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Open modified Latarjet coracoid bone block transfer anterior shoulder stabilisation

    Overview

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    Described here is my surgical technique for the open modified Latarjet coracoid bone block transfer anterior stabilisation of the shoulder. This operation was originally described by the Frenchman Latarjet in the 1960s for the treatment of shoulder instability. Some surgeons around the world use this as their primary operation for patients with recurrent shoulder instability regardless of whether there is bone loss or not. The majority will use it only in patients with anterior glenoid bone loss identified on the preoperative imaging or as a revision procedure for failed soft tissue repair stabilisation. I have described it, and perform it, in a form modified from the original because there have been a number of well established improvements made over the years to the original technique.
    The principle behind the operation is to replace the anterior glenoid bone lost, due to recurrent trauma from the humeral head during dislocations, with bone. Whilst this can be achieved by using autograft such as free iliac crest bone graft or allograft (techniques have been described using distal tibial plafond from fresh frozen cadaveric donor) but this technique uses the native coracoid process, keeping its conjoint tendon attached.
    Once the decision has been made to use the technique for either primary or revision surgery then an anterior deltopectoral approach is used. Once the coracoid bone graft is harvested it is rotated through a split in subscapularis and fixed onto the prepared anterior glenoid with two partially threaded cancellous screws. This technique describes repair of the capsulolabral soft tissues to the native glenoid on the inside of the graft.
    The modified technique described here uses the congruent arc Latarjet procedure, in which the curvature of the undersurface of the coracoid which matches neatly to the concavity of the glenoid socket. The cut bony surface on the medial aspect of the coracoid is created by detaching pectoralis minor with a slither of bone. This cut bony surface is then rotated to be seated onto the prepared bony surface of the anterior glenoid. This differs from the traditional or classic Latarjet technique where the entire coracoid process is harvested and then the undersurface is decorticated to be placed flat onto the glenoid surface. This technique then allowed repair of the capsular labral structures to a stump of the coracoid acromion ligament left on the lateral edge of the coracoid autograft.
    In recent years arthroscopic variations of this operation have been described. These arthroscopic techniques however often ignore the repair of the soft tissues of the capsular labral complex. There is also no doubt that even for the most experienced arthroscopist this is significantly complex and challenging surgery .
    All Latarjet techniques utilise the conjoint tendon attached to the tip of the coracoid to act as a sling, thus reproducing the function of the damaged anterior band of the inferior glenohumeral ligament. As the repaired shoulder rotates into abduction and external rotation the position of the conjoint tendon tightens with a tenodesis effect to further prevent anterior translation of the proximal humerus over the glenoid.
    The technique I describe here, I believe is safe, reproducible and gives really very good results of stabilising a shoulder. There have been several publications highlighting potential risks and complications of the Latarjet stabilisation technique but I believe that the technique described here when used regularly and carefully is at low risk of producing such complications.

