Latarjet Procedure for Shoulder Instability

The Latarjet procedure is a bone-transfer surgery for recurrent anterior shoulder instability, in which the coracoid process (a small hook-shaped projection of the shoulder blade) is detached along with its attached tendons and repositioned onto the front rim of the glenoid, the shallow socket that holds the ball of the upper arm bone. First described by the French surgeon Michel Latarjet in 1954, the operation has become the benchmark for shoulders that keep dislocating, especially when bone has been lost from the socket’s edge or when a softer-tissue repair has already failed. Its durability comes from the way it addresses instability on three fronts at once, a design that gives it markedly lower redislocation rates than the more common Bankart repair over time spans of a decade or longer.

How the Triple Blocking Effect Works

The Latarjet’s staying power is rooted in what surgeons call the “triple blocking effect.” A biomechanical study published in the Journal of Bone and Joint Surgery confirmed that the transferred coracoid graft extends the glenoid arc (essentially widening the socket), the conjoined tendon that remains attached to the graft acts as a dynamic sling across the front of the joint during the vulnerable position of arm abduction and external rotation, and the coracoacromial ligament reinforces the capsule from behind.¹ No single one of those three elements carries the load alone. The bony block prevents the humeral head from sliding forward over a worn-down socket edge. The tendon sling tightens precisely when the arm is cocked back, the position where anterior dislocations typically happen. And the ligament patch adds a passive layer of capsular reinforcement. Together they create redundancy: even if one component weakens over time, the other two keep the shoulder in place.

Latarjet Versus Bankart Repair

The most common soft-tissue alternative, the arthroscopic Bankart repair, reattaches the torn labrum (the cartilage rim of the socket) using suture anchors. It works well in certain shoulders, but large comparative data consistently show higher failure rates than the Latarjet, particularly in the long run. A meta-analysis pooling over 3,200 patients found that Bankart repair carried roughly three times the risk of redislocation and about three times the risk of recurrent instability episodes compared with the Latarjet, while also noting a lower risk of surgical-site infection with Bankart.² That advantage for the Latarjet grew even more pronounced in follow-up periods beyond six years. A separate long-term retrospective study reported that overt instability recurred after only about 3% of Latarjet procedures compared with roughly 28% of arthroscopic Bankart repairs.³

Functional outcome scores, however, tend to be similar between the two procedures when the shoulder stays stable. The differences show up mainly in recurrence and revision rates, not in how the shoulder feels day-to-day when everything goes well. A 2024 meta-analysis confirmed the roughly threefold higher risk of recurrence and revision from Bankart repair while also noting that complication profiles differ: Bankart patients face more instability-related reoperations, whereas Latarjet patients face more hardware-related and infection issues.⁴ This is why the decision between the two is not simply “Latarjet is better.” Bankart repair remains appropriate for many first-time or low-risk shoulders, while the Latarjet is favored when bone loss, high-demand athletics, or prior failed repair tips the equation toward durability.

Open Versus Arthroscopic Latarjet

The Latarjet was originally an open procedure, performed through an incision at the front of the shoulder. Over the past two decades, arthroscopic versions have been developed, and the question of which approach is superior has generated a lot of research. A systematic review comparing the two found similar rates of total recurrent instability (about 2% for open versus 2.4% for arthroscopic), similar revision rates, and similar complication rates overall. One notable difference: open surgery had a substantially lower rate of persistent apprehension afterward.⁵ Operative time also converged once surgeons had passed the arthroscopic learning curve.

A more recent review in Current Reviews in Musculoskeletal Medicine concluded that arthroscopic Latarjet can produce outcomes comparable to, and in some measures slightly better than, the open approach in terms of functional scores and patient satisfaction, though the arthroscopic technique demands significantly more surgeon experience and longer operating times early in a surgeon’s practice.⁶ In practical terms, which approach you get often depends more on your surgeon’s training and volume than on any clear clinical superiority of one technique over the other.

Fixation Methods and Hardware Choices

Once the coracoid graft is positioned on the glenoid rim, it needs to be held there while it heals. The two main fixation strategies are metal screws and suture-button devices (sometimes called cortical buttons). A systematic review and meta-analysis comparing the two found that screw fixation had a significantly lower rate of recurrent instability (about 1.5% versus 5% for suture buttons). But screw fixation also came with a significantly higher reoperation rate (about 4% versus 0% for suture buttons), largely because screws sometimes need to be removed due to irritation or loosening.⁷ Total complication rates and graft fracture rates did not differ significantly between the two methods.

A head-to-head retrospective comparison of open screw fixation against arthroscopic cortical button fixation found equivalent functional scores at two years. Each group had one case of recurrent instability, but the cortical button group had several additional complications including neuropraxia (temporary nerve irritation), infections, a graft fracture, and graft migration, all in small numbers.⁸ Hardware choice remains a matter of surgeon preference and patient anatomy, though the trend in the literature leans slightly toward screws for raw stability and toward buttons for avoiding hardware-removal surgery.

