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Technicalguideandtipsontheall-arthroscopic
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Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-3038-x
SHOULDER
Technical guide and tips on the all-arthroscopic Latarjet
procedure
Claudio Rosso • Vito Bongiorno • Gonzalo Samitier
Guillaume D. Dumont • Gregor Szöllösy •
Laurent Lafosse
•
Received: 1 January 2014 / Accepted: 22 April 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Shoulder dislocation and subsequent anterior
instability is a common problem in young athletes. The
arthroscopic Bankart repair was originally described by
Morgan et al. in 1987. The procedure has benefited from
many technical advancements over the past 25 years and
currently remains the most commonly utilized procedure in
the treatment of anterior glenohumeral instability without
glenoid bone loss. Capsulolabral repair alone may not be
sufficient for treatment of patients with poor capsular tissue
quality and significant bony defects. In the presence of
chronic anterior glenoid bony defects, a bony reconstruction should be considered. The treatment of anterior
shoulder instability with transfer of the coracoid and
attached conjoint tendon such as the Latarjet procedure has
provided reliable results. The arthroscopic Latarjet procedure was described in 2007 by the senior author, who has
now performed the procedure over 450 times. The initial
surgical technique has evolved considerably since its
introduction, and this article presents a comprehensive
Claudio Rosso and Vito Bongiorno have contributed equally to this
manuscript.
C. Rosso V. Bongiorno G. Samitier G. Szöllösy L. Lafosse
Department of Orthopaedic Surgery, ALPS Surgery Institute,
Clinique Générale, Annecy, France
C. Rosso (&)
Orthopaedic Department, University Hospital Basel and
University of Basel, Basel, Switzerland
e-mail: [email protected]
G. D. Dumont
Department of Orthopaedic Surgery and Sports Medicine,
University of South Carolina School of Medicine, Columbia, SC,
USA
update on this demanding but well-defined procedure. This
article reviews technical tips to help the surgeon perform
the surgery more smoothly, navigate through challenging
situations, and avoid potential complications. Level of
evidence V.
Keywords Arthroscopic Latarjet Instability Bony
defect Glenoid bone loss Arthroscopy Stabilization Shoulder dislocation
Introduction
Anterior–inferior shoulder dislocations are common in the
young population, making up 90 % of shoulder dislocations [13]. Multiple soft tissue lesions have been described
in association with anterior shoulder instability, including
the Bankart lesion, anterior labral periosteal sleeve avulsion (ALPSA), humeral avulsion of the glenohumeral ligament (HAGL) [2, 5], and bony Bankart. Injured
capsulolabral structures or bony glenoid fragments typically do not heal anatomically and can result in recurrent
instability manifested by repeat dislocations or subluxations [4, 5, 8]. In addition to soft tissue injury, instability
events often also lead to bony injuries of the humerus
(Hill–Sachs lesion, HAGL with bony flake) or glenoid
(bony Bankart fragment, or erosive bone loss) [4]. In
contrast, patients with generalized hyperlaxity may present
with severe ligament distension and little or no glenoid or
humerus bony defects after numerous recurrent instability
episodes [7].
In the treatment of anterior shoulder instability, two
main categories of surgical treatment exist. The most
common belief is that a soft tissue repair (Bankart) can lead
to restoration of native anatomy and thus restore sufficient
123
Knee Surg Sports Traumatol Arthrosc
stability to the shoulder. Alternatively, a bony reconstruction can restore stability to the shoulder by means of
augmentation of the deficient anterior glenoid. The
arthroscopic capsulolabral repair (Bankart repair) has been
extensively described and reported on in the past and is still
the preferred surgical treatment modality in most of Europe, Asia, and North America. However, the Bankart repair
relies on the presence of sufficient anterior glenoid bone
and soft tissue quality. Inferior outcomes have been
reported for this technique in the presence of glenoid bony
defects, HAGL lesions, and engaging Hill–Sachs lesions
[6, 14]. In cases of Bankart failure or any of the abovementioned lesions, the arthroscopic or open Latarjet procedure is a reliable and durable method of treating anterior
instability [1, 4, 11, 16].