    Indications

    INDICATIONS
    The indications for using a bone block grafting procedure such as the modified Laterjet technique described here is essentially for bone loss anterior shoulder instability. This will typically be a patient who has lost bone from the anterior glenoid either as a primary single injury glenoid rim fracture or repeated injuries accumulating damage to the glenoid rim resulting in recurrent anterior dislocations of their shoulder. Such a patient will be identified from their history and examination findings as well as getting confirmation from imaging with x-rays and scans and to confirm that there is loss of bone reducing the arc of curvature of the glenoid socket of the shoulder joint.
    There is almost certain to be bone loss from the humeral side of the joint in the form of an impaction fracture of the softer bone at the posterior aspect of the humeral head, the so-called Hill-Sachs lesion. A combination of bone loss from both sides of the joint, the glenoid and the humeral head, will significantly reduce the arc of curvature and hence put the patient at risk of an anterior dislocation as the humeral head rotates and translates across the glenoid. The Hill-Sachs lesion engages with the anterior edge of the glenoid and falls off the front of the deficient socket.
    Several techniques have been described by orthopaedic surgeons and radiologists to try and quantify the amount of bone loss using techniques with computer software for CT scans. More recently authors have discussed the phenomenon of whether the bone lesion is “on track” or “off track” also giving an indication as to whether this is significant bone loss. There has been plenty published material about the reasons for failure of soft tissue stabilisation and the predominant feature has been the unrecognised bone loss from either side of the joint. We know that there are significant risk factors from sporting activities in particular. Collision sports, such as rugby and American football or high impact activities such as surfing or mixed martial arts put the patient at significant risk of initial bone loss but also failure of soft tissue stabilisation. In my practice I tend not to use techniques assessing whether a bone lesion is on or off track but I take care in ascertaining an accurate history including the patients sporting activities and future desires. Examination techniques are less helpful in decision making concerning bony surgery for instability but if there is any indication of a bone loss on the scans and x-rays then I will consider this procedure as a primary operation. If a patient presents to me having had further dislocations following previous soft tissue stabilisation, either arthroscopic or open surgery, then irrespective of whether there is significant bone loss on their imaging, I feel that this procedure provides reliable and reproducible stability that I use it for almost all revision anterior stabilisation surgery.
    SYMPTOMS & EXAMINATION
    A patient will present with a history of anterior instability which may or may not be recurrent. It is important to ascertain from them the circumstances of their first time dislocation and how much force was required. Usually such a situation is resolved either with a spontaneous or the patient’s self-reduction of the dislocation or the intervention of medical staff, either outside hospital or within an emergency department. Once a dislocated shoulder has been reduced and clinical examination and plain radiographs confirm such, then the patient can be treated with sling immobilisation, simple analgesia and physiotherapy rehabilitation. I believe an indication of bony damage is significant pain following reduction of the primary dislocation.
    A patient with recurrent instability will describe significant apprehension and worries about their shoulder on a daily basis. They may describe the sensation of the shoulder slipping or pain and apprehension in certain positions. Classically for anterior instability this would be with reaching high laterally or backwards and placing their shoulder into abduction and external rotation.
    Examining such a patient may reveal a full range of motion but they may demonstrate discomfort or visible and palpable apprehension placing the arm in a position of risk. It is important to assess range of motion and strength of the rotator cuff muscles comparing with the opposite shoulder. Assessment of general hyperlaxity is important using criteria such as a Beighton’s score for generalised soft tissue and ligamental laxity. The neurological status of the upper limb should be examined and documented carefully. In particular it is important to assess the function of the axillary nerve, testing the sensation in the regimental badge patch area on the lateral deltoid and also assessing by palpation the contraction of deltoid muscle with active abduction of the elbow away from the trunk.
    Anterior apprehension tests should be performed classically with assessment of the abduction and external rotation in the supine patient and then repeating this with a so-called relocation test by placing a hand across the front of the shoulder and actively reducing the humeral head into the glenoid during abduction and external rotation. The patient is usually highly apprehensive if this hand is then gently released and this manifests with patient’s concern as well as active contraction of shoulder musculature.
    Assessment should also be made as to whether there is any posterior instability in the shoulder. This can be more difficult clinically but by loading the posterior structures of the shoulder with active resistance of elevation of the arm in the cross body abducted position which reproduces symptoms and posterior apprehension of a feeling that the shoulder may fall out backwards.
    IMAGING