Why Graft Positioning Matters So Much

The single most surgeon-controllable factor that affects long-term outcomes is exactly where the bone block sits on the glenoid face. A computational biomechanical analysis found that the graft only contributes meaningfully to joint stability when it extends at least 3 mm lateral to the glenoid rim. At 4.5 mm of lateral extension, stability actually exceeded that of a healthy intact joint, but contact pressures on the cartilage also spiked sharply.⁹ Cadaveric pressure testing echoed this: even 1 mm of graft lateralization beyond flush significantly increased cartilage contact pressures, while 1 mm of medialization in shoulders with large bone defects actually brought pressures back closer to normal preoperative levels.¹⁰

These laboratory findings translate directly to clinical reality. A study with more than five years of follow-up found that osteoarthritis developed or worsened in about 71% of patients whose grafts overhung the glenoid laterally, compared with only about 17% when the graft was flush or slightly medial.¹¹ A pooled analysis also confirmed that lateral overhang carried nearly five times the hazard of developing or worsening osteoarthritis compared with flush or medial placement.¹² The bottom line for patients: your surgeon’s precision in seating that bone block flush with or just barely inside the glenoid face is the single biggest modifiable predictor of whether your shoulder develops arthritis in the coming decades.

Graft Resorption Over Time

One thing many patients are not warned about is that the coracoid graft does not stay the same size forever. CT scans consistently show that the bone remodels over time, and a significant portion of it can be resorbed. One study using CT evaluation found some degree of graft resorption in over 90% of patients.¹³ A volumetric 3D CT analysis found that the superior half of the graft undergoes significant bone loss as early as six months after surgery.¹⁴

A more detailed look showed that major resorption near the upper screw occurred in roughly three-quarters to four-fifths of patients, regardless of whether they had a large glenoid defect beforehand. Near the lower screw, resorption was minimal in almost all patients. None of the usual suspects — screw angle, graft positioning, prior bone defect size, age, or smoking status — turned out to be independent predictors of resorption.¹⁵ This pattern suggests that the upper portion of the graft is simply less mechanically loaded, so the body naturally reclaims the bone. Despite the dramatic-sounding resorption numbers, recurrence rates stay low, which makes sense when you recall that the bone block is only one of three stabilizing mechanisms. The conjoined tendon sling and the capsular reinforcement keep working even as some bone melts away.

Nerve Injury Risks

Working near the coracoid puts two nerves at risk: the musculocutaneous nerve and the axillary nerve. Anatomic studies show the musculocutaneous nerve’s main trunk averages about 5 cm below the coracoid, but smaller branches can arise much closer, within about 2 cm in some specimens. In roughly a third of cadaveric specimens, the main nerve trunk entered the coracobrachialis muscle less than 5 cm below the coracoid, and when smaller branches were counted, that proportion jumped to over 90%.¹⁶ This anatomic variability is why nerve injuries, while uncommon, are not vanishingly rare.

A neuromonitoring study at Harvard found that about a quarter of subspecialty shoulder surgeons had observed musculocutaneous nerve palsies after the Latarjet, and 20% had observed axillary nerve palsies. When intraoperative neuromonitoring was used, alerts occurred most frequently during glenoid exposure and graft insertion. About one in five monitored patients had a clinically detectable nerve deficit after surgery, all involving the axillary nerve, and every one resolved fully within roughly one to six months.¹⁷ Arm position during surgery also matters. A neurophysiology study found that when the arm was placed in the at-risk position (abduction and external rotation) during surgery, 61% of patients showed nerve changes, compared with almost none in the neutral anatomical position.¹⁸ Reported overall complication rates for the Latarjet range from roughly 15% to 30%, a figure that includes everything from transient numbness to graft malposition, though severe complications like nonunion and screw breakage each occur in fewer than 5% of patients.¹⁹

The Subscapularis Split and Its Effect on Rotation

To reach the front of the glenoid, the surgeon must pass through the subscapularis muscle, the large internal-rotation muscle on the front of the shoulder blade. How the subscapularis is split affects both its long-term function and the patient’s range of motion. A biomechanical modeling study found that splitting the subscapularis at the midlevel or lower third significantly deformed the muscle fibers below the split, increasing the downward pull of those fibers, especially in the vulnerable overhead throwing position. A midlevel split also created a greater depressor effect on the subscapularis compared with upper-third or lower-third splits.²⁰

A prospective clinical comparison of mid-subscapularis versus upper-lower split techniques found that both approaches resulted in similar external rotation deficits compared with the opposite normal shoulder (roughly 9 to 14 degrees of loss depending on position). However, only the mid-split group showed a statistically significant improvement in external rotation deficit from baseline to final follow-up.²¹ The practical message: some loss of external rotation is essentially universal after the Latarjet, typically around 10 to 15 degrees, and the split location can influence recovery trajectories even if the final deficits look similar.

