Surgical Technique for the Latarjet Procedure Using Non-Cannulated Screws

Abstract

Background:

The Latarjet procedure is effective for patients with anterior glenohumeral instability with substantial glenoid bone loss due to its triple blocking effect.

Indications:

Indications include high-risk patients with recurrent anterior glenohumeral instability with any glenoid bone loss or low-risk patients with 15% to 30% glenoid bone loss.

Technique Description:

An incision is made lateral to the coracoid and the deltopectoral interval is established. The pectoralis minor is released medially off the coracoid and the coracoacromial (CA) ligament is released close to the acromion. The coracoid is cut with a right-angle saw and the inferior coracoid is decorticated with a burr. Two holes are pre-drilled in the coracoid. The subscapularis is split between the upper two-thirds and lower one-third with the arm in external rotation. The capsule is split vertically at the joint line and the humeral head is retracted. The anterior glenoid is decorticated with a burr, and a hole is drilled inferiorly. The depth is measured and added to the depth of the inferior bone block hole. A fully threaded 3.5-mm solid stainless steel screw is placed in the inferior hole. Care is taken to ensure that the lateral border of the bone block is flush with the articular margin. This is repeated for the superior hole. A 1.8-mm knotless suture anchor is placed between the screws. The repair stitch is passed through the capsule and loaded onto the anchor and tensioned. The CA ligament is laid over the capsule and repaired. The subscapularis split is repaired side to side and the wound is closed in layers.

Results:

High return-to-sport rates, including at the same level of play, have been observed among young competitive athletes with significant glenoid bone loss who underwent a Latarjet, with similarly favorable results in older patients. Ninety-day complication rates have been reported around 9%, 5% of which constituted graft or hardware failures.

Discussion/Conclusion:

The Latarjet procedure is an effective option for indicated patients with anterior glenohumeral instability and may be enhanced with solid screws, proper anatomic technique, and capsulolabral repair augmentation.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

The following video demonstrates our preferred surgical technique for performing the Latarjet procedure using solid, non-cannulated screws in patients with anterior shoulder instability and glenoid bone loss. We will begin by covering the background of the Latarjet procedure. We will also provide a case presentation to demonstrate the surgical technique. Afterward, we will discuss tips and tricks and postoperative management. We will also review return-to-sport guidelines and patient outcomes that have been reported in the literature to date.

Transfer of the coracoid to the anterior glenoid is generally indicated for patients with recurrent anterior glenohumeral joint instability with substantial glenoid bone loss. It provides a triple blocking effect to increase anterior shoulder stability, and this has been well described in the literature.^1-6

Although the indications vary from surgeon to surgeon, we typically consider Latarjet for high-risk patients for recurrent instability who have any glenoid bone loss or low-risk patients who have between 15% and 30% anterior glenoid bone loss.^3,7 For those lower risk patients with <15% glenoid bone loss, we typically perform an arthroscopic stabilization procedure. If glenoid bone loss is >30%, we typically perform an allograft reconstruction of the glenoid.

In this surgical demonstration, our patient is a 14-year-old male football player. He had his initial dislocation while playing football that recurred after nonoperative treatment. He underwent an arthroscopic anterior labral repair at an outside institution. Although he did well initially, after returning to sport, he ultimately developed recurrent instability that persisted despite additional nonoperative treatment. On examination, he had normal scapulothoracic rhythm and an intact rotator cuff with full strength. He had slightly limited shoulder abduction and forward elevation, as well as slightly reduced external rotation due to pain and discomfort. He had positive apprehension/relocation and a 2+ anterior load and shift test. X-rays demonstrated a reduced glenohumeral joint with evidence of previous arthroscopic labral repair. His magnetic resonance imaging demonstrated anterior glenoid bone loss, which measured approximately 15% of the width of the glenoid.

Accordingly, he was indicated for a Latarjet procedure. The patient is positioned in the beach chair position and the portion of the table behind the scapula is removed to allow adequate mobilization. The incision starts approximately 1 cm lateral to the coracoid and travels distally for 6 cm. Sharp dissection is carried through skin down to fascia. Once we reach the fascia, the skin is reprepped with dilute peroxide. Through a deltopectoral approach, the coracoid is identified deep. The pectoralis minor is released off the coracoid medially. The coracoacromial (CA) ligament is identified laterally. It is then released as close to the acromion as possible to leave a long flap that can be used to augment the capsular repair later. Blunt dissection is then used to elevate the soft tissue off the coracoid.

A right-angle saw with a length of 25 mm is then used to cut the coracoid; this is cut from medial to lateral. Great care is taken to not injure the neurovascular structures that are inferior and medial. Once the coracoid is freed, soft tissue is released off the inferior surface and a sponge is used to bluntly dissect the posterior aspect of the conjoint tendon, knowing that the musculocutaneous nerve is approximately 3 to 5 cm distal to the tip of the coracoid.

A burr is used to decorticate and contour the inferior surface.