    In any patient with shoulder instability plain radiographs are essential. There may or may not be availability of x-rays confirming dislocation at the time of either primary or subsequent recurrent dislocations. As always with shoulder plain x-rays, 3 views should ideally be obtained with an anterior posterior (AP) image, as well as lateral and axial/modified axillary views. Such imaging may be normal but clinicians should look for the posterior indentation of a Hill-Sachs impaction on the humeral head and assess whether there is any bone fragment in the region of the anterior glenoid. This may be small and subtle or in some cases maybe a bigger glenoid rim fracture.
    The use of ultrasound imaging in instability is not indicated as cross-sectional scans are much more useful.
    CT scanning is useful to look at bony architecture and this can be enhanced with intra-articular injection of radio-contrast which will further delineate any significant bone loss. Transverse cross-sections of the glenoid are useful as well as saggital images across the face of the glenoid.
    I tend to use MR arthrography as standard imaging because this gives me the most information concerning not only the bone but the soft tissue structures. In any patient with shoulder instability it is important to exclude a significant rotator cuff tear. The use of intra-articular contrast is important given that subtle intra-articular lesions of the glenohumeral joint may not be picked up in the stationary supine shoulder as positioned in the MRI scanner. Given that the glenohumeral joint has a negative intra-articular pressure then soft tissues collapse down into a normal anatomical state and the best way to identify intra-articular damage is to relatively to distend the joint with radio-contrast injected into the glenohumeral joint prior to the MRI scan.
    ALTERNATIVE OPERATIVE TREATMENT
    There are a variety of techniques which can be used for the same clinical problems. Over the years the Latarjet procedure described here has been modified. Original descriptions were also called the Bristow or Bristow-Latarjet procedure. This would classically have taken the tip of the coracoid process fixed to the anterior glenoid with a single screw. Whilst this was successful in reducing recurrent dislocations, the patient would often still have apprehension. Here the bone graft may rotate around a single screw and possibly never fully unite, although the sling effect of the conjoint tendon prevented further dislocations. The classic Latarjet procedure takes the coracoid as bone graft but decorticates the undersurface and places the bone flat on the anterior glenoid.
    As described here, I use the congruent arc modification whereby the coracoid graft with the cut bony surface from detachment of pectoralis minor tendon medially is placed against the anterior glenoid utilising the concave undersurface of the coracoid which matches the concavity of the articular face of the glenoid. As some authors believe that this non-anatomical procedure is bettered by using free bone graft procedure through a similar approach. Classically autologous iliac crest bone graft can be used or techniques have been described using fresh frozen allograft, in particular the distal tibial plafond has a similar curvature to the anterior glenoid and can be fashioned to provide a good bone graft.
    Alternative bone grafting techniques are also described such as the J-graft. In cases where there is a large anterior glenoid bone fragment, such cases should be considered more as a glenoid rim fracture. On occasions in acute injuries a large such fragment fracture can be fixed acutely using screws with an open technique or arthroscopically assisted.
    Arthroscopic Latarjet procedures are now widely described and in common use but this is a technically challenging procedure and has a significant learning curve. Techniques have also been described using arthroscopy to place free autologous bone grafts or allograft bone blocks and even blocks of bone substitute. In my practice if there is significantly large bone fragment from the anterior glenoid that I feel is not going to be sufficiently reconstructed using autologous coracoid then I will use autologous iliac crest which can be harvested and fashioned to fit the glenoid defect.
    NON-OPERATIVE MANAGEMENT
    As with all instability if the patient finds that they can cope by rehabilitating the shoulder with the physiotherapy guidance, concentrating on improving range of motion and strength and appreciating positions of risk of their arm and shoulder then such management alone is entirely reasonable avoiding the need for surgery. Patients may have worked out the positions of risk and activities that give them most apprehension of their shoulder but they can always be advised further. It is important to explain to such patients that they should be extremely careful entering water for leisure pursuits. I always warn them to never go into water alone and always make sure that there are people in attendance with them who understand that they have a potentially unstable shoulder as shoulder dislocation in open water is potentially life-threatening.
    CONTRAINDICATIONS
    As with any orthopaedic surgical technique the patient has to be medically fit enough to consider surgery under general anaesthetic and also have the capabilities to comply with post-operative treatment regimes. Specific to the Latarjet procedure it is important to assess the pre-operative imaging for the state of the coracoid process given that this is the local autologous bone graft. If there is evidence of a coracoid fracture or the process is developmentally thin or small, then this may not achieve the desired outcome and consideration should be given to alternative bone graft techniques as previously described.

