Abstract
Background:
The Latarjet procedure is a common treatment of anterior shoulder instability associated with glenoid bone loss. Advanced arthroscopic technique provided a safe cortical-button fixation of the coracoid process transferred onto the glenoid neck combined with a Bankart repair.
Indications:
This is an 18-year old woman, complaining of recurrent right shoulder dislocation and subluxation, which made her unable to play handball at competitive level. Physical examination confirmed anterior apprehension without hyperlaxity. Computed tomography (CT) scan identified a Hill-Sachs lesion and a glenoid bone loss of 11%. Instability Severity Index Score was calculated at 7 points.
Technique Description:
Patient was placed in a beach-chair position under general anesthesia combined with an interscalene nerve block. A 70° scope and specifically designed instruments were used. The technique required 5 steps: (1) coracoid preparation: pectoralis minor and coracoacromial ligament release, flattening of the undersurface, positioning of the peg button, and osteotomy of the coracoid; (2) glenoid preparation: flattening of the neck of the scapula, insertion of 2 anchors (3 and 6 o’clock), and glenoid drilling with a specific guide; (3) subscapularis split: use of an intra-articular and extra-articular spreader splitting the subscapularis muscle at the level of the glenoid wire (shoulder in neutral rotation) and opening of a “safe window”; (4) fixation step: transfer of the coracoid through the subscapularis split with shuttle suture and permanent fixation with a posterior cortical button (compression controlled at 100 Newtons with a dynamometer); and (5) Bankart repair. The shoulder was protected in a sling 4 weeks, and external rotation recovery was allowed at 6 weeks.
Results:
Favorable outcomes were reported at 6 months of follow-up without any complication. Full range of motion with limited external rotation deficit was obtained and a negative apprehension test. Radiologic assessment confirmed graft incorporation at 6 months, allowing return to overhead sports at a competitive level.
Discussion/Conclusion:
Arthroscopic cortical-button Latarjet procedure is a safe option to treat anterior shoulder instability associated with glenoid bone loss in patient with high demand sports. The procedure is safe and combine bone graft and Bankart repair. Using a cortical button fixation avoids screw related complications.
This is a visual representation of the abstract.
Keywords
Video Transcript
My name is Nicolas Bonnevialle and I present to you an innovation arthroscopic technique of Latarjet procedure used to treat anterior shoulder instability.
Here are my disclosures.
The literature explored for a long time the limits of Bankart repair, and this recent study of Dekker highlighted that the rate of failure ranged from 6% to more than 20% at 5 years.
Bad prognostic factors were an age under 20 years old, a long duration of symptoms before surgery, and a glenoid bone loss above 15% of the glenoid surface.
That is why Latarjet procedure was proposed as a primary surgery for a long time. Biomechanically, the coracoid transfer acts in a triple-locking effect. First, bony effect with the anterior inferior glenoid graft. Second, a sling effect because the conjoint tendon entraps the lower part of the subscapularis muscle. Finally, a bump effect provided the capsule and the labrum were reattached including the stump of the acromio-clavicular ligament.
The success of the Latarjet procedure in terms of stability reaches 95% but is darkened of 7-to-10% of complications related to the screw fixation. In this context, Pascal Boileau was the first to describe an arthroscopic cortical button Latarjet procedure in order to improve accurateness of graft position, to avoid specific screw complications, and to be less aggressive with soft tissue. Boileau’s arthroscopic technique requires specific devices including a coracoid guide to center a peg button, and 2 mechanical spreaders to perform safely the subscapularis split.
Current indications are based on the Instability Severity Index Score (ISIS) and radiographic analysis. Therefore, an arthroscopic Latarjet procedure is indicated in case of glenoid or bipolar bone loss when the ISIS is above 2 points.
The aim of this video is to show step-by-step how the cortical button Latarjet procedure is a safe and reliable option and to help surgeons to be proficient in performing this procedure.
This is the case of an 18-year-old woman, complaining of anterior shoulder instability with dislocation and subluxation of her right dominant shoulder when playing handball. Clinical examination has shown a positive apprehension test and a positive relocation test in abduction full external rotation. She had no hyperlaxity. ISIS is calculated at 7 points. The glenoid bone loss is measured at more than 10% of glenoid diameter.
General anesthesia, interscalene block and beach chair position are used in all patients. The arm is placed in a movable support without traction. We first draw our anatomical landmarks and 5 anterior specific portals are required:
The south portal is in the axillary fold.
The east portal (passing obliquely through the pectoralis major muscle) is 3 fingerbreadths medial to the tip of the coracoid.
The north portal is 1 fingerbreadth medial and proximal.
The northwest it is located at the anterolateral corner of the acromion.
The west is in between south and northwest.
