Latarjet procedure

Bristow-Latarjet procedure
Summary

This operation is performed for shoulder dislocations with associated bone loss or revision cases when a shoulder has dislocated after surgical stabilisation.  The glenoid socket is at risk of damage when a shoulder dislocates.  Normally it is the labrum (lip of the socket) that gets torn from the glenoid rim.  However, it is possible for part of the glenoid socket to fracture.  This results in a smaller socket for the shoulder to rest in.  A Latarjet procedure is an operation that takes a bony prominence near the shoulder joint called the coracoid process and inserts it onto the front of the glenoid to restore the glenoid socket.

Factors to Consider

The shoulder has the most movement out of all the joints in the body and so consequently is prone to dislocating.  Arthroscopic shoulder stabilisations are normally considered first for the surgical management of traumatic shoulder dislocations.  If a dislocation occurs after this procedure, repeating the procedure is unlikely to be effective.  A Latarjet procedure is an open surgical procedure that is effective at reducing the risk of dislocation in this group of patients.  It is also used when significant bone loss on the socket or ball has occurred as a result of dislocation.  

Description of Surgery

The operation is performed through a 10cm incision at the front of the shoulder.  The coracoid process is cut off from its base leaving the tendons attached to the coracoid.  The joint is then entered by splitting the muscle at the front of the shoulder called the subscapularis.  The coracoid process is then attached to the deficient socket using 2 screws.

The operation takes about 90 minutes.  You will most likely need to stay overnight following your surgery.

Anaesthetic

The operation is performed under a general anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

It is common for you to be offered a nerve block to help with the pain.  The nerve block allows excellent pain relief immediately after the operation.  It is considered a safe method of providing pain relief with few complications (less than 1%).  You will wake up with a numb arm, similar to when you sleep on your arm awkwardly.  The block wears off within 12-24 hours and so it is important to take pain killers the night after the surgery even if you don’t have pain when you go to sleep.

The anaesthetist will talk more about the nerve block when they see you.  If you do not want a nerve block your pain can be well controlled with local anaesthetic given during the operation.

 

What are the risks?

All operations involve an element of risk.  The risks for this particular operation are small but the consequences can be significant and so it is important that you are aware of them.

The risk of infection is small and is thought to be about 0.5%.  Most infections will settle simply with antibiotics.  

There are important nerves and blood vessels that run near the operation site.  Although rare (1%), it is possible that these nerves can get damaged which could lead to temporary or permanent weakness or altered sensation to your arm.  

The risk of dislocating your shoulder after surgery is about 2%.  The coracoid process that is attached to the socket needs to heal similarly to how a fracture heals.  Sometimes it will heal with scar tissue and not bone (fibrous union) or not heal at all (non union).  This rarely causes a problem but could lead to the procedure failing more easily. 

After Surgery

Pain

Local anaesthetic or a nerve block will be used during the operation and so you will feel comfortable when you first wake up.  The nerve block can make your whole arm feel numb.  This can last up to 12 hours but the shoulder may be sore after it wears off.  You will be given a combination of pain killers to go home with.  It is important that you take regular pain relief so that you can start moving your arm early.  

You may also be given an icepack.  The nurses will show you how to place the icepack on your shoulder.  The icepack should be taken off after 15 minutes  and can be used every 2 hours.

Sling

You will wake up with your arm in a sling.  The arm should be comfortable but it is important to let the nurses know if you have pain so that further pain killers can be given.  The sling is for comfort and is normally used during the first 4 weeks.  You can take your arm out of the sling if you would like but it is best to keep your arm below shoulder height during the first month after surgery.  You should wear your sling to be for the first 4 weeks.

Dressings

The wound is closed using dissolvable stitches.  There will be dressings applied to the wound following your operation.  These can occasionally come off and will need to be replaced during the first 2 weeks after surgery to protect the wound.  

The dressings are splash proof but not waterproof and so you should avoid getting them wet.

The stitches do not need to be removed but there may be loops at each end of the wound that can be trimmed.  The nurses will arrange this to be done at your local GP practice before you are discharged.

Physiotherapy

Physiotherapy is absolutely essential in ensuring that your shoulder fully recovers.  The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you within 3 weeks of the operation.  Physiotherapy can be arranged local to you.  

Driving

You should not drive for the first 4-6 weeks.  After this, you can drive when you feel you are safe to drive.  This means that you feel confident that you have full control of your car and are able to swerve out of the way of something in the road.  This will vary between patients but normally takes about 6 weeks.  

Return to work

This depends on what your job is.  You should be able to return to a “desk job” within a few weeks of your surgery.  If you have a more manual job it can take up to 6 weeks before you feel ready to return to work.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable.  Most people will be using their arm comfortably below shoulder height within the first 6 weeks.   Your symptoms should be improved by 3 months with the majority fully recovered by 6 months.  It can, however, take up to a year for some patients to fully improve.