    Setup

    I perform this operation as a day case procedure and to help post-operative analgesia, my anaesthetist uses an interscalene nerve block. This is generally performed while the patient is awake prior to the general anaesthetic. The patient is given intravenous antibiotics and during the operation has Flowtron intermittent calf compression to help prevent thromboembolic disease. A warming blanket is applied to the patient for the duration of the operation. Placed supine on the operating table, I elevate the head end of the table approximately 20-30 degrees. I attach a narrow moveable arm-board to the operating side of the table. After ensuring the patient’s head and neck are protected and secure, I perform an examination of the shoulder under anaesthetic to confirm my clinical suspicions and the radiological imaging findings of anterior instability. Occasionally a social wash with soap and water is required and sometimes the front of the shoulder requires shaving. I prepare the patient’s hand and entire arm and shoulder girdle with a chlorhexidine solution. Adhesive drapes are used to cover the patient’s head at the base of the neck and to protect the anaesthetic tubing. I use a cloth stockinette rolled up the arm above the elbow and then apply the rest of the drapes, keeping the arm free with good access to the front of the shoulder.

    Operation – 1

    Transverse section MRI scan.
    The plain x-ray images in this patient were essentially unremarkable and were reported as being normal.
    These are 2 transverse MRI sections showing the intra-articular contrast of the arthrogram study. Humeral head (HH) can be seen articulating with the glenoid but the asymmetry of the cross-section of the glenoid is seen with clear indication of a bony Bankart (BB). Both these images show a step in the articular cartilage and a separate fragment of bone with the attached capsular labral structures.

    Saggital section images of the MRI arthrogram.
    These saggital images from the MRI arthrogram show the calvicle (Cl), glenoid (G) and coracoid process (Co). On each section it can be seen that there is disruption to the anterior glenoid with a longitudinal cleavage at the front of the normally circular face of the glenoid articulation. This shows the bony Bankart (BB) lesion. Using software with the MRI facility this can quantify the area of damage being approximately 20% of the glenoid surface.

    The patient is set up in the semi-sitting position . Under general anaesthetic the patient is placed into this semi-sitting position with the operating table broken to allow relative flexion of the hip and elevation of the trunk.
    Note the position of the pillow (P) under the patient’s knees, allowing their resting position in flexion. A moveable arm-board (AB) is positioned underneath the operation arm elbow. This allows the arm to be moved during the operation and for the limb to be supported.

    The incision is marked on the front of the shoulder from just lateral to the palpable coracoid process (Co), running distally along the length of the proximal humerus. For cosmetic reasons this incision can be adapted, which may be desirable in female patients, to run continuously with the anterior axillary fold. This lower incision simply requires more retraction of the tissues during the procedure.

    Initially the hand is prepared with chlorhexidine solution and then covered with a cloth stockinette which can be rolled down the arm once the skin is prepared. The hand is usually prepared with non-staining solution whereas the rest of the upper limb and shoulder girdle is prepared using pink staining chlorhexidine solution. Once the shoulder girdle is adequately prepared, the initial drape is placed transversely across the base of the neck protecting the anaesthetic tubing.

    Next a U-drape is placed under the axilla ensuring adequate exposure to the front of the shoulder.

    Final position of the adhesive drapes can be seen. The forearm stockinette is over wrapped with a crepe bandage and tied at the wrist. A quiver containing diathermy and suction is placed on the top of the patient’s trunk.

    To help with superficial haemostasis I inject the proposed surgical incision site with 10-20mls 0.5% bupivacaine with adrenaline.

    The anterior incision is made using a scalpel.

    Superficial haemostasis with monopolar diathermy forceps.

    Sharp dissection of superficial fascia and fat.

    Insertion of self-retaining Jackson Burrows retractors after sharp dissection of superficial fascia and fat.Place the self-retainers initially in the fat layer but keep adjusting them deeper as the deltopectoral approach proceeds.

    Dissection of the fatty streak between deltoid and pectoralis major muscles exposes the cephalic vein and the deltopectoral interval.

    Adjust the Jackson Burrows deeper between deltoid and pectoralis major muscles.

    Take a forked blade retractor.

    Place the forked blade retractor on top of coracoid process to retract superior soft tissues.The coracoid process arises from the front of the scapula at the anterosuperior aspect of the glenoid. It can be palpated at the superior aspect of the deltopectoral interval.

    Remove Jackson Burrows retractors and assemble Kolbel’s retractors.

    Insert Kolbel’s retractors into deltopectoral interval. Atraumatic blades are placed under deltoid laterally and pectoralis major medially.

    Excellent exposure of surgical site using described retractors. is achieved by simply opening the deltopectoral interval.

    Identification of structures attached to coracoid process after Kolbels retarctors have been inserted.The forked blade retractor is placed on the top of the coracoid process. Coracoacromial ligament (CAL) is seen inserting into the lateral border of the coracoid and beneath it a flat Cobb-like retractor is placed. Pectoralis minor tendon and muscle (PMi) is seen inserting on the medial aspect of the coracoid. The conjoint tendon (CT) is seen from the tip of the coracoid running distally down the arm.
    Care must be taken in the interval between pectoralis minor and the conjoint tendon as this is where the brachial plexus and large vessels are found.

