The Biomechanics of the Latarjet

Reconstruction: Is It All About the Sling?

Nobuyuki Yamamoto, MD,* and Scott P. Steinmann, MD†

It has been clinically believed that the stabilizing mechanism of the Latarjet procedure is the
sling effect. Biomechanical studies have demonstrated that there are 3 stabilizing mecha-
nisms of the Latarjet procedure, the main one being the sling effect produced by the sub-
scapularis and conjoint tendons. The other 2 mechanisms are the suturing of the capsular
flap at the end-range arm position and reconstruction of the glenoid concavity at the mid-
range arm position. All 3 stabilizing mechanisms function at both the mid- and end-range
arm positions. After the Latarjet procedure, the shoulder even with a large glenoid defect
can have stability increased by 14% compared to the normal shoulder. The acceptable clini-
cal outcomes of the Latarjet procedure are supported by these 3 stabilizing mechanisms.
Oper Tech Sports Med 27:49-54 © 2019 Elsevier Inc. All rights reserved.

KEYWORDS biomechanics, Latarjet reconstruction, sling, subscapularis

Why Good Clinical Results Can in which the essential lesion, the Bankart lesion is not
repaired? To date, “sling effect of the subscapularis muscle”
Be Obtained Without the Bankart has been clinically believed as the main stabilizing mechanism
Repair? of this procedure. This was speculation among surgeons. Its
precise stabilizing mechanism had not been studied.
T he Latarjet procedure has gained popularity with recent
reports1,2 showing that postoperative arthritis can be
avoided by appropriate positioning of the coracoid bone
graft. Excellent clinical results even for shoulders with a large Biomechanical Experiments
glenoid defect have been reported. Surgical procedures for
treating anterior shoulder instability can be divided into 2 Using Cadaveric Shoulders
groups: intra-articular and extra-articular. The Latarjet proce- Stability in the Mid- and End-Range Arm
dure is included in extra-articular techniques, and the Bank- Positions
art repair is included in intra-articular stabilizing procedures.
It is biomechanically known that shoulder stability depends
Although a Bankart lesion itself is not repaired in the original
on arm position. The main stabilizer of the shoulder joint is
Latarjet procedure or in most of the modified Latarjet proce-
the capsuloligamentous tissues in the end-range arm position
dures, excellent clinical outcomes have been reported.3-5 A
(abduction and maximum external rotation) (Fig. 1A, B) and
Bankart lesion is known to be an essential lesion in patients
the concavity compression effect by the rotator cuff muscles
with anterior shoulder instability. Surgeons have asked why
in the mid-range arm position (the other arm positions).
good clinical results can be obtained by the Latarjet procedure
That is why it is important to simulate 2 arm positions in
research studies: 60° of abduction relative to the scapula and
*Department of Orthopaedic Surgery, Tohoku University School of Medi- maximum external rotation and neutral rotation to clarify
cine, Sendai , Japan. the stabilizing mechanisms in all range of motions.
y
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
Investigation performed at the Mayo Clinic, Rochester, Minnesota.
Address reprint request to Scott P. Steinmann MD, Department of
Subjects and Methods
Orthopedic Surgery, Mayo Clinic College of Medicine, 200 First Street Fresh-frozen cadaveric shoulders were used. A custom multi-
SW, Rochester, MN 55905. E-mail: [email protected] axis electromechanical testing machine with a 3-degrees-

https://doi.org/10.1053/j.otsm.2019.01.008 49
1060-1872/© 2019 Elsevier Inc. All rights reserved.
50 N. Yamamoto and S.P. Steinmann

Figure 1 Two arm positions. Shoulder stability depends on the arm position: the capsuloligamentous tissues in
the end-range arm position (A) and the concavity compression effect by the rotator cuff muscles in the mid-
range arm position (B).

of-freedom load-cell was utilized (Fig. 2). With a 50-N axial Part I Study
force, the humeral head was translated in the anterior direc- Few biomechanical studies6 have demonstrated the stabiliz-
tion, and the peak translational force was measured. Three ing mechanism of Latarjet procedures. To clarify the experi-
sets of loads were applied to see the relationship between the mental steps, we divided the study into 2 experimental parts.
loading on muscles: (10 N, 2.5 N), (20 N, 5 N), and (30 N, In the first experiment,7 we tried to clarify the main stabiliz-
7.5 N) applied to the subscapularis and conjoint tendon, ing mechanism and the contribution of the subscapularis
respectively. A large glenoid defect (25% of glenoid width) and conjoint tendons. Specimens were divided into 2 groups
was created. (A and B) according to the order of removing the subscapula-
ris and conjoint tendons because it was expected that this
Surgical Technique order might affect the results. In the group A, the conjoint
There are many variations of the Latarjet procedure. We fol- tendon was removed following removal of the subscapularis
lowed Walch’s surgical technique1 in this study. The subsca- tendon. In the group B, first, the conjoint tendon was
pularis muscle was divided at the junction of the superior removed.
two-thirds. A small anterior capsulotomy (1.5 cm) was per- The main stabilizing mechanism of the Latarjet procedure
formed. The bone block was positioned flush to the anterior- was demonstrated to be the sling effect produced by the sub-
inferior margin of the glenoid at 4 o’clock. Two AO 4.5-mm scapularis and conjoint tendons at both the end-range and
malleolar screws driven into the posterior cortex secured the the mid-range arm positions. After removing either the sub-
coracoid process (CP) to the glenoid. The Bankart repair was scapularis or conjoint tendon, the force significantly
not performed. decreased. However, there were no significant differences
The Biomechanics of the Latarjet Reconstruction 51

