroScribe
G2LX coordinates of the screw placed on the proximal humerus as the With regard to ROM, after creation of the capsulolabral
change from the humerus centered in the glenoid and after a trans- tear, there was a statistically significant increase in internal
lational load was applied. It should be noted that translational and external ROM. Total ROM in abduction significantly
measurements were performed through a standardized set of increased as well, from 141.4 to 147.9 (P < .05). After
4 J.S. Dines et al.

Figure 4 Translation measured in each of 4 testing states.

the Latarjet procedure, ROM was comparable to pre- the conjoined tendon. We further used the model to char-
capsulotomy ROM (Table I). acterize the stabilizing mechanism of the Latarjet procedure
There was also no significant difference in external when used in cases of soft-tissue insufficiency.
rotation between the pre–capsulolabral tear state and after There are limited studies in the literature that have
the Latarjet procedure (70 and 72 , respectively). When attempted to biomechanically assess the Latarjet procedure.
the conjoined tendon was unloaded, external rotation In an eloquent study, Wellman et al10 compared the effects of
increased from 72 to 76 , which was significant (P ¼ .028) a modified Latarjet procedure with a bone graft to treat
(Fig. 3). instability due to a glenoid bony defect. They found the
After capsulotomy, with the shoulder abducted to 90 in modified Latarjet procedure to be more stable to ante-
neutral rotation, translation significantly increased in the roinferior loading, particularly at 60 of abduction. There
anterior (P ¼ .028), posterior (P ¼ .046), and inferior (P ¼ were several important differences between our study and
.028) directions. Loading the conjoined tendon after the their study, however. They only compared the modified
Latarjet procedure significantly decreased anteroinferior Latarjet procedure (and bone block procedures) with them-
translation (P ¼ .046). This had no effect on posterior or selves and the capsulotomy state. There was no comparison
superior translation. When the conjoined tendon was of the modified Latarjet procedure with the normal state, as
unloaded, anterior translation significantly increased rela- was done in our study, which enabled us to comment on how
tive to the conjoined tendon–loaded state (P ¼ .046). There normal shoulder kinematics is affected by the procedure.
were no significant differences in translation in any other They did not perform an analysis of ROM or humeral head
direction (Table II, Fig. 4). tracking, and they used a bone deficiency model of instability.
When compared with the intact and capsulolabral tear In a soft-tissue insufficiency model of instability, we
states, there was no significant difference in humeral head found that the Latarjet procedure significantly decreased
position through the tested ROM after the Latarjet proce- anteroinferior translation while preserving ROM in both
dure with the conjoined tendon loaded. When the conjoined internal and external rotation. When the conjoined tendon
tendon was unloaded, however, the humeral head shifted was unloaded, external rotation increased, and there was an
anteriorly by a mean of 3.6 mm both at 30 of external associated increase in anterior translation. Interestingly,
rotation and at maximal external rotation (P < .046) when the conjoined tendon was unloaded, there was no
(Fig. 5). effect on inferior translation. This study did not support
previous arguments that inferior stability is provided by the
sling effect because release of the conjoined tendon did not
Discussion affect inferior translation.
All cadaveric studies that attempt to analyze the Latarjet
Many authors contend that a critical component of the procedure will face the limitation that it is impossible to
Latarjet procedure centers on its use of the conjoined tendon perfectly simulate the physiological tension inherent in the
as a sling to lower the subscapularis muscle, reinforcing the conjoined tendon. In the work by Wellman et al,10 they
anteroinferior capsule.3,9 Proving this in the laboratory has passively tensioned the tendon to about 10 N in each test
been difficult given the inherent difficulties in modeling the position. It was fixed through a transhumeral bone tunnel
conjoined tendon in cadaveric studies. In this study, we located at the origin of the medial biceps. Halder et al2
successfully described a biomechanical model to test the tested the dynamic effect of conjoined tendon inhibition
Latarjet procedure that accurately accounts for the effect of on anteroinferior humeral translation. They tested the
Stabilizing effects of Latarjet procedure 5

Figure 5 Humeral head position throughout ROM. ER, External rotation; IR, internal rotation.

dynamic contributions of 5 shoulder muscles to inferior


In this study, we developed a model to test the procedure
stability, including the short head of the biceps and the
biomechanically. The findings of our study support the
coracobrachialis. A 15-N force was applied to the humerus,
majority of clinical studies of the Latarjet procedure in
and the tendons were loaded in proportion to their muscles’
the sense that it limited anterior translation of the
cross-sectional areas. The conjoined tendons were capable
humeral head while preserving ROM. In addition, as the
of translating the humeral head superiorly. This study was
Latarjet procedure becomes more prevalent, the model
one of the few in the literature to biomechanically analyze
developed here can serve as a useful tool to better
the effects of the conjoined tendon; however, it was clearly
analyze the technique.
performed in a much different clinical scenario than the
Latarjet procedure.
This study has several limitations. It is a cadaveric study,
which deals with only the immediate postoperative in vitro Disclaimer
behavior, excluding the important effects of postoperative
rehabilitation and healing. This limits our ability to draw The authors, their immediate families, and any research
any conclusions about the longevity, strength, or healing foundations with which they are affiliated have not
potential of the described procedures. In addition, as was received any financial payments or other benefits from
mentioned earlier, the Latarjet procedure has been used to any commercial entity related to the subject of this
treat anterior instability due to both glenoid bone defects article.
and soft-tissue insufficiency. It is possible that the stabi-
lizing mechanism of the procedure differs in different
situations. In this study, we chose to focus on the soft-tissue
insufficiency scenario. The model represents a somewhat-
normal cadaveric shoulder that has been made unstable by References
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