    Using a cutting diathermy blade the coracoacromial ligament is released from the lateral coracoid by cutting down onto the surface of the Cobb-like retractor, which protects the underlying rotator cuff tendons. I aim to stay close to the edge of the bone releasing the ligament completely. This area can bleed as there are blood vessels within the coracoacromial ligament.

    Lifting the arm opens the subcoracoid space. This allows digital palpation beneath the coracoid process to ensure that there is no soft tissue adhesions.Palpate the musculocutaneous nerve as it runs from medially into the back of the conjoint tendon distal to the musculotendinous junction.

    Index finger placed beneath the conjoint tendon from the lateral side to palpate the position of the musculocutaneous nerve.This step is to make the surgeon aware of the position of the nerve when mobilising the coracoid process.

    Take a straight sharp osteotome of approximately 1cm in width.

    Release pectoralis minor from medial coracoid. Pectoralis minor inserts onto the medial edge of the coracoid process and occasionally a prominent and palpable facet is present which indicates how much bone can be left attached to the tendon. Otherwise use the osteotome to make a clean cleavage of a slither of bone attached to the pectoralis minor tendon.

    Operation – 2

    Detachment of pectoralis minor using osteotome.

    Using a small mallet take care cleaving pectoralis major with the slither of bone, approximately 1.5cms along the medial aspect of the coracoid.

    Use the osteotome to leave a hinge of bone at the base of the coracoid (Co).Pectoralis minor (PMi) muscle left attached to base of coracoid.

    Take a curved sharp osteotome.
    The osteotome should be width 1-2cms to cover the coracoid process.

    Position the curved osteotome on the top of the coracoid in preparation for osteotomy.
    The curved osteotome is placed in front of the forked blade retractor on top of the coracoid process. At this stage the surgeon can palpate the curvature on the undersurface of the coracoid to ascertain adequate length of bone graft and position of the osteotomy.

    Remove the forked blade retractor keeping the curved osteotome in position.

    Use heavy mallet on curved osteotome for the coracoid osteotomy.

    Use controlled careful blows to the osteotome to divide the base of the coracoid bone.
    This step can be performed using a small bladed oscillating saw.

    Grasp coracoid with Kocher’s bone holding forceps.
    Suction is used here as the base of the freshly divided coracoid process can bleed.

    Use the Kocher’s bone holding forceps to lift the coracoid process away from the base.

    Dissecting scissors can be used to release soft tissue attachments and periosteum from behind the coracoid bone graft.
    Take care to protect the musculocutaneous nerve which enters the back of the conjoint tendon distally.

    Here the coracoid process can be seen with a small tail of bone left on the undersurface curvature of the coracoid process. This indicates an adequate size of graft has been harvested.

    Dissecting scissors are used to further carefully release soft tissue from the posterior aspect of the conjoint tendon. The musculocutaneous nerve can be palpated and identified at this stage, protecting the nerve throughout.

    Forceps monopolar diathermy are used to ensure haemostasis behind the conjoint tendon.

    Bone nibblers are used to tidy up the coracoid graft. Here the bone nibblers are used to resect the tail left on the coracoid process from the osteotomy.

    The forked blade retractor is taken from the base of the coracoid and laid in the top of the wound. Against the retractor the resected coracoid bone graft is inspected. Here it has been rotated so that the cut bony surface from which the pectoralis minor tendon was released is inspected.

    Ensure smooth flat surface from the resected side of the coracoid graft using bone nibblers.

    Take a standard 2.5mm drill and place the first drill hole towards the resection end of the coracoid graft onto the original pectoralis minor surface. Hold the graft securely with the Kocher’s bone holding forceps against the forked blade retractor. Aim the drill towards the ridge on the original lateral side of the coracoid from which the coracoacromial ligament was removed.

    Use the same 2.5mm drill to create the second drill hole on the cut bony surface leaving a good bridge of bone between the two drill holes. The second drill hole is towards the conjoint tendon attachment.

    Turn the coracoid graft over with the lateral surface facing. Using the cutting diathermy probe ensure the exit position from the drill can be found for both holes and confirm soft tissue cleared from this surface of the coracoid bone graft.

