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

www.elsevier.com/locate/ymse

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
frequently given its success treating recurrent anterior
shoulder instability.9 Authors have reported successful
Institutional review board approval: not applicable (cadaveric study).
*Reprint requests: Joshua S. Dines, MD, Hospital for Special Surgery,
935 Northern Blvd, Ste 303, Great Neck, NY 11021, USA.
E-mail address: jdinesmd@gmail.com (J.S. Dines).
outcomes for patients treated with the procedure for insta-
bility due to both bony defects on the glenoid and soft-
tissue (ie, capsular) insufficiency. Unlike the traditional
Bristow procedure, which only describes a transfer of the
tip of the coracoid, the Latarjet-Bristow procedure transfers
the coracoid along with the attached conjoined tendon
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 1 A custom testing system was used in which the
shoulder was secured with a scapula-mounting bracket in 30
of
abduction.
coracoacromial ligament is maintained on the coracoid and
used to reinforce the anterior capsule.3,9 It has been
hypothesized that the procedure works because of its
‘‘triple effect’’: (1) osseous, by coracoid fixation to the
glenoid neck; (2) ligamentous, by coracoacromial ligament
reinforcement of the inferior glenohumeral ligament; and
(3) muscular, through conjoined tendon transfer lowering
the inferior portion of the subscapularis.9
Many authors contend that the main concept of the
operation is to use the conjoined tendon as a sling to lower
the subscapularis to reinforce the anteroinferior capsule.3,9
Unfortunately, given the difficulty associated with
modeling of the conjoined tendon and subscapularis in
cadaveric models, the biomechanical effects of the ‘‘sling,’’
as well as stability and range of motion (ROM), after the
Latarjet procedure have not been accurately documented.
Another issue that arises when trying to characterize the
stabilizing mechanisms of the Latarjet procedure is that it
may work differently in different situations (ie, bone loss vs
no bone loss). To date, there is only one biomechanical
study of the effectiveness of the Latarjet procedure.10 The
authors found that the procedure significantly decreased
translation at both 30
and 60
of abduction.
In this study, we describe a novel biomechanical model
to test the Latarjet procedure and the effect of the conjoined
tendon. We then use the model to characterize the stabi-
lizing mechanism of the Latarjet procedure in the setting of
soft-tissue insufficiency, hypothesizing that the sling effect
is the main stabilizing component of the procedure.
Materials and methods
We tested 6 matched pairs of cadaveric shoulders (2 female and 4
male cadavers). The mean age was 53.2 years (range, 40-68
years). The specimens were dissected of all soft tissue, leaving
the subscapularis, infraspinatus, supraspinatus, joint capsule,
Figure 2 Conjoined tendon spring loaded after completion of
Latarjet procedure.
Table I Range of motion
Group Internal External Total
rotation (
) rotation (
) ROM (
)
Intact 71.8 69.7 141
Capsulolabral tear 74.1 73.8 148
Latarjet procedure 75.2 72.3 147
Latarjet procedure 74.9 76.1 151
with conjoined
tendon unloaded
coracoacromial ligament, and conjoined tendon intact. Three
sutures were attached to the anterior, middle, and inferior insertion
sites of the subscapularis and infraspinatus, and 2 sutures were
attached to the anterior and posterior supraspinatus. The local
coordinate systems of the glenoid and the humerus were defined
by 6 small screws that were inserted into the acromion and on the
proximal humerus. The systems were used to calculate the
humeral head apex position, the most prominent point on the
articular surface, relative to the geometric center of the glenoid.4
The scapula was mounted onto a mounting plate with the
medial border parallel to the mounting bracket, and an aluminum
rod was secured into the humeral medullary canal.
