Management of Failed Latarjet Procedure Using a Distal Clavicular Autograft

Abstract

Background: Latarjet procedure is the gold standard surgery in cases of shoulder instability with substantial bone loss. Recurrence is scarce but its management may be challenging. Numerous revision techniques, based on soft tissue repairs with autograft or allograft augmentations, have been developed. Autografts are associated with potential donor-site morbidity while allografts may generate additional costs. We present here the use of the ipsilateral distal clavicular osteochondral autograft in the setting of failed Latarjet procedure. Indication: The indication is a failed coracoid bone block procedure with recurrent instability and preoperative imaging demonstrating intact acromioclavicular (AC) joint with preserved coracoclavicular (CC) ligaments. This technique should not be used if there was a previous lesion of the CC ligaments during coracoid harvest. Technique Description: A delto-pectoral approach is used and extended superiorly to access the distal clavicle end as well as the glenohumeral (GH) joint anterior aspect. A distal clavicular osteochondral autograft is harvested with an oscillating saw after identifying the AC joint with a needle to prevent any resection medial to the CC ligament insertions, which would compromise distal clavicle stability. The GH joint anterior aspect is exposed, similar to the Latarjet procedure, to first remove the coracoid graft remnants along with any scar tissues surrounding the joint anterior aspect. Distal clavicular autograft is predrilled and fixed to the scapula using 2 cortical screws. The clavicular articular surface may be used to replace the glenoid cartilage defect. In this case, the anatomy of the distal clavicle did not allow us to perform such articular replacement. Results: Return to daily activities was authorized after 3 weeks postoperatively. After 6 weeks, shoulder pain lowered and no clavicle instability or donor-site complication was reported. Return to sport is expected in 50% of cases, compared with other revision procedures. Computed tomography (CT) scan showed an adequate positioning of the bone block and its fusion at 3 months postoperatively. Conclusion: In the setting of a failed Latarjet procedure with recurrent shoulder instability, distal clavicular autograft appears to be a reliable option to reduce donor-site morbidity and avoid additional costs. A prospective clinical study is needed to evaluate this technique in the long term.