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Arthroscopy-Assisted Latarjet Procedure With Coracoid Exteriorization

ABSTRACT: The Latarjet procedure is a method for treating complicated glenohumeral joint dislocation that is often associated with a bone defect in the anterior glenoid. The Latarjet procedure addresses both soft-tissue and bone deficiencies by creating a biceps tendon sling and through bone reconstruction of the anterior glenoid defect. The arthroscopic Latarjet procedure provides good visual control in the structures and eliminates the need for an arthrotomy. We present an arthroscopy-assisted Latarjet technique where the coracoid is temporarily exteriorized to facilitate shaping and preparation for subsequent fixation to the glenoid. Coracoid debridement, anterior glenoid preparation, and the subscapular split are conducted arthroscopically. Cutting the coracoid process is also conducted under arthroscopic control, and the coracoid is exposed through the anteroinferior portal. Once the coracoid is openly shaped and the drill-holes are made, the coracoid is resituated and fixed to the glenoid edge in arthroscopic visual control. The purpose of this technique is to combine favorable elements of the open and arthroscopic procedures. Additionally, the instrumentation is simple, which makes the operation safe and practical to perform. Technique Video Video 1 The patient is placed in the beach chair position. The lateral portal is marked with a needle. The interval is opened exposing the coracoid. The surrounding attachments are removed leaving the conjoined tendon intact. The arthroscope is moved to the lateral portal. All the portals are marked with a needle. It’s very important to get the portals in right places. The antero-inferior portal is opened. The access to the subscapular tendon is made bluntly. The debridement of the coracoid is completed. Especially the coracoid neck area needs to be exposed. The pectoralis minor tendon is released. The conjoined tendon is released from the surroundings. Excessive soft tissue is removed around the subscapular tendon. The anterior glenoid edge is debrided. The glenoid edge is leveled for subsequent coracoid transfer. The subscapular split is conducted viewing through the lateral or anterolateral portal. An internal view of the split. The glenoid edge is now ready for the transfer. A suture-tape is attached to the conjoined tendon. The coracoid is now ready to be cut. At least two centimeters is needed for the coracoid bone graft. The coracoid is cut with an osteotome. The bone-graft is then pulled out through the anteroinferior portal. The bone block is cut to the right size with an oscillating saw. The coracoid is ground flat to match the glenoid edge. Two 4 mm drill holes are made through the bone block with 10 mm offset. The bone block is attached to the Block Passer. The coracoid is secured to the Block Passer with a suture. The coracoid is then transferred back in and through the subscapular opening. The subscapular split may be lifted open with a suture-tape. The block is taken to the glenoid edge. The passer hook gauge helps to orientate the position of the bone block. The block in place the guide pins are drilled through the glenoid bone. The inner sleeve of the block passer is removed. The coracoid bone block is fixed in place with two 4 mm cannulated self-drilling titanium screws. The inferior screw is inserted first and then the superior one. Inserting of the screws can be made in visual control. With the fixation completed the guide wires are removed. The movements of the joint are checked, especially the external rotation.

SUBMITTER: Ranne J

PROVIDER: S-EPMC8556665 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundThe Latarjet procedure was developed for the treatment of anterior shoulder instability in young, high-demand patients with attritional glenoid bone loss, whose risk of redislocation following primary dislocation may exceed 90%. Coracoid graft osteolysis and prominent screws are commonly observed in late computed tomography (CT) scans of patients who re-present following the procedure, but the clinical relevance of osteolysis in the overall Latarjet cohort is undetermined. We aimed to evaluate clinical and radiological outcomes in patients who underwent the Latarjet procedure, and to determine if severe coracoid graft osteolysis compromised clinical outcomes.MethodsThis was a retrospective analysis of patients who underwent the open Latarjet procedure. Patients were invited via an e-questionnaire that contained a Western Ontario Shoulder Instability Index (WOSI), and queried about redislocation and reoperation since index surgery. Preoperative glenoid bone loss was calculated on CT using the best-fit circle method. Osteolysis was graded (0, screw head buried in graft; 1, screw head exposed; 2, threads exposed; 3, complete resorption/severe osteolysis) at the level of the proximal and distal screws respectively, on axial CT scans performed ≥ 12 months postoperatively.ResultsBetween 2011 and 2022, a single surgeon performed 442 Latarjet procedures. One hundred fifty eight patients responded to the questionnaire at median (interquartile range [IQR]) 44 (27-70) months postoperatively, among whom the median (IQR) WOSI score was 352 (142-666) points (0 = best, 2100 = worst). Recurrent anterior instability occurred in 3/158 (2%) patients. One patient required reoperation for this indication. Among patients who had CT scans ≥ 12 months postoperatively (median [IQR] 40 [29-69] months), 1 patient developed severe osteolysis around both screws (WOSI = 90), 17/62 (27%) patients developed severe osteolysis around 1 screw, all of which were proximal (median [IQR] WOSI = 235 [135-644]), and 44/62 (71%) patients did not develop severe osteolysis around either screw (median [IQR] WOSI = 487 [177-815]). There were no statistically significant differences in WOSI scores between groups based on the presence of severe osteolysis.ConclusionThe Latarjet is reliable procedure that has a low rate of redislocation and reoperation. Severe coracoid graft osteolysis occurs with time, and always affects the proximal graft first. The presence of severe osteolysis did not compromise clinical outcomes.

Project description:PurposeTo review arthroscopic findings at the time of open Latarjet procedures to determine whether preoperative magnetic resonance imaging reports (MRRs) correlate with arthroscopic findings, as well as whether the arthroscopic findings critically affected surgical interventions performed at the time of a Latarjet procedure.MethodsThis was a retrospective case series of all patients who received a Latarjet procedure between 2006 and 2018. Patients were excluded if they had inadequate records or underwent revision of a bony reconstruction procedure. Both primary Latarjet procedures and Latarjet procedures for revision of a failed arthroscopic procedure were included. MRRs, arthroscopic findings, and diagnoses were collected, and differences were noted. A "critical difference" was one that affected the surgical intervention in a significantly anatomic or procedural fashion or that affected rehabilitation.ResultsIn total, 154 of 186 patients (83%) were included. Of these, 96 of 154 (62%) underwent revision Latarjet procedures. The average bone loss percentage reported was 20.6% (range, 0%-40%). A critical difference between MRR and arthroscopic findings was noted in 60 of 154 patients (39%), with no difference between Latarjet procedures and revision Latarjet procedures. Of 154 patients, 29 (19%) received an additional 52 intra-articular procedures for diagnoses not made on magnetic resonance imaging, with no difference between primary and revision procedures. This included biceps and/or SLAP pathology requiring a tenodesis, debridement, or repair; rotator cuff pathology requiring debridement or repair; complex (>180°) labral tears requiring repair; loose bodies; and chondral damage requiring debridement or microfracture. Patients undergoing revision Latarjet procedures were less likely to have bone loss mentioned or quantified in the MRR.ConclusionsDiagnostic imaging may not reliably correlate with diagnostic arthroscopic findings at the time of a Latarjet procedure from both a bony perspective and a soft-tissue perspective. In this series, diagnostic arthroscopy affected the surgical plan in addition to the Latarjet procedure in 19% of cases. We recommend performing a diagnostic arthroscopy prior to all Latarjet procedures to identify and/or treat all associated intra-articular shoulder pathologies.Level of evidenceLevel IV, diagnostic case series.

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Arthroscopy-Assisted Latarjet Procedure With Coracoid Exteriorization

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