الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Shoulder instability is the inability to maintain the humeral head centered in
the glenoid fossa. It is a pathologic condition of excessive translation of the
humeral head on the glenoid during shoulder motion that manifests in pain and
clinical symptoms of subluxation (symptomatic instability without complete
dislocation of the articular surfaces ) or dislocation.( complete separation of the
articular surfaces, often requiring a reduction maneuver to restore joint
alignment).
Anterior shoulder instability represents ( 94 - 98 % ) of shoulder
instabilities. The management of anterior shoulder dislocation has thus evolved
with time and depends on variables such as patient age, sports participation, and
physical and radiological characteristics. The goal, whether nonoperative
treatment or surgical stabilization is selected, is to achieve a stable functional
shoulder, with full painless range of motion.
Chronic recurrent anterior instability can often lead to clinically significant
glenoid bone defect and vise versa. Bone loss can be determined with CT scans
especially the three-dimensional computed tomography scan which is considered
the gold standard for glenoid imaging because it allows digital subtraction of the
humeral head from images of the glenohumeral complex reconstructions. In
addition, the amount of glenoid bone loss can be verified arthroscopically by
measuring the distance from the glenoid rim to the bare spot thereby assisting
the surgeon in identifying an inverted pear glenoid, and confirming substantial
bone loss and the likely failure of an isolated soft tissue repair .
Hill–Sachs lesions (humeral bone loss )can occur after anterior dislocations.
Summary
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If large enough, these lesions can engage the anterior glenoid rim, leading to
instability secondary to loss of congruence of the glenohumeral articulation, in
other words, allowing the humeral head to “fall off” the glenoid as the defect
engages the anterior rim of the glenoid (engaging Hill–Sachs). For the purpose of
evaluating the size of the Hill-Sachs lesion together with the size of the glenoid, a
new concept has been introduced: the glenoid track. The glenoid track is a
contact zone of the glenoid on the humeral head with the arm at the end range of
motion, e.g., in various degrees of elevation with the arm in maximum external
rotation and maximum horizontal extension. This end range of motion is critical
for anterior dislocation because the anterior soft tissue structures become tight
and prevent the anterior translation of the humeral head in this position. The
width of the glenoid was measured and it was found that with the arm at 90° of
abduction, the medial margin of the glenoid track was located at the distance
equivalent to 84% of the glenoid width from the medial margin of the footprint of
the rotator cuff. By the use of this value we can assess an On-Track/Off-Track
Hill-Sachs lesion by means of a CT scan or arthroscopiclly.
Many different procedures have been described for anterior shoulder
insitability like capsulolabral reconstructions and coracoid transfer procedures.
In 1954, Latarjet described a coracoid bone block technique to prevent anterior
dislocation. Laterjet procedure has been modified extensively but
modifications usually involve transfer of the distal tip of the coracoid
process with the attached conjoined tendon to the anterior rim of the glenoid
through a split or division of the subscapularis muscle-tendon unit fixing it
with screws or miniplates through open approach or arthroscopiclly, these
techniques are explained in our review . After sugery ,a rehabilitation program
with four phases is done for about 20 weeks before the return to full recreational
activities.
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Latarjet procedure has some complications related to the graft position,graft
fracture,graft non union or osteolysis and others related to the implant like screw
loosening, prominence in the joint, or breakage. Also there are some
complications like post operative haematoma ,infection,arthritis and instability
( less than 2%).. Most reported complications associated with this procedure can
be avoided with proper patient selection and a systematic surgical technique.
The open Latarjet procedure is a safe and reliable technique for treating
recurrent anterior instability. It is particularly useful in the setting of anterior
instability with associated glenoid bone loss or a large Hill-Sachs lesion, or both .
The Latarjet procedure successfully restores glenohumeral stability (recurrence
rate of less than 2%), does not limit external rotation, mange the patients with
complex soft tissue injuries especially if the initial stabilizing procedure fails.
The arthroscopic Latarjet is a reliable but difficult technique, with a steep
learning curve. An excellent knowledge of the anatomy of this area and of the
instrumentation is mandatory as we can open the shoulder at any stage in case ofproblems or to aid visualization. The ultimate goal of the surgery is a
successful coracoid transfer with sound healing and stability restored.