Figure 4 The stabilizing mechanism of the Latarjet procedure. At the

end-range arm position, 76%-77% of the stability was contributed
by the sling effect and the remaining 23%-24% by the suturing of
the coracoacromial ligament. In the midrange arm position, the
contribution of the sling effect was 51%-62%. Reconstruction of the
glenoid concavity contributed the remaining 38%-49%. CAL
suture, suturing the coracoacromial ligament (capsular flap); gle-
noid plasty effect, reconstruction of the glenoid concavity.

capsule reattached to the CAL. The 2 tendons were then

removed to see the contribution of the sling effect to stability,
and the sutures of the capsular flap to the CAL were removed
Figure 2 A custom multiaxis electromechanical testing machine A to see its contribution.
6-degrees-of-freedom load-cell is indicated as * in the photo. At the end-range arm position, 76%-77% of the stabil-
ity was contributed to the sling effect (Fig. 4). The
between 2 groups. It was concluded that the 2 tendons con- remaining 23%-24% was contributed to the suturing of
tributed to stability equally. the CAL (suture effect). In the mid-range arm position,
the contribution of the sling effect was 51%-62%. Recon-
struction of the glenoid concavity contributed the remain-
Part II Study ing 38%-49% (glenoid plasty effect). The shoulder with a
In the Part I study, small capsulotomy and bone exposure to large glenoid defect became stable and stability increased
transfer the CP, which are performed in real surgery, were by 14% compared to the normal shoulder after the Latar-
not simulated. In the Part II study,8 we further investigated jet procedure. Stability increased significantly with
the effect of suturing the lateral capsular flap to the stump of increases in the load applied to the subscapularis and
the coracoacromial ligament (CAL) which is a common addi- conjoint tendons at the mid-range arm position. This
tion to the Latarjet technique (Fig. 3). The peak translational means that if the muscle strength of the subscapularis
force was measured (1) with the intact capsule, (2) with a and conjoint tendons increases, the shoulder becomes
Bankart lesion, and (3) after the Latarjet procedure with the more stable at the mid-range arm position. This might
benefit contact or collision athletes who need stability in
the mid-range arm position during athletic contests.

What Is the Sling Effect?

The sling effect was demonstrated to be the main stabiliz-
ing mechanism of the Latarjet procedure. Results showed
that the sling effect was provided by both the subscapula-
ris and conjoint tendons. The split subscapularis tendon
provided muscle stability because the intersection of the
transferred conjoint tendon added tension to the inferior
portion of the subscapularis (Fig. 5). At the end-range
arm position, the intersection of the 2 tendons became
taut together in front of the humeral head. Observation
by ultrasound elastography revealed that the intersection
of the subscapularis and conjoint tendons became stiffer
Figure 3 Latarjet procedure with the capsule reattached to the cora- with the arm in external rotation compared to that with
coacromial ligament. The lateral capsular flap (*) was sutured to the the arm in internal rotation (Fig. 6A, B).
stump of the coracoacromial ligament. Two AO 4.5-mm malleolar For these reasons, the shoulder becomes stable after the
screws secured the coracoid process with the conjoint tendon (}) Latarjet procedure even though a Bankart lesion is not
to the glenoid. The subscapularis muscle was elevated in this photo. repaired. Stability increased with load at the mid-range arm
52 N. Yamamoto and S.P. Steinmann

Which Is More Important,

Conjoint or Subscapularis
Tendon?
In our studies, specimens were divided into 2 groups accord-
ing to the order of removing the subscapularis and conjoint
tendons. After removing either the subscapularis or conjoint
tendon, the peak translational force significantly decreased.
However, there were no significant differences between 2
groups. This means both 2 tendons contributed to stability
equally. Surgeons have believed that the subscapularis ten-
don is important for the sling effect but our results indicated
that both of them are necessary so that the intersection of 2
Figure 5 Schematic illustration of the sling effect. The sling effect tendons works as a stabilizer. If the subscapularis or conjoint
was provided by the subscapularis and conjoint tendons. The split tendon is dysfunctional for some reason, one cannot expect
subscapularis tendon provided muscle stability, working as a barrier the sling effect to be reproduced by these 2 tendons.
because the intersection (I ) of the conjoint tendon added tension to
the inferior portion of the subscapularis.