A custom testing system was used in which the shoulder was
secured with a scapula-mounting bracket in 30
of abduction5-7
(Fig. 1). The humerus was fixed in 90
of abduction in the scap-
ular plane but allowed for rotation, as well as translational degrees
of freedom. A square mounting bracket also allowed the humerus
to be locked in rotation while still allowing 3 degrees of trans-
lational freedom. On the basis of previous studies, a goniometer
was attached to the distal end of the humeral rod, and rotational
position was defined by aligning the bicipital groove with the
anterior edge of the acromion to simulate 20
of external rota-
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
was loaded based on physiological cross-sectional area ratios: 9 N on
the subscapularis and infraspinatus and 6 N on the supraspinatus.8
The conjoined tendon was sutured and attached to a spring that
was attached to the mounting track at the distal humerus. When
engaged, the spring applied 6 N of tension across the conjoined
tendon, which was based on the physiological cross-sectional area.
Stabilizing effects of Latarjet procedure
Figure 3 Rotational ROM in each of 4 testing states.
Table II Translation
Group Translation (mm)
Anterior) Inferior) Posteriory Superiory
Intact 7.4 1.7 13.4 0.7
Capsulolabral tear 9.7 3.0 14.4 0.6
Latarjet procedure 6.2 0.5 13.8 0.6
Latarjet procedure 9.3 1.3 14.4 0.4
with conjoined
tendon unloaded
) As a result of anterior translational force.
y
As a result of posterior translational force.
Testing protocol
Rotational ROM was measured with 2.2 Nm of torque after pre-
conditioning with the same amount of torque for 10 cycles. The
position of the humerus relative to the glenoid was measured by
digitizing the scapular position and the humeral position throughout
the rotational ROM, specifically at maximum internal rotation, 30
of
internal rotation, 0
of rotation, 30
of external rotation, and
maximum external rotation. This was done by digitizing the 6 refer-
ence screws, 3 on the scapula and 3 on the humerus, with a Micro-
Scribe G2LX (Revware, Raleigh, NC, USA). Humeral translation that
occurred with an anterior and posterior load was measured with the
humerus locked at 0
of rotation and 20 N and 30 N of translational
force applied in both the anterior and posterior directions. Trans-
lational force was applied by attaching 2 sutures at the distal portion of
the pectoralis major insertion. These sutures were then directed to 2
pulleys directly anterior and posterior from where the translational
load could be administered. The position of the humerus was digitized
with the MicroScribe G2LX when it was centered in the glenoid and
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
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
change from the humerus centered in the glenoid and after a trans-
lational load was applied. It should be noted that translational
measurements were performed through a standardized set of
3
positions; the specimens were preconditioned before each measure-
ment, and the forces applied were non-destructive.
Rotational ROM, the position of the humeral head relative to
the glenoid, and translation of the humerus with an anterior and
posterior force applied were measured for the intact glenohumeral
joint, after creation of a capsulolabral tear (simulating soft-tissue
insufficiency) from the 3- to 6-o’clock position on the glenoid for
right shoulders with corresponding positions for the left shoulders,
and after the Latarjet procedure. The capsulolabral tear was
created through a subscapularis split.
The Latarjet procedure was performed as described by Walch and
Boileau.9 The coracoacromial ligament was incised 1 cm from its
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-
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
block was placed through the soft tissue and positioned with the
inferior surface of the coracoid flush with the anteroinferior margin of
the glenoid. Two 3.5-mm malleolar screws were used to secure the
bone block to the glenoid. The coracoacromial ligament was used to
reinforce the anterior capsule. After the Latarjet procedure, the
conjoined tendon was reloaded with 6 N, the vector of which was in
line with the humerus directed toward the short head of the distal biceps
attachment (Fig. 2). Data were recorded after the Latarjet procedure
with the conjoined tendon loaded and after conjoined tendon release.
At the completion of testing, the specimens were disarticulated
to digitize the geometry of the glenoid and the humeral head
articular surfaces relative to the local coordinate systems. The
position of the humeral head apex relative to the geometric center
of the glenoid was then calculated at each rotational ROM posi-
tion. Two trials of each data point were recorded, and the mean
was used for comparison. A Wilcoxon matched-pairs test was used
for statistical analysis with a significance level of .05.