At this point, the two drill holes are predrilled in the coracoid. After drilling, the drill is then rotated to increase the diameter of the hole. This allows more robust compression once a 3.5-mm screw is placed. The inferior drill hole is then measured for depth. A tagging suture is placed.

Here, you can see the bone block with the CA ligament still attached laterally and the conjoint tendon attached distally. The subscapularis is split, with the arm in external rotation to put it on tension. The split occurs between the junction of the upper two-thirds and the lower one-third. Blunt dissection is carried out through the muscle to get down to the capsule. The upper and lower portions of the subscapularis are tagged with vicryl tagging suture. The joint line is then identified. The capsule is split vertically at the joint line and a Fukuda retractor is used to retract the humeral head laterally and posteriorly. Soft tissue is then removed off the anterior neck of the glenoid using cautery and a rongeur. Any previous sutures or anchors that are encountered are also removed.

A burr is then used to debride, decorticate, and contour the anterior aspect of the glenoid. An inferior retractor can be placed, but great care has to be taken to avoid any injury to the axillary nerve during this portion of the case. A burr is used for final debridement and decortication of this area to allow for optimal healing of the bone graft.

The bone block is brought back up into the field, and the location of the inferior drill hole is noted. Great care needs to be taken to precisely measure the distance from the drill hole to the lateral edge of the bone block. An inferior drill hole is then placed in the glenoid that corresponds to this drill hole that was just assessed in the bone block. The depth is measured and this depth is then added to the previous depth that we obtained when we measured the inferior hole of the bone block.

A fully threaded 3.5-mm solid stainless steel screw is then placed in the inferior hole of the bone block. This screw is advanced approximately halfway across the bone block so that the tip can easily be identified posterior to the bone block. The tip of the screw is then placed in the hole that was drilled in the inferior aspect of the glenoid and is tightened. Care is taken to ensure that the lateral border of the bone block is flush with the articular margin of the joint. An elevator can be placed to ensure appropriate and proper alignment.

After this is completed, the superior hole is then drilled through the glenoid. This is done using the previously drilled superior hole in the coracoid. The depth is measured and another 3.5 mm solid stainless steel screw is placed across the bone block and the glenoid. The position of the bone block is carefully evaluated. If it is too prominent, a burr can be used to gently burr back the lateral side of the bone block to ensure that it is flush or slightly recessed compared with the articular surface of the glenoid.

Here you can see the CA ligament still attached to the lateral aspect of the coracoid. A 1.8-mm knotless FiberTak suture anchor is placed in the anterior aspect of the glenoid. This is typically positioned between the two screws. The repair stitch will then be passed through the capsule to provide a capsular repair.

The stitch is passed in a vertical mattress fashion and is done in a lateralized and inferior position; that way, when it is repaired, it will shift the capsule medially and superiorly. Once the repair stitch is passed, it is loaded onto the anchor using the shuttle stitch provided. This is then tensioned, which draws the capsule superiorly and medially and keeps the bone block in an extra-articular position.

After the capsule is repaired back to the glenoid, the CA ligament is laid over the top of the capsule and repaired using an interrupted vicryl suture to further augment the repair. The subscapularis split is then repaired in a side-to-side fashion using multiple 0-Vicryl sutures; these are all placed just lateral to the coracoid.

Here’s the final appearance and you can see the conjoint tendon diving between the split in the subscapularis with the subscapularis being re-approximated and closed. The wound is then closed in layers and Steri-Strips (NextCare) are applied. A small waterproof bandage is then placed over the incision. This remains in place for approximately 1 week.

During a Latarjet procedure, it’s important to be mindful of the musculocutaneous nerve when dissecting inferior to the coracoid. It’s helpful to keep the arm in external rotation during the subscapularis split, but then keep the arm in internal rotation to relax the subscapularis for the remainder of the case. A vertical split in the capsule allows for robust repair at the end of the case. It is also important to remember that the coracoid should not be placed lateral to the glenoid. If anything, it should flush with the articular margin or slightly recessed. Also, we prefer to use solid screws due to the greater strength that they have, which can be particularly helpful in seizure patients.

For the first 6 weeks, patients are kept in a sling with an abduction pillow with no shoulder range of motion. Beginning at 6 weeks, the sling is removed and range of motion is advanced as tolerated. Strengthening begins around 3 months and is slowly progressed as tolerated. Around week 20, a return-to-sport progression is initiated, with a goal of getting athletes back to competitive sports around 5 to 6 months post-operatively.

To return to sports, athletes must demonstrate radiographic union, full range of motion, full strength, no pain, no apprehension, and have successfully completed their return-to-sport progression.

In terms of patient outcomes, in a recent study of 60 competitive athletes under 20 years old with significant glenoid bone loss who underwent a Latarjet, 93% were able to return to sport and 84% returned to the same level of play.^8-10 Similarly favorable results have been observed in older patients as well.^7,8 In a recent retrospective, single institution study of 190 patients, the 90-day complication rate was 9% and roughly 5% of those complications were graft or hardware failures.^8-10