Contribution of the Sutures of the

position. It has been reported by various authors that
dynamic stability depends on the muscle contraction force in
Capsular Flap to the CAL
the mid-range arm position.9-11 This finding explains why The contribution of the sutures of the capsular flap to the
the sling effect works most effectively in the mid-range arm CAL to the stability was 19%-20% as the load changed at the
position, at which the force of muscle contraction is related end-range position, whereas the sutures to the CAL did not
to the stability of the joint. contribute to the stability at the mid-range position. Some

Figure 6 Observation of the sling effect by ultrasound elastography. Softer tissue is colored red and harder tissue blue in
the ultrasound elastography image. (A) With the arm in internal rotation, the intersection he subscapularis and con-
joint tendons (circle B) showed yellow. (B) With the arm in external rotation, the intersection he subscapularis and
conjoint tendons (circle B) showed blue. (Color version of figure is available online.)
The Biomechanics of the Latarjet Reconstruction 53

surgeons do not suture the capsular flap to the CAL. How- Difference Between Latarjet and
ever, by adding sutures of the capsular flap, a 19%-20% Bristow Procedures
increase in stability is expected at the end-range position.
Thus, we recommend that the capsular flap be sutured to the There are 2 coracoid transfer procedures (the Bristow and
CAL when performing the Latarjet procedure. Latarjet procedures), which are frequently used to treat a
large glenoid defect in patients with anterior shoulder insta-
bility. Giles et al14 compared the biomechanical effects of
these 2 procedures and they reported that both procedures
“Triple Locking” have equivalent stabilizing effects in shoulders without gle-
noid defect. However, the Latarjet procedure conferred supe-
At the end-range arm position, 76%-77% of the stability was
rior stabilization in shoulders with 30% glenoid defect
contributed to the sling effect. The remaining 23%-24% was
compared to Bristow procedure. Nourissat et al15 assessed
contributed to the suturing of the CAL. In the mid-range
the effect of the position of the bone graft on anterior and
arm position, the contribution of the sling effect was 51%-
inferior stability. They showed that the lying position at 4
62%. Reconstruction of the glenoid concavity contributed
o’clock substantially decreased anterior and inferior displace-
the remaining 38%-49%. These 3 are the stabilizing mecha-
ment of the humeral head respectively. The standing bone-
nisms of the Latarjet procedure. Interestingly, the concept of
block position did not affect translation.
“triple locking” proposed by Patte12 (often now referred to as
“triple blocking”), which includes repair of the capsule
(capsular locking), preservation of the lower one-third of
the subscapularis (tendinomuscular locking), and exten- Is Coracoid Process Large
sion of the osseous glenoid concavity (osseous locking),
is consistent with our laboratory results. In our studies,
Enough for the Latarjet
capsular locking is equal to CAL suturing effect, and ten- Procedure?
dinomuscular locking is the same as sling effect. Osseous As the Latarjet has gained in popularity, the question arises if
locking is the glenoid plasty effect. Thus, our biomechan- the CP is large enough for the Latarjet procedure in smaller
ical studies clarified the same stability mechanisms which proportioned peoples? Takahashi et al16 investigated the
Patte12 clinically proposed. dimension of the CP of Japanese patients. The DICOM data
of CT images of 102 shoulders from 51 Japanese patients
with unilateral anterior instability were reviewed. The CP
maximum length, the average width, and the average height
Surgical Indication for Latarjet were measured for the affected and unaffected side. The
Procedure transferable CP length was defined as the difference between
Based on our biomechanical studies, we are able to comment the CP length and the width of the coracoid base. The mean
on the indications for the Latarjet procedure. Surgical indica- length of the transferable CP was 28.5 mm in the affected
tions would include: (1) shoulders with a large glenoid defect side and 29.1 mm in the unaffected side. The transferable CP
(greater than 25% of the glenoid width), (2) shoulders with a length in the affected side was significantly shorter than that
large Hill-Sachs lesion (off-track lesion13), (3) contact or col- of the unaffected side. There were 5 women in 7 cases (14%)
lision athletes, (4) shoulders with tears on the capsule, and who had shorter CP lengths than the ideal length. It was
(5) revision Bankart repairs. In our study, the shoulder with reported that the Latarjet procedure transferred most of the
a large glenoid defect became stable and stability increased coracoid as a bone graft that usually measured 2.5-3 cm in
by 14% compared to the normal shoulder after the Latarjet length.17 Our results revealed that the less ideal cases for the
procedure. Stability increased significantly with increases in Latarjet procedure were mostly observed in women and its
the load applied to the subscapularis and conjoint tendons at total incidence was 14%. Surgeons should measure the size
the mid-range arm position. Relative surgical indications are of CP preoperatively in the planning of Latarjet procedure
(1) a Bankart lesion or its variants, such as Perthes lesion, for smaller patients.
anterior labroligamentous periosteal sleeve avulsion (ALPSA)
lesion, (2) glenoid labral articular defect (GLAD) lesion, (3)
shoulders without a glenoid defect, and (4) humeral avulsion
References
1. Walch G, Boileau P: Latarjet-Bristow procedure for recurrent anterior
of the glenohumeral ligament (HAGL) lesion. Although our
instability. Tech Shoulder Elbow Surg 1:256-261, 2000
studies simulated a shoulder with a glenoid defect, the results 2. Edwards TB, Boulahia A, Kempf JF, et al: The influence of rotatorcuffdi-
of an unpublished preliminary study confirmed that a shoul- seaseontheresultsofshoulderarthroplastyforprimaryosteoarthritis:
der without a glenoid defect became stable after performance Results of a multicenter study. J Bone Joint Surg Am 84:2240-2248,
of the Latarjet procedure. Contra-indications are (1) dysfunc- 2002
tion of the subscapularis or conjoint tendon and (2) young 3. Allain J, Goutallier D, Glorion C: Long-term results of the Latarjet proce-
dure for the treatment of anterior instability of the shoulder. J Bone Joint
patients with open growth plate. If the subscapularis or con- Surg Am 80:841-852, 1998
joint tendon is dysfunctional for some reason, one cannot 4. Hovelius L, Sandstrom B, Saebo M: One hundred eighteen Bristow-
expect the sling effect to be produced by these 2 tendons. Latarjet repairs for recurrent anterior dislocation of the shoulder
54 N. Yamamoto and S.P. Steinmann

