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Seediscussions,stats,andauthorprofilesforthispublicationat:https://www.researchgate.net/publication/262228541 Technicalguideandtipsontheall-arthroscopic Latarjetprocedure ArticleinKneeSurgerySportsTraumatologyArthroscopy·May2014 DOI:10.1007/s00167-014-3038-x·Source:PubMed CITATIONS READS 6 347 6authors,including: ClaudioRosso GonzaloSamitier UniversityofBasel HospitalGeneraldeVillalba 76PUBLICATIONS249CITATIONS 20PUBLICATIONS597CITATIONS SEEPROFILE SEEPROFILE GuillaumeDumont GregorSzöllösy UniversityofSouthCarolina UniversitätsspitalBasel 19PUBLICATIONS164CITATIONS 6PUBLICATIONS12CITATIONS SEEPROFILE Allin-textreferencesunderlinedinbluearelinkedtopublicationsonResearchGate, lettingyouaccessandreadthemimmediately. SEEPROFILE Availablefrom:ClaudioRosso Retrievedon:15August2016 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. References 1. Bhatia S, Frank RM, Ghodadra NS, Hsu AR, Romeo AA, Bach BR Jr, Boileau P, Provencher MT (2014) The outcomes and surgical techniques of the Latarjet procedure. Arthroscopy 30(2):227–235 2. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC (1992) Tensile properties of the inferior glenohumeral ligament. J Orthop Res 10(2):187–197 3. Boileau P, Mercier N, Old J (2010) Arthroscopic Bankart-Bristow-Latarjet (2B3) procedure: how to do it and tricks to make it easier and safe. Orthop Clin North Am 41(3):381–392 4. 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