The Trillat procedure: the man and the technique revisited through the lens of arthroscopy

Abstract

The Trillat procedure, initially described by Albert Trillat, is historically one of the first techniques for addressing recurrent anterior shoulder instability, incorporating fascinating biomechanical mechanisms. After lowering, medializing, and fixing the coracoid process to the glenoid neck, the subcoracoid space is reduced, the subscapularis lowered, and its line of pull changed, accentuating the function of the subscapularis as a humeral head depressor centering the glenohumeral joint. Furthermore, the conjoint tendon creates a 'seatbelt' effect, preventing anteroinferior humeral head dislocation. Even though contemporary preferences lean towards arthroscopic Bankart repair with optional remplissage, bone augmentation, and the Latarjet procedure, enduring surgical indications remain valid for the Trillat procedure, which offers joint preservation and superior outcomes in two distinct scenarios: (i) older patients with massive irreparable cuff tears and anterior recurrent instability with an intact subscapularis tendon regardless of the extent of glenoid bone loss; (ii) younger patients with instability associated shoulder joint capsule hyperlaxity without concomitant injuries (glenoid bone loss, large Hill-Sachs lesion). Complications associated with the Trillat procedure include recurrent anterior instability, potential overtightening of the coracoid, leading to pain and a significant reduction in range of motion, risk of subcoracoid impingement, and restriction of external rotation by up to 10°, a limitation that is generally well-tolerated. The Trillat procedure may be an effective alternative technique for specific indications and should remain part of the surgical armamentarium for addressing anterior shoulder instability.

Keywords: hyperlaxity; massive cuff tears; shoulder instability; trillat procedure.

Figure 1

Professor Albert Trillat.

Figure 2

Rationale of the Trillat procedure: the conjoint tendon is repositioned medially closer to the glenohumeral joint, while the nail lowers the subscapularis. This results in a ‘seatbelt’ effect, preventing anteroinferior dislocation of the humeral head, pushing it backwards in the vulnerable at-risk position (i.e. throwing position or abduction-external rotation (ABER)). Reproduced with permission from Boileau et al. (9).

Figure 3

The Trillat procedure involves performing a close-wedge osteotomy of the coracoid process, tilting it inferiorly, posteriorly, and medially. The coracoid is then secured to the glenoid neck using a nail (later replaced with a screw) positioned above the subscapularis. Additionally, the capsule and labrum are repositioned and fixed in place with the nail Reproduced with permission from Boileau et al. (9).

Figure 4

The evolution of the coracoid fixation in an all-arthroscopic Trillat procedure by Boileau and colleagues: (A) fixation with a cannulated screw, (B) suture anchor with cortical button, (C) cortical button Reproduced with permission from Boileau et al. (9).

Figure 5

The arthroscopic Trillat procedure with the use of suture buttons involves several key steps: (A) following the drilling of the coracoid and the glenoid, a suture is utilized to thread double buttons, with one button positioned against the posterior neck of the scapula and the other placed over the coracoid process; (B) a wedge osteotomy is performed at the base of the coracoid process, and a suture tensioner is employed after securing a sliding-locking knot (Nice knot) to tilt the coracoid process inferiorly, medially, and posteriorly Reproduced with permission from Boileau et al. (8).

Figure 6

Algorithm demonstrating the Trillat procedure’s role in managing recurrent anterior shoulder instability in elderly patients with rotator cuff tears.

Figure 7

Algorithm showing the Trillat procedure's role in managing recurrent anterior shoulder instability in young patients with an isolated joint capsule hyperlaxity.