The Latarjet procedure was described in 1954 [10]; the
coracoid is transferred through a horizontal split in the
subscapularis, with the attached conjoint tendon, and fixed
in a vertically oriented position on the anterior glenoid with
two bicortical screws. The conjoint tendon and inferior
portion of the subscapularis create a dynamic ‘‘sling
effect’’ with the shoulder in external rotation and abduction. This procedure is indicated for treatment of both bony
defects and capsular–ligamentous insufficiency [12].
Recently, a biomechanical study showed that the soft tissue
sling effect is the most significant contributor to stabilizing
the shoulder [15]. The Latarjet procedure relies on the
biomechanics of the so-called triple-block effect [3]. First,
the deficient anterior bony glenoid is augmented by the
coracoid graft. Second, the passage of the coracoid and
conjoint tendon through a split in the subscapularis creates
a dynamic sling effect that prevents anterior translation of
the humeral head. Finally, repair of the capsule/anterior
band of the inferior glenohumeral ligament at the stump of
the coracoacromial ligament on the coracoid graft retensions the antero-inferior capsule. The arthroscopic Latarjet
technique was first performed in late 2003 and its technique
published in 2007 [9]. Since December 2003, over 450
arthroscopic Latarjet procedures have been performed by
the senior author. The technique has constantly evolved
and been refined. Although it remains a challenging procedure, various modifications have addressed some of its
technical challenges and improved its reproducibility.
In this manuscript, the technique will be reviewed in
detail, noting modifications since the original description.
Technical tips will be discussed to improve the surgeon’s
ability to successfully and safely perform the procedure. In
order to make the steps of this technique more reproducible, the authors have now described the procedure in 10
steps (vs. the previously published 5 steps) [9]. This procedure has proven to be a reliable and reproducible technique in the hands of skilled shoulder surgeons. The
arthroscopic Latarjet procedure does allow for conversion
123
to open technique at any stage of the surgery, which may
be necessary during a surgeon’s initial attempts at performing it.
Surgical technique
Although the technique does include arthroscopic portions,
the majority of the coracoid preparation is done extra-articularly and should be referred to as endoscopic. Patients
receive a combination of general anaesthesia and an interscalene regional block. Cerebral blood flow is monitored
using ultrasound for optimal patient safety. The patient is
placed in the beach chair position with the arm free to
allow movement of the arm during different stages of the
procedure and without any traction to avoid scapula protraction. The surgical field must be draped wide, including
the shoulder but also a major portion of the hemithorax to
permit access through the more medial portals but also to
control swelling (Fig. 1).
The presence of one to two surgical assistants and a
surgical scrub nurse familiar with the instrumentation and
the different stages of the procedure is recommended. The
anaesthesia team provides complete muscular relaxation
and maintains a low, but safe, systemic blood pressure to
improve visualization and thus facilitate the procedure.
Meticulous haemostasis during this largely extra-articular
endoscopic procedure is provided from endoscopic surgical
haemostasis using a radio frequency ablation and electrocautery device and by maintaining a balance between the
systemic blood pressure and the arthroscopic pump pressure. Arthroscopic pump pressure is kept low to allow good
visualization, while avoiding excessive swelling of the
shoulder and hemithorax. The balance of the arthroscopic
pump pressure and the patient’s systemic blood pressure is
crucial. The relationship between these two parameters is
critical even in less demanding arthroscopic procedures
and becomes paramount in this more challenging procedure, which requires excellent visualization. In cases of left
shoulders when excessive swelling is noted, for example in
a lengthier procedure or one requiring increased arthroscopic pump pressure, cardiac monitoring is advised.
Portal placement
Seven portals are used for this procedure (Fig. 1): The (A)portal is the posterior soft spot portal and is used for initial
visualization. The (D)-portal is the antero-lateral portal
positioned adjacent to the antero-lateral acromial angle. It
provides the ability to visualize in line with the superior
border of the subscapularis and is also used for instrumentation during coracoid process preparation. The (E)-
Knee Surg Sports Traumatol Arthrosc
portal is the classic antero-inferior portal commonly used
for arthroscopic Bankart repair. It allows intraarticular
access through the interval rotator. The (H)-portal is the
superior portal directly superior to the coracoid and is used
for coracoid preparation and to create the coracoid osteotomy. The (I)-portal is an axillary portal in line with the
coracoid and is used mostly for visualization during coracoid preparation. The (J)-portal is along an arc mid-way
between the (D)- and (I)-portals and is used for visualization during the subscapularis split as well as instrumentation during various stages. The (M)-portal (Fig. 1) is the
most unusual to most arthroscopic surgeons because of its
far medial placement. This portal is safe if the surgeon
remains anterior to the pectoralis minor while creating it.