    Ensure both drill hole exit points are clearly identified.

    Final confirmation of position of drill holes on the lateral surface of the coracoid which will become the anterior surface of the fixed graft.

    Place a stay suture in the superior coracoid graft drill hole.I use a no 2 Ethibond stitch placed through the superior drill hole.

    Pass the needle of the traction stay suture through the superior hole.

    Stay suture in place through superior drill hole.

    Operation – 3

    Second view showing stay suture through superior drill hole and configuration of graft.

    Tuck the bone graft and conjoint tendon behind the medial blade of the Kolbel’s retractor.

    With the coracoid bone graft tucked behind the medial blade the Kolbel retractors can be opened and the forked blade retractor can be replaced onto the stump of the coracoid process superiorly. This exposes the subscapularis tendon (SSc).

    External rotation of the arm further exposes the subscapularis.

    Clear subscapularis bursaThis is a view from superiorly showing release of the subscapularis bursal tissue from the front of the shoulder.

    Identify the junction of the middle and inferior thirds of the subscapularis tendon and incise this transversely using a cutting diathermy blade being careful to only incise the tendon protecting the underlying anterior glenohumeral joint capsule.Prior to this identify the borders of the subscapularis tendon by palpating the rotator interval superiorly rolling over the top of the subscapularis tendon. Identify the lateral border of the subscapularis tendon and the lateral extent of the lesser tuberosity by palpating the intertubercular groove and the tendon of the long head of biceps. The lower border of the subscapularis tendon is identified by the three sisters – the anterior circumflex humeral vessels.

    Take a deep subscapularis Gelpi-type self-retaining retractor.

    Place the forks of the subscapularis spreader into the incised subscapularis tendon and open to expose the anterior glenohumeral joint capsule

    Rotate the self-retaining retractor within the subscapularis split and open the forks.

    With the subscapularis tendon retracted reflect subscapularis muscle from the anterior glenohumeral joint capsule using scissors.

    Further exposure of anterior glenohumeral joint capsule reflecting muscle fibres of subscapularis.

    Use a Cobb-like retractor to sweep the subscapularis muscle fibres from the anterior shoulder capsule.

    Laterally the subscapularis tendon is adherent to the anterior capsule. More medially once the muscle fibres have been swept and reflected from the joint capsule this gives good exposure to the front of the shoulder joint.

    Take the forked blade retractor and place into the subscapularis split.

    Palpation deep into the shoulder through the split in subscapularis will reveal the edge of the glenoid. Place a forked blade retractor medially onto the glenoid neck.

    Take a stay suture on a small curved needle.
    I use a no. 2 Vicryl stitch on a small curved cutting needle.

    Take a decent 5mm bite of anterior capsule labral soft tissues at the upper edge of the exposed capsule.With the retractors in place as described, gentle elevation of the elbow and posterior pressure on the humerus will further delineate the anterior capsule at the glenohumeral joint junction.

    Use a second suture to take another bite into inferior aspect of the exposed capsule at the joint margin and place a clip on both of these stay sutures.

    Bend the tip of the cutting diathermy blade.

    Ensure that the cutting diathermy blade is bent from medial to lateral when inserted into the shoulder and facilitate access to the control button (CB) on the handle piece.

    Use the cutting diathermy blade to incise the capsule parallel to the glenoid whilst maintaining traction on the stay sutures pulling the soft tissues taut.At the same time use the Cobb-like retractor to sweep the muscle fibres from the capsule.

    Take a pair of dissecting scissors to complete the capsulotomy once the joint has been opened. Scissors are used to complete the capsulotomy both superiorly and inferiorly.

    Traction on the stay sutures pulls the anterior capsule away from the glenohumeral joint. Digital palpation of the glenohumeral joint surfaces confirms capsulotomy is complete.

    Take a Fukuda humeral head ring retractor.

    Place a Fukuda retractor into the glenohumeral joint.This can be facilitated by elevating the arm and pushing the ring retractor into the glenohumeral joint such that it engages on the posterior glenoid rim. Take a swab to wrap around the handle to facilitate traction on this retractor.

    Operation – 4

    Traction on the swab of the Fukuda retractor facilitates access to the joint.