Results
With regard to ROM, after creation of the capsulolabral
tear, there was a statistically significant increase in internal
and external ROM. Total ROM in abduction significantly
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-
capsulotomy ROM (Table I).
There was also no significant difference in external
rotation between the pre–capsulolabral tear state and after
the Latarjet procedure (70
and 72
, respectively). When
the conjoined tendon was unloaded, external rotation
increased from 72
to 76
, which was significant (P ¼ .028)
(Fig. 3).
After capsulotomy, with the shoulder abducted to 90
in
neutral rotation, translation significantly increased in the
anterior (P ¼ .028), posterior (P ¼ .046), and inferior (P ¼
.028) directions. Loading the conjoined tendon after the
Latarjet procedure significantly decreased anteroinferior
translation (P ¼ .046). This had no effect on posterior or
superior translation. When the conjoined tendon was
unloaded, anterior translation significantly increased rela-
tive to the conjoined tendon–loaded state (P ¼ .046). There
were no significant differences in translation in any other
direction (Table II, Fig. 4).
When compared with the intact and capsulolabral tear
states, there was no significant difference in humeral head
position through the tested ROM after the Latarjet proce-
dure with the conjoined tendon loaded. When the conjoined
tendon was unloaded, however, the humeral head shifted
anteriorly by a mean of 3.6 mm both at 30
of external
rotation and at maximal external rotation (P < .046)
(Fig. 5).
Discussion
Many authors contend that a critical component of the
Latarjet procedure centers on its use of the conjoined tendon
as a sling to lower the subscapularis muscle, reinforcing the
anteroinferior capsule.3,9 Proving this in the laboratory has
been difficult given the inherent difficulties in modeling the
conjoined tendon in cadaveric studies. In this study, we
successfully described a biomechanical model to test the
Latarjet procedure that accurately accounts for the effect of
the conjoined tendon. We further used the model to char-
acterize the stabilizing mechanism of the Latarjet procedure
when used in cases of soft-tissue insufficiency.
There are limited studies in the literature that have
attempted to biomechanically assess the Latarjet procedure.
In an eloquent study, Wellman et al10 compared the effects of
a modified Latarjet procedure with a bone graft to treat
instability due to a glenoid bony defect. They found the
modified Latarjet procedure to be more stable to ante-
roinferior loading, particularly at 60
of abduction. There
were several important differences between our study and
their study, however. They only compared the modified
Latarjet procedure (and bone block procedures) with them-
selves and the capsulotomy state. There was no comparison
of the modified Latarjet procedure with the normal state, as
was done in our study, which enabled us to comment on how
normal shoulder kinematics is affected by the procedure.
They did not perform an analysis of ROM or humeral head
tracking, and they used a bone deficiency model of instability.
In a soft-tissue insufficiency model of instability, we
found that the Latarjet procedure significantly decreased
anteroinferior translation while preserving ROM in both
internal and external rotation. When the conjoined tendon
was unloaded, external rotation increased, and there was an
associated increase in anterior translation. Interestingly,
when the conjoined tendon was unloaded, there was no
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
affect inferior translation.
All cadaveric studies that attempt to analyze the Latarjet
procedure will face the limitation that it is impossible to
perfectly simulate the physiological tension inherent in the
conjoined tendon. In the work by Wellman et al,10 they
passively tensioned the tendon to about 10 N in each test
position. It was fixed through a transhumeral bone tunnel
located at the origin of the medial biceps. Halder et al2
tested the dynamic effect of conjoined tendon inhibition
on anteroinferior humeral translation. They tested the
Stabilizing effects of Latarjet procedure
Figure 5 Humeral head position throughout ROM. ER, External rotation; IR, internal rotation.