The (M)-portal is initially used for preparation of the
medial coracoid, to perform the subscapularis split and to
introduce the double-barrel cannula from the Latarjet kit
(DePuy Synthes Mitek, Raynham, MA, USA), which is
used for coracoid handling and final fixation. Whatever
portal is used, the proximity of the plexus to the coracoid
process creates a potential source of risk to structures of the
brachial plexus: the musculocutaneous nerve, which travels
into the conjoint tendon and most importantly the axillary
nerve, which crosses immediately inferior to the subscapularis muscle. Figure 3b shows the musculocutaneous
nerve; Fig. 6a shows the proximity to the axillary nerve.
Surgical stages
In order to facilitate its reproducibility, the initial 5-step
technique is now described in 10 surgical stages.
First stage: joint evaluation
Pertinent anatomic landmarks (acromion, clavicle, coracoid process), skin portals, and the glenohumeral joint axis
are marked (Fig. 1). One assistant initially provides forward traction of the arm. The entry point for the posterior
(A)-portal is confirmed with a needle to ensure it is parallel
with the glenoid, allowing the antero-posterior axis of the
joint to be identified and drawn on the skin. A thorough
joint evaluation is performed, including the glenoid and
humeral chondral surfaces, the rotator cuff, glenoid labrum,
and glenoid or humeral bony defects. Soft tissue injuries,
including anterior and posterior labral lesions, ALPSA
lesions, and HAGL lesions and SLAP tear, are noted.
Posterior labral tears can be repaired prior to performing
the arthroscopic Latarjet procedure, while lesions including
the ALPSA, HAGL, anterior Bankart, or bony Bankart are
included in the indications for arthroscopic Latarjet and
need not be specifically addressed. The thickness and
quality of capsule and ligaments is often compromised,
Fig. 1 The most important landmarks including the anterior portals
are marked on the skin. Note the medial placement of the (M)-portal
at the height of the axillary fold and in line with the glenoid version
precluding adequate soft tissue repair. The presence and
size of a Hill–Sachs lesion is assessed. The extent of glenoid bone loss can be difficult to evaluate initially from the
posterior (A)-portal prior to resection of the scarred,
injured capsulolabral tissues on the anterior glenoid. Glenoid defects are more effectively assessed later from the
(E)-portal after resection of the anterior capsule and labrum. Engagement of the Hill–Sachs lesion with the anterior
glenoid is assessed by abduction and external rotation of
the shoulder. This step is identical to previous reports.
In the case of previous anterior Bankart repairs, the
capsuloligamentous complex is removed including the
sutures as outlined in stage two of the surgical steps. In the
case of metal anchors, it is tried to extract them. If this is
not possible, their location should be evaluated with respect
to the future coracoid graft placement.
Second stage: intraarticular joint preparation
The anterior labrum and capsule from the 2 to 5 o’clock
position, along with the attached middle glenohumeral ligament (MGHL) and anterior band of the inferior glenohumeral
ligament (IGHL), are resected using radio frequency ablation
through the (E)-portal. The resection should expose the
posterior aspect of the subscapularis muscle (Fig. 2). The 2
and 5 o’clock positions are marked for precise graft positioning near the end of the procedure. With the rotator interval
then widely open, a needle is inserted parallel to the superior
edge of the subscapularis to orient the (D)-portal. This step is
identical to previous reports.
Third stage: coracoid preparation
The antero-lateral (D)-portal is now used for instrumentation. The coracoacromial (CA) ligament is detached from
123
Knee Surg Sports Traumatol Arthrosc
Fig. 2 Part of stage 2: Marking of the 2 o’clock position before
capsulectomy. View from the (A)-portal
the coracoid, and the lateral conjoint tendon released from
the deltopectoral fascia (Fig. 3a). Care should be taken not
to damage the conjoint tendon.
The arthroscope is then moved into the (D)-portal,
allowing the (I)- and (J)-portals to be created under direct
visualization using two spinal needles. The medial (M)portal is created carefully. One of two methods can be
utilized to create the (M)-portal: a switching stick can be
placed in the posterior (A)-portal, through the glenohumeral joint, to identify the orientation of the glenoid at its
inferior level (where the subscapularis split level will be) or
by direct visualization with the arthroscope facing medially
and looking at the interval anterior to the pectoralis minor
tendon and posterior to the pectoralis major muscle. The
(M)-portal can also be located at the intersection of a
horizontal line at the level of the axillary fold and an antero-posterior line overlying the plane of the glenoid.
