Procedure

An example of the Latarjet procedure performed by the study’s surgeon can be viewed using the following link: https://www.vumedi.com/video/complete-footage-of-an-arthroscopic-latarjet-for-an-off-track-lesion-with-anterior-instability/.

The overall setup and approach for our procedure follow similar principles as that described in a prior report by our surgeon.³ Preoperatively, the patient is provided either single-shot or catheter-infused regional anesthesia to aid in postoperative pain management. The patient is then brought to the operative theater and placed in the modified beach chair position. The head and neck are placed in the neutral position followed by a slight bend toward the contralateral shoulder. An arm positioner (Spider; Smith & Nephew, Andover, MA, USA) is secured at the head of the bed. Once the patient is appropriately positioned, the arm is prepared and draped in a meticulous sterile fashion. Perioperative prophylactic antibiotic is provided intravenously before incision. Arthroscopic Latarjet technique anatomic landmarks are drawn as described by Lafosse and Boyle including portal sites A, D, E, H, M, and J.¹⁷ A slightly medialized posterior portal (portal A) is first created in order to conduct a standard diagnostic arthroscopy assessing the 15 points of Snyder.²⁴ The anterior portal (portal E) is created through the rotator interval under direct visualization. After confirmation that the bony Bankart lesion is not viable, the anterior labrum and anterior rim of the glenoid are débrided and skeletonized using a radiofrequency wand (VAPR Suction Electrode; DePuy Synthes, Raynham, MA, USA) and shaver (Omnicut; DePuy Synthes Mitek, Raynham, MA, USA).

Next, the joint capsule is opened and débrided from the posterior surface of the subscapularis using the VAPR device through portal E. The capsule is removed until the subscapularis muscle is seen from the posterior portal. The rotator interval is cleaned out in order to identify the coracoid. The coracoacromial ligament is partially removed. The medial sling of the biceps is preserved in attempt to prevent medial biceps instability. Next, portal D is created 1 cm lateral and inferior to the anterolateral corner of the acromion to offer better visualization of the anterior structures as well as anterosuperior and anteroinferior glenoid bone loss. The anterior and posterior space around the subscapularis is then carefully defined using a radiofrequency ablator and shaver. The axillary nerve is encountered inferior and medial to the coracoid in its predictable position. Once the axillary nerve has been found, dissection can continue, staying lateral to its location. Portals D and E are used until the coracoid is clearly defined. Portals M and J are then developed and used to better define the conjoint tendon and pectoralis minor. The coracoacromial ligament is removed off the coracoid, leaving the conjoint tendon attached. Next, the scope is placed in portal J to view the axis of the coracoid process. A switching stick through portal D is used to retract the superior deltoid and improve visualization of the coracoid. A spinal needle is used to determine the location of portal H over the coracoid. This portal comes down directly over the coracoid. Through this portal, the coracoid drill guide (DePuy Synthes Mitek, Raynham, MA, USA) can be placed. Correct placement of the K-wires must be confirmed. The alpha hole on the coracoid drill guide must be approximately 1 cm proximal to the tip of the coracoid process. The beta hole of the coracoid drill guide is placed appropriately in the center of the coracoid from medial to lateral. The guide can be removed, and the coracoid drill is used over the guidewires in the alpha and beta positions. Next, the subscapularis split is created. A switching stick is placed through the posterior portal across the glenoid face and into the subscapularis to define the appropriate position. The previously made portal A is slightly medialized for this portion of the case. Because of its position, the switching stick lies directly on the glenoid face. The subscapularis split is made at the union between the superior two-thirds and inferior one-third of the tendon into the muscle in the same plane as the future graft site location. The split is made using the radiofrequency ablator until the glenoid is appropriately exposed. Care must be taken to avoid injury to the axillary nerve while completing the split medially. In addition, it is important to carefully dissect the subscapularis split with the radiofrequency ablator to prevent iatrogenic injury to the humeral head cartilage. The conjoint tendon can also be visualized medial to the longitudinal split. The anterior glenoid is then prepared to accept the graft using the shaver and burr (DePuy Synthes Mitek, Raynham, MA, USA). It is important to make sure there is no soft-tissue interposition on the glenoid neck to prevent nonunion of the graft. Care is taken around the inferior glenoid neck to make sure no iatrogenic injury to the axillary nerve occurs. Next, the coracoid osteotomy is performed. The osteotomy is made using straight and curved osteotomes through portal H. It is important to burr circumferentially around the proximal coracoid to serve as a stress riser before making the osteotomy. This prevents the osteotomy from fracturing into the scapular body. Once the osteotomy is completed, 2 coracoid screws are placed into the alpha and beta holes of the postosteotomy coracoid through portal M using a graft handle (DePuy Synthes Mitek, Raynham, MA, USA). Decortication of the inferior coracoid, as well as any bone off the inferior aspect of the proximal coracoid, is performed to allow for a better fit on the glenoid neck. The coracoid is then mobilized through the subscapularis split. The switching stick from the posterior portal is used to widen the split and facilitate mobilization of the graft through the subscapularis until reaching the prepared glenoid neck. The scope is placed back into portal J, and the coracoid is placed in the desired position on the anterior rim of the glenoid in the 2- to 5-o’clock position. The graft is lined up with the subchondral bone roughly 3 to 4 mm medial to the glenoid cartilage. Once the surgeon is satisfied with the position, a K-wire can be drilled through the cannulated coracoid screw in the alpha hole across the glenoid until it penetrates out the posterior shoulder through the skin, where it is clamped. Clamping the wire prevents retrograde advancement of the wire back into the shoulder. This process is repeated for the beta hole in the same fashion. The coracoid screw is then removed from the alpha hole, and a 3.2-mm drill is used over the wire into the glenoid. Next, the length is measured, and an appropriate-length Latarjet cortical screw (4.5 mm; DePuy Synthes Mitek, Raynham, MA, USA) is placed over the wire into the coracoid and glenoid. This process is repeated for the beta hole. To prevent malpositioning or fracture of the graft, it is important to not completely tighten either screw initially. Once provisional fixation is completed, it is paramount to alternate between the screws until final fixation is completed. Fixation should be assessed through multiple views, along with confirmation of no soft-tissue interposition. Completing the fixation of the graft, the case is complete. No capsular repair is completed as the capsule was removed earlier in the case. The portals are closed with a 3-0 Vicryl in a subcuticular interrupted fashion followed by a 4-0 Monocryl in a subcuticular running fashion. Steri-Strips are used to cover the incisions. A non-adherent bandage is placed over the portals and the arm is placed in a sling with an abduction pillow or bolster. The arm is placed in a neutral position.