prospectively followed for fifteen years: Study II—the evolution of dislo- end-range of motion. A study in cadavera. J Bone Joint Surg Am
cation arthropathy. J Shoulder Elbow Surg 15:279-289, 2006 82:849-857, 2000
5. Spoor AB, de Waal Malefijt J: Long-term results and arthropathy follow- 12. Patte D, Bernageau J, Bancel P: The anteroinferior vulnerable point of
ing the modified Bristow-Latarjet procedure. Int Orthop 29:265-267, the glenoid rim. In: Bateman JE, Welsh RP (eds): Surgery of the shoul-
2005 der, New York: Dekker 94-99, 1985
6. Wellmann M, de Ferrari H, Smith T, et al: Biomechanical investigation 13. Di Giacomo G, Itoi E, Burkhart SS: Evolving concept of bipolar bone
of the stabilization principle of the Latarjet procedure. Arch Orthop loss and the Hill-Sachs lesion: From “engaging/non-engaging” lesion to
Trauma Surg 132:377-386, 2012 “on-track/off-track” lesion. Arthroscopy 30:90-98, 2014
7. Yamamoto N, Muraki T, An KN, et al: What is the stabilizing mecha- 14. Giles JW, Degen RM, Johnson JA, et al: The Bristow and Latarjet proce-
nism of the Latarjet procedure? In: American Shoulder and Elbow Sur- dures: Why these techniques should not be considered synonymous.
geons Open Meeting February 28; 2009 Las Vegas, Nevada J Bone Joint Surg Am 96:1340-1348, 2014
8. Yamamoto N, Muraki T, An KN, et al: The stabilizing mechanism of the 15. Nourissat G, Neyton L, Metais P, et al: Functional outcomes after open
Latarjet procedure: A cadaveric study. J Bone Joint Surg Am 95:1390- versus arthroscopic Latarjet procedure: A prospective comparative
1397, 2013 study. French Arthroscopic Society. Orthop Traumatol Surg Res 102:
9. Lippitt S, Matsen F: Mechanisms of glenohumeral joint stability. Clin S277-S279, 2016
Orthop Relat Res 291:20-28, 1993 16. Takahashi H, Yamamoto N, Nagamoto H, et al: Is coracoid process large
10. Tammachote N, Sperling JW, Berglund LJ, et al: The effect of glenoid enough for the Latarjet procedure in Japanese? Measurement by 3-dimen-
component size on the stability of total shoulder arthroplasty. J Shoul- sional computed tomography. J Shoulder Elbow Surg 23:604, 2014
der Elbow Surg 16(Suppl):S102-S106, 2007 17. Burkhart SS, De Beer JF, Barth JR, et al: Results of modified Latarjet
11. Lee SB, Kim KJ, O’Driscoll SW, et al: Dynamic glenohumeral stabil- reconstruction in patients with anteroinferior instability and significant
ity provided by the rotator cuff muscles in the mid-range and bone loss. Arthroscopy 23:1033-1041, 2007