With the arthroscope in the (I)-portal facing the tip of
the coracoid, the medial aspect of the coracoid process can
be accessed with instrumentation through the (M)-portal.
The pectoralis minor is detached using radio frequency
ablation (RFA) (Fig. 3b). It is important to orientate the
RFA to the bone to avoid damage of the brachial plexus. A
switching stick is placed in the (D)-portal to lift up the
anterior deltoid, thus creating additional working space and
Fig. 3 Stage 3: coracoid
preparation. a shows the lateral
view from the (D)-portal while
b shows the (I)-portal view
before pectoralis minor
detachment. Note the
musculocutaneous nerve (MCN)
in the background of b
123
improved visualization. The medial aspect of the conjoint
tendon is dissected from adjacent soft tissues using a
combination of blunt dissection and intermittent, cautious
use of RFA to avoid injury to the musculocutaneous nerve,
which lies in close proximity inferomedial to the conjoint
tendon.
Soft tissues are cleared from the superior aspect of the
coracoid process, to its base as defined by visualization of
the coracoclavicular ligaments. Coagulation of a branch of
the cephalic vein during this step can help avoid potential
bleeding when creating the superior (H)-portal. Finally, the
undersurface of the coracoid is cleared of soft tissues.
Certain points are emphasized for this stage, which were
not found in previous reports, including emphasis on lateral
orientation of the RFA during detachment of the pectoralis
minor tendon from the coracoid and consistent coagulation
of the branch of the cephalic vein superiorly.
Fourth stage: coracoid harvesting
The shoulder is positioned in retropulsion without arm
traction, with the arthroscope still in the (I)-portal. The (H)portal is localized with a needle and then created to
accommodate the double coracoid drill guide. The tip of
the coracoid is identified with a long K-wire to avoid
excessively distal placement of the drill guide.
Two 1.5-mm K-wires are inserted using the coracoid
drill guide, with the most distal wire approximately 5 mm
proximally to the tip of the coracoid. The wires should be
placed between the middle and medial third of the width of
the coracoid process (2/3 lateral and 1/3 medial) to avoid
lateral screw placement. The drill guide is removed and the
position of the wires is evaluated on the superior and
inferior aspects of the coracoid. The holes are then drilled
using the cannulated coracoid step drill bit and then tapped.
A ‘‘Top Hat’’ washer is inserted into each hole with the
K-wire still in place as a guide (Fig. 4). A circumferential
stress riser is created at the base of the coracoid using a 5.5mm burr from the medial (M)-portal (2–6 o’clock), the
lateral (D)-portal (6–11 o’clock), and the superior side (H)-
Knee Surg Sports Traumatol Arthrosc
portal (11–2 o’clock), keeping one K-wire in the proximal
coracoid hole as a point of reference for the stress riser.
Care is taken not to burr into the drilled whole. Once the
cortical bone at the coracoid base is burred circumferentially, the osteotomy is performed from the (H)-portal using
the curved osteotome (Fig. 5). The coracoid is mobilized
medially and inferiorly to fully expose the anterior subscapularis as it is done in open surgery. This stage has only
been slightly modified: the burr is now introduced first in
the (M), (D), and then the (H)-portals in order to create a
symmetrical stress riser. The wire (CHIA) is not used
anymore as the osteotomized graft can easily be found and
retrieved without the wire.
Fifth stage: anterior subscapularis preparation and split
The anterior bursa of the subscapularis is removed with a
shaver to visualize the entire subscapularis muscle, and the
anterior humeral circumflex artery and its two veins (three
sisters), which mark the inferior border of the subscapularis. The medial limit is delineated by the axillary nerve,
which should be visualized with caution. While viewing
through the (J)-portal, the split is now performed at the
junction of the inferior 1/3 and superior 2/3 of the tendon,
using the radio frequency ablation device via the (M)portal: move laterally towards the insertion into the lesser
tuberosity (using external and internal rotation of the arm
to better view and expose the muscle and tendon, Fig. 6a).