dynamic contributions of 5 shoulder muscles to inferior
stability, including the short head of the biceps and the
coracobrachialis. A 15-N force was applied to the humerus,
and the tendons were loaded in proportion to their muscles’
cross-sectional areas. The conjoined tendons were capable
of translating the humeral head superiorly. This study was
one of the few in the literature to biomechanically analyze
the effects of the conjoined tendon; however, it was clearly
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
behavior, excluding the important effects of postoperative
rehabilitation and healing. This limits our ability to draw
any conclusions about the longevity, strength, or healing
potential of the described procedures. In addition, as was
mentioned earlier, the Latarjet procedure has been used to
treat anterior instability due to both glenoid bone defects
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
a capsulotomy alone. However, despite the changes found
that are consistent with anterior instability, this model still
may not reflect the capsular redundancy seen clinically in
patients with anterior instability. Finally, the age of our
cadavers does not accurately reflect the typical age of this
population of patients. Given that instability is typically
a pathology encountered in a younger population, it is
extremely difficult to obtain cadavers of an appropriate age.
Conclusion
The Latarjet procedure provides very successful clinical
outcomes for a variety of causes of anterior instability.
5
In this study, we developed a model to test the procedure
biomechanically. The findings of our study support the
majority of clinical studies of the Latarjet procedure in
the sense that it limited anterior translation of the
humeral head while preserving ROM. In addition, as the
Latarjet procedure becomes more prevalent, the model
developed here can serve as a useful tool to better
analyze the technique.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
References
1. Alberta F, ElAttrache NS, Mihata T, McGarry M, Tibone J, Lee T.
Arthroscopic anteroinferior suture plication resulting in decreased
glenohumeral translation and external rotation: study of a cadaver
model. J Bone Joint Surg Am 2006;88:179-87. http://dx.doi.org/10.
2106/JBJS.D.02974
2. Halder AM, Halder CG, Zhao KD, O’Driscoll S, Morrey B, An KN.
Dynamic inferior stabilizers of the shoulder joint. Clin Biomech 2001;
16:101-6.
3. Latarjet M. Treatment of recurrent dislocation of the shoulder. Lyon
Chir 1954;49:994-7.
4. Lee YS, Lee TQ. Specimen specific method for quantifying gleno-
humeral joint kinematics. Ann Biomed Eng 2010;38:3226-36. http://
dx.doi.org/10.1007/s10439-010-0074-7
5. Mihata T, Lee Y, McGarry MH, Abe M, Lee T. Excessive humeral
rotation results in increased shoulder laxity. Am J Sports Med 2004;
32:1278-85. http://dx.doi.org/10.1177/0363546503262188
6 J.S. Dines et al.
6. Remia LF, Ravalin RV, Lemly KS, McGarry M, Kvitne R, Lee T.
Biomechanical evaluation of multidirectional instability and repair.
Clin Orthop Relat Res 2003;416:225-36.
7. Shafer BL, Mihata T, McGarry MH, Tibone J, Lee T. Effects of
capsular plication and rotator interval closure in simulated multidi-
rectional instability. J Bone Joint Surg Am 2008;90:136-44. http://dx.
doi.org/10.2106/JBJS.F.00841
8. Veeger HE, Van Der Helm FC, Van Der Woude LH, Pronk G,
Rozendal RH. Inertia and muscle contraction parameters for muscu-
loskeletal modeling of the shoulder mechanism. J Biomech 1991;24:
615-29.
9. Walch G, Boileau P. Latarjet-Bristow procedure for recurrent anterior
instability. Tech Shoulder Elbow Surg 2000;1:256-61.
10. Wellman M, Peterson W, Zantop T, Herbort M, Kobbe P, Raschke M,
et al. Open shoulder repair of osseous glenoid defects: biomechanical
effectiveness of the Latarjet procedure versus a contoured structural
bone graft. Am J Sports Med 2009;37:87-94. http://dx.doi.org/10.
1177/0363546508326714
11. Youm T, Tibone JE, ElAttrache NS, McGarry M, Lee T. Simulated
type II SLAP lesions do not alter the path of glenohumeral articula-
tion. Am J Sports Med 2008;36:767-74. http://dx.doi.org/10.1177/
0363546507312169