We use a 70° scope, as it offers superior visualization of the anterior neck of the scapula introduced through a standard posterior portal.
Step 1 is coracoid preparation.
A spinal needle is used to make sure that northwest is at the right spot and an electrocautery open the rotator interval to identify the coracoid process. The scope is pushed through the rotator interval. This allows to release the conjoint tendon and the fascia. Then, the coracoacromial ligament is released from the lateral border and the undersurface of the coracoid is cleaned.
The north portal is then created with the help of the spinal needle allowing the pectoralis minor release from the medial border of the coracoid.
The undersurface of the coracoid process is abraded with the motorized rasp (introduced through the northwest portal) to create a flat surface on a 1.5 cm length.
The coracoid guide is introduced to grasp the coracoid perpendicular to its surface. This means that it must be tilted in 45° medially more or less in front of the face of the patient.
A first male/female K-wire is advanced through the guide and drilled until it exits the inferior surface of the coracoid. The male is retrieved and a polydioxanone (PDS) suture is pushed. Through the northwest portal, the suture is retrieved and the peg button (with the 4-strand sutures) is pulled thanks to the relay of the PDS suture.
The coracoid is then osteotomized with a motorized saw perpendicular to the main axis.
Step 2 is glenoid preparation.
The anterior labrum is completely detached and preserved to visualize the glenoid bone defect. A stick helps to get an access deeper, and a suture is passed through the labrum at the 5 o’clock position, allowing the labrum to be pulled away from the glenoid neck. The glenoid neck is abraded with the same motorized rasp in order to obtain a flat refreshed surface. Two glenoid anchors are inserted at 3 and 6 o’clock. The PDS suture is used to shuttle the 3 o’ clock anchor in order to shift the capsule and repair the labrum later on.
The scope is then transferred to the northwest portal, while a short half-pipe cannula is placed through the posterior portal. The glenoid drill guide is introduced inside the joint along the cannula. The guide is placed flush to the glenoid surface, at the 5 o’clock position and locked. The male/female is drilled from posterior to anterior through the guide under the vision of the scope. The glenoid guide is removed, leaving the female guide in place. The subscapularis spreader is inserted along the canula into the joint and pushed through the subscapularis on 1.5 cm.
Step 3 is subscapularis splitting.
After moving the scope in the west portal, the subscapularis muscle is fully exposed, and the posterior spreader is gently pushed through the muscle in a lateral direction. We pay attention to the position of the axillary nerve at this step and while the spreader is opened, the cautery completes the split in lateral direction respecting the capsule. The east portal should always be established in an outside-in technique, passing through the pectoralis major muscle with a superficial trajectory, using a switching stick in 45° orientation toward the tip of the coracoid. A visual control is required to check that it passes medial to the coracoid osteotomized.
The anterior spreader is then pushed along the half pipe protecting from the brachial plexus. The “safe window” is created to visualize the posterior wire.
Step 4 is coracoid transfer.
A suture retriever is used to catch the coracoid PDS suture, which is then retrieved posteriorly. The cortical button sutures are shuttled and the graft transferred. Great care is taken to avoid any impingement with the arm of the posterior spreader at this step, allowing a free landing of the coracoid through the subscapularis. The scope is placed in posterior portal, and the 4 strands of suture are passed through the posterior cortical button. A Nice knot is then tied. This is a locking sliding knot. The suture tensioner is placed, and the position of the coracoid graft is controlled with the help of a hook, ensuring no overhang or medial rotation. A compression of 100 Newton of the bone graft against the anterior glenoid neck is obtained under the control of suture tensioner. The Nice knot will be locked after a minimum of 3 cycling procedure of the cortical button.
Step 5 is Bankart repair.
Finally, the Bankart repair and capsular shift is performed, placing the graft extra-articular.
Postoperatively, the shoulder was protected for the first 4 weeks in a sling. Self-pendulum exercises were initiated in the second week, and active range of motion recovery from the fourth week, protecting external rotation up to the sixth week.
Clinical examination at 6 months demonstrated full range of motion recovery with a slight decrease of external rotation and a negative apprehension test. Scars are acceptable especially the east portal.
Postoperative computed tomography scan proved graft incorporation and remodeling, allowing to resume overhead sport in competition.
To conclude, arthroscopic Latarjet procedure is a reliable option to treat anterior shoulder instability in young athlete with glenoid bone loss.
The procedure is safe and combine bone graft and Bankart repair.
Scars are acceptable and minor. Using a cortical button fixation would avoid screw related complications.
Thank you for your attention.
Footnotes
Submitted June 2, 2021; accepted July 19, 2021.
One or more of the authors has declared the following potential conflict of interest or source of funding: N.B. is a paid consultant for SBM and Move Up. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