The axillary nerve is at potential risk of injury during this
step. It is crucial to visualize the nerve during this step.
Special attention must be paid to avoid approaching the
nerve with the radio frequency ablation device. The split is
completed by placing the dull large trocar through it and
onto the glenoid, and externally rotating the shoulder with
the arm adducted (Fig. 6b). A switching stick from the (A)portal in line with the dull trochar is used to lift the superior
2/3 of the tendon through the split (Fig. 6b). This stage has
been modified to its original description: the location of the
split was previously identified by placing a switching stick
through the posterior (A)-portal, piercing it through the
subscapularis and using it to retract the brachial plexus
medially while the split was performed through the (J)- and
(I)-portals. The split is now performed under direct visualization from the (M)-portal. Care is taken to orient the
electrocautery laterally during this step to protect the
axillary nerve.
Sixth stage: glenoid exposure and preparation
The bony bed of the glenoid is now prepared from anteriorly [arthroscope in (I)-portal, instruments in (E)-portal]
using radio frequency ablation and a burr. The bony bed
should show capillary bleeding and have a flat surface. No
change has been implemented in this stage.
Seventh stage: coracoid retrieval
Fig. 4 Stage 4: placed ‘‘Top Hats’’ in the coracoid. Note the posterior
K-wire which is maintained during the performance of the stress riser.
View from the (I)-portal
Fig. 5 Stage 4: coracoid osteotomy with the curved osteotome (white
arrow). View from the (I)-portal
The double cannula, with its plastic blue trocars, is inserted
via the (M)-portal (Fig. 7a). The two plastic trocars are
removed together to minimize loss of pressure by fluid loss,
and the long 3.5-mm coracoid holding screws are inserted
and used to engage the previously drilled holes and secure
the coracoid to the double cannula (Fig. 7b). The coracoid
can now be completely mobilized and any remaining soft
tissue tethers released.
The inferior aspect of the graft is further decorticated
with a burr to ensure a flat surface to match the anterior
glenoid neck. A surgical assistant holds the arthroscope
in (I)-portal, while the surgeon moves the graft using the
double cannula over the stationary 5.5-mm burr for better
control, with no suction through the burr (see Technical
Tips #6). This step has changed from its original
description. The coracoid graft is being retrieved using
the double cannula and the long 3.5-mm coracoid holding
screws. The double cannula and attached graft are now
123
Knee Surg Sports Traumatol Arthrosc
Fig. 6 Stage 5: subscapularis
tendon split. a depicts the
medial extension and the
proximity to the axillary nerve
while b shows the condition
after the split. The white arrow
shows the switching stick with
the blunt trocar in the
background. Cameral view is
from (J)-portal
Fig. 7 Stage 7: coracoid
retrieval. The coracoid is
retrieved with the DoubleBarrel Cannula and the blue
pins inserted (a). The coracoid
screws are then inserted into the
‘‘Top Hat’’ washers
Fig. 8 Stage 8: joystick and graft placement. The white arrow marks the drilled coracoid base. The black arrow shows the switching stick
inserted from the (A)-portal
moved, while the burr is held still, facilitating burring of
the coracoid.
Eighth stage: coracoid placement
Before coracoid fixation, the scapula often has to be
retracted posteriorly as the thorax can get in the way of the
(M)-portal when trying to be in line with the glenoid plane.
This can be done by screwing a 5.5-mm tap into the coracoid osteotomy site through the (J)-portal and using it as a
joy stick to retract the scapula. A drill is used prior to
inserting the tap to avoid coracoid base fracture (Fig. 8a).
123
The arm is then placed in internal rotation and slight
forward flexion in order to relax the conjoint tendon and
open the subscapularis split, thus facilitating correct
placement of the graft.
The double cannula is then used to manipulate the graft
through the subscapularis split and into position on the
glenoid. The switching stick from the posterior (A)-portal
is used to open the split allowing passage of the graft
(Fig. 8b). The switching stick is also used to ensure there is
no prominence of the graft with respect to the glenoid rim.
Optimal positioning is about 1–2 mm medially to the cartilage surface ensuring bony congruence.