Return to Sport

For athletes, the Latarjet generally delivers strong return-to-play numbers, but the timeline is not as fast as many expect. A multicenter study of 65 athletes found that 55% failed to meet at least one objective return-to-play criterion at six months after surgery. Most of those failures were due to residual motion loss rather than persistent weakness.²² That finding argues against pushing athletes back at six months based purely on how they feel, because motion deficits measurable by testing persisted even when the shoulder subjectively felt stable.

Over the longer term, about 74% of young contact and limited-contact athletes returned to play, and of those, 88% returned at their prior competitive level. Among athletes who did not return, the most common reasons were aging out of their sport or fear of re-injury, not actual instability.²³ Early rehabilitation appears to accelerate recovery. A study of patients who began immediate self-guided rehabilitation after open Latarjet found that those who adhered to the protocol in the first month had significantly better mobility and less pain at three months, recovering essentially their preoperative range of motion for most directions of movement.²⁴

The Latarjet as a Revision After Failed Bankart Repair

One of the most common reasons for a Latarjet today is that a prior Bankart repair has failed. In that scenario, a study of 49 patients found that 86% achieved a stable shoulder after the Latarjet, with good functional scores and a low reoperation rate.²⁵ It works, but not as well as when the Latarjet is performed as the first-line operation. A direct comparison found that patients who had the Latarjet after a failed Bankart experienced about twice the rate of recurrent instability (roughly 21%) compared with primary Latarjet patients (about 9%).²⁶ A systematic review confirmed this pattern, finding that the revision Latarjet also carried higher rates of complications and further revisions than the primary Latarjet.²⁷

This evidence has shifted surgical thinking for high-risk shoulders. If a patient has significant bone loss, plays a collision sport, or has multiple risk factors for recurrence, there is a growing argument for going straight to the Latarjet rather than attempting a Bankart repair first and reserving the Latarjet as a backup. The revision Latarjet still works, but the tissue quality and anatomy are compromised by the prior surgery, making everything harder the second time around.

Adolescent and Skeletally Immature Patients

Teenagers and young athletes present a unique challenge because their growth plates may still be open, and their high activity levels put them at extreme risk for re-dislocation after any repair. Research on the Latarjet in adolescent athletes with multiple risk factors (prior surgeries, significant bone loss, off-track lesions) found return-to-sport rates around 94%, recurrent instability rates of about 17%, and no cases of nerve palsy or graft nonunion.²⁸ A study specifically looking at skeletally immature patients found that the Latarjet provided low recurrence rates with acceptable complications and, crucially, no significant disturbance to glenoid growth.²⁹ Young collision athletes separately showed high return-to-play rates with excellent functional outcomes and low recurrence at mid-term follow-up.³⁰ These results are reassuring for families worried about performing a bone-transfer procedure on a growing shoulder.

Cost-Effectiveness Compared With Bankart Repair

The Latarjet costs more upfront than an arthroscopic Bankart repair, mainly because it is a bigger operation with longer surgical time. But cost-effectiveness analyses that account for downstream failures, re-operations, and quality of life consistently favor the Latarjet over longer time horizons. A microsimulation model analyzing male patients with first-time dislocations and less than 10% glenoid bone loss found that the open Latarjet was the preferred cost-effective strategy in virtually all simulated patients over a ten-year period, producing both lower mean total costs and higher quality-adjusted life years than arthroscopic Bankart repair.³¹ A hospital-perspective analysis from a different healthcare system similarly found the Latarjet more cost-effective than Bankart repair in patients with intermediate instability severity scores.³² In one setting where implant costs were the primary driver, the Latarjet’s total cost came in at less than half that of Bankart with remplissage, largely because it uses simpler hardware.³³

The Bristow Variation

You may see the terms “Latarjet” and “Bristow” used interchangeably, but they are technically different procedures. In the Bristow technique, only the tip of the coracoid is transferred, and it is typically fixed with a single screw. In the Latarjet, a longer segment of the coracoid is transferred and fixed with two screws, providing a larger bone block and a more robust sling effect. A prospective randomized comparison of the two in high-demand athletes found no significant difference in functional outcome scores or return-to-sport rates, but the Latarjet group recovered passive external rotation and elevation somewhat faster in the first two months after surgery.³⁴ In current practice, the full Latarjet has largely superseded the Bristow in most centers because the larger graft addresses bigger bone defects more reliably, though both operations share the same fundamental concept that Latarjet first reported seven decades ago.³⁵