Knee Surg Sports Traumatol Arthrosc
With the graft in place and aligned with the previously
placed marks at the 2 and 5 o’clock position, the inferior
K-wire is inserted through the long cannulated screw: it is
only advanced approx. 2 mm into the glenoid in order to (1)
ensure bony contact and (2) being able to rotate around it to
optimize graft placement. Once the desired position is
achieved, both K-wires are advanced through the graft and
the glenoid (Fig. 8c), perforating the skin of the shoulder
posteriorly. The K-wires are firmly held posteriorly with
clamps to ensure they remain in place during drilling for the
cannulated screws and graft fixation. Looking from above
the shoulder, the two K-wires should diverge from the
switching stick (alpha angle) by 10° (two fingers between
the switching stick and the K-wires) and be parallel to each
other in order to avoid divergent screws. New to this step is
the initial advancement of the inferior K-wire of approximately 2 mm into the glenoid bone in order to create a
fulcrum to still allow the ability to reorient the graft.
Ninth stage: coracoid fixation
The inferior hole is drilled first to ensure good positioning
of the screw in bone. The inferior (alpha) cannulated
holding screw is removed and the hole drilled with a 3.2mm cannulated drill. Screw length measurement is taken off
the drill bit when the posterior glenoid cortex is perforated
(usually 26–32 mm). The inferior screw is then inserted and
the process is repeated for the superior screw (Fig. 9a). The
screws are then alternatively tightened to ensure symmetrical compression of the graft onto the glenoid neck
(Fig. 9b). Over-tightening may fracture or medialize the
graft and should be avoided. This stage has not been
changed, but care is taken not to have an excessively long
screw all while ensuring posterior cortical purchase.
Tenth and final stage: dynamic final joint evaluation
The graft position is checked from anterior (I)- and (J)portals and the posterior (A)-portal. It is ideally positioned
between 2 and 5 o’clock. The K-wires are then removed
posteriorly prior to removal of the cannula anteriorly. This
ensures that the K-wires do not damage the brachial plexus
during removal or accidentally pull out the screw if the
wire is bent. Mild graft prominence can be corrected with
the burr. The surgeon should verify that the screw heads are
directed away from the humeral head (this is dependent on
accurate wire guide placement and drilling of the coracoid
process during the harvesting phase, See Technical Tips
#3). The sling effect can be immediately observed with the
arm in abduction and external rotation (Fig. 10). This stage
has not been changed as graft placement is still visualized
from different portals in order to ensure a good placement.
Technical tips
1. Correct placement of the graft is crucial: Therefore,
after initial joint assessment, the graft position on the
glenoid rim is marked using the radio frequency ablation
device (a burr can also be used). This must be done with
the arthroscope in the (A)-portal keeping the camera parallel to the glenoid and oriented downward in order to have
a view with minimal optical distortion. If the graft position
is marked later in the operation through a superior or antero-lateral portal, the angle of vision of the 30° arthroscope makes it more difficult to accurately identify correct
positioning on the glenoid. Be sure to create a clearly
visible mark as it can wash off during the procedure and
thus be difficult to find when it is time to place the graft.
2. (M)-Portal placement: An inadequately placed (M)portal will make the subscapularis split and correct graft
placement very difficult. Usually, when misplaced, the
(M)-portal is too lateral. It is definitely safe to go medial as
long as you stay anterior to the conjoined tendon and the
pectoralis minor to avoid brachial plexus injury. As stated
above, there are two ways of determining the (M)-portal.
When commencing to perform this procedure, the switching stick option is preferred (switching stick through the
(A)-portal and aligning it with the glenoid plane). Looking
from above and aside the shoulder, the switching stick
gives the precise direction and height in which the (M)portal should be placed on the thorax. Make sure not to
Fig. 9 Stage 9: graft fixation.
The inferior screw is inserted
first. The white arrow marks the
graft
123
Knee Surg Sports Traumatol Arthrosc
Fig. 10 Stage 10: final dynamic joint evaluation. Depicted is the
sling effect of the subscapularis tendon and muscle (SSC)
advance the switching stick anteriorly through the subscapular muscle as one can damage the brachial plexus. In
women, the (M)-portal can be placed more laterally in the
breast fold since skin and subcutaneous tissue are often
more elastic, avoiding uncomfortable scars or possible
damage to breast implants.
3. Avoid a proud graft: It is important to not have a
proud coracoid graft or proud screws that can damage the
humeral head. Therefore, when inserting the K-wires on
the coracoid, the authors take care to place them at the
junction of the medial 1/3 and lateral 2/3 of the bone so that
later the screws will be far medial to the glenoid articular
surface and at a safe distance from the humeral head.
4. Coracoid preparation: This step is time-consuming
and requires special attention at different phases. When
detaching the pectoralis minor tendon, mind the musculocutaneous nerve, which is distally and slightly medial to the
tip of the coracoid. Before the creation of the circumferential stress riser around the coracoid, adequate liberation of
the coracoid from its surrounding soft tissue must be performed especially along the inferior and medial aspects in
order not to have any excessive bleeding after the osteotomy. The inferior part of the coracoid is especially a site of
potential bleeding. A switching stick through the (D)-portal
can lift the deltoid muscle and help to create more space.
One must also take care to liberate the conjoint tendon well
from its adhering tissue on the lateral and anterior side
creating a well-mobilized graft. Care must be taken not to
harm the musculocutaneous nerve when liberating the
conjoined tendon medially. The inferior stress riser has to
be extended proximally into the body of the scapula to not
only avoid any remaining spike after the osteotomy, but also
to gain extra length of the coracoid graft.
5. Subscapularis split: (Fig. 6) The split must be made
at the junction of the lower 1/3 and upper 2/3 of the muscle
in order not to restrict external rotation. The authors prefer
the option with direct anterior visualization as described
above. The surgeon must be cautious during this stage to
123
avoid harming the axillary nerve. The axillary nerve should
be visualized initially and the surgeon should be aware of
its position at all times when performing the split. Additionally, the radio frequency ablation device should always
be directed laterally to avoid damage the axillary nerve.
6. Graft radius adjustment: After the graft is harvested,
the authors keep it on the guide and use the burr to adjust
the inferior radius of the graft to make it flat/coplanar with
the glenoid neck and to address any remaining irregularities. It is safer to the surrounding neurovascular structures
and technically simpler to move the graft with the attached
double cannula while keeping the burr still than to move
the burr on the graft. Suction on the burr should be off to
avoid soft tissue injuries. The vicinity to the brachial
plexus and its branches should always be appreciated.
7. Scapular retropulsion: In order to properly position
the graft and place the screws parallel to the glenoid plane
(thus ensuring the screw heads are not proud), it is helpful
to retract the scapula. If this cannot be achieved by simple
retropulsion, the authors screw an anchor 5.5-mm tap
through the (J)-portal into the base of the coracoid at the
osteotomy site (Fig. 8a). This is used as a joystick to lever
and retract the scapula and facilitate correct screw placement. Traction on the arm should be avoided when performing the arthroscopic Latarjet procedure as this will pull
forward the scapula and inevitably increase the angle
between glenoid plane and the screws.
8. Graft placement: The authors use a switching stick
through the (A)-portal along the glenoid plane to guide
accurate placement of the graft in the medial–lateral plane.
A lateral graft will hit against the tip of the switching stick.
Placement can easily be corrected by using the switching
stick to push the graft more medially. It is recommended to
temporarily advance the inferior wire just 2 mm in order to
stabilize the graft in and verify its position. This allows the
adjustment of the direction and rotation to define the best
position before the inferior wire is completely advanced.
This manipulation allows medial adjustment without losing
the correct height.
9. To ensure that the graft is not too low: The inferior
screw hole should be drilled first (Fig. 9a). This allows the
surgeon to feel whether the drill is within the glenoid bone.
A too inferiorly placed graft may cause recurrence of
anterior dislocation above the graft.
10. Reasons for a limitation of postoperative external
rotation: If the extent of subscapularis split was not medial
enough, external rotation can be limited. Maximal external
rotation of the shoulder, with the arm at the side, while a
switching stick is held through the subscapularis split will
avoid this limitation. Also, if the graft is positioned too
superior on the glenoid, the conjoint tendon is over tensioned. Post-operative arthrofibrosis can also lead to
stiffness.
Knee Surg Sports Traumatol Arthrosc
Conclusion
The Arthroscopic Latarjet Procedure is a safe, reliable, and
reproducible procedure in the hands of experienced and
skilled arthroscopic surgeons. The technique is constantly
evolving with fine tuning of its steps and modern instrumentation that allows for a logical sequence of steps and
avoidance of errors. The authors recommend heeding the
above technical tips to safely and reproducibly perform the
procedure within a reasonable operative time while
achieving good results. Converting to the open technique
can be accomplished at any of the above stages of the
procedure.
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