    With the retractors in position the white articular cartilage of the glenoid can be seen deep in the wound with the anterior glenoid rim well exposed.

    A curved osteotome is used to elevate the mobile bony fragment and in combination with a scalpel blade on a long handle or cutting diathermy, the so-called ‘bone lesion’ fragment of anterior glenoid rim with attached redundant soft tissues can be removed.

    This redundant bony Bankart lesion specimen is approximately 2.5cm in length.

    Width of resected bone fragment approximately 1cm.

    With the redundant bone and soft tissue fragment removed the anterior glenoid surface can be prepared.

    Take a small straight osteotome.

    Use an osteotome to hatch-score the anterior glenoid bone.

    Hatch scoring with the osteotome and scraping with the Cobb or a curette will further prepare a healthy bleeding flat bone surface onto which the coracoid bone graft will be seated.

    Relax the Kobel retractors and pull on the coracoid bone graft traction suture.

    Relax the Kobel retractor to retrieve the coracoid bone graft traction suture from underneath medial blade.

    Retrieve coracoid bone graft.

    Ensure the coracoid bone graft and attached conjoint tendon is freely mobile.

    Remove traction stay suture from graft drill hole and grasp the coracoid with Kocher’s bone holding forceps.

    Position coracoid bone graft onto anterior glenoid.
    Replacing the retractors to give maximum exposure of the prepared anterior glenoid, rotate the graft into the subscapularis split and place congruent arc of the undersurface of the coracoid against the native glenoid rim with the cut flat bony surface of the coracoid up against the prepared anterior glenoid surface. Ensure the graft sits approximately 1mm off the native glenoid surface.

    Take the 2.5mm drill.

    Holding the coracoid graft firmly against the glenoid insert the first drill into either of the pre-prepared drill holes on the surface of the coracoid bone graft. Then drill the second hole also.Here the drill bit remains in place in the inferior hole on the coracoid bone graft.

    Take a second and preferably longer 2.5 drill bit.

    Drill the second hole.
    Here the longer second drill bit is used to drill the superior hole keeping the graft in position using the Kocher’s bone holding forceps to prevent graft rotation. Using the longer drill bit avoids clashing with the first drill bit in situ.

    Measure for the first screw with the depth gauge.

    I fix with a standard small fragment 4mm partially threaded cancellous screw and this is usually measures 35 or 40mms depending on the size of the patient, the size of the bone defect and the size of the coracoid bone graft.

    Seat the screws in the glenoid graft.
    Personally I have never used or needed to use a washer on either screw.

    . Insert the first screw until finger tight with the screwdriver
    Do not overtighten as this risks splitting the bone graft or stripping the threads

    Position of the first screw fully inserted.

    Take the drill handpiece without a drill bit.
    Note the flat surface position and orientation of the drill bit still in the lower drill hole.

    Operation – 5

    Take the drill handpiece without a drill bit to assess the position of the flat surface of the attachment. Adjust the end of the drill accordingly to match the orientation of the flat of the drill in situ. This facilitates the next step.

    Attach the drill handpiece to the drill bit in situ and remove that drill bit.

    Use the depth gauge to measure the length of the second screw.

    Insert second partially threaded cancellous screw.
    Depending on the relative stability of the graft, given the first screw has already been inserted, it may or may not need to be stabilised using the Kocher’s again.

    Note the ideal position of the graft showing the congruent arc of the undersurface of the coracoid just offset the curvature of the native glenoid by approximately 1mm.

    Insert 2 suture anchors into the glenoid.I use the Arthrex shoulder repair equipment and use a 2.9 anchor.

    The aim of the next few steps is to re-attach the capsulolabral structures on the inside of the graft leaving the bone extra-articular. I use the previously placed pair of stay sutures fixed to the anterior glenoid rim with knotless anchors. Ideally as with any anterior stabilisation procedure this step should incorporate a relative capsular shift from inferior to superior. Generally, I would choose to place one anchor at a position on the edge of the native glenoid between the two screws on the bone graft and a second anchor at the superior edge of the bone graft. Here the first anchor position is chosen on the edge of the native glenoid between the two screws.

    Ensure anchor drill guide has good purchase on the bone by tapping gently with a small mallet.

    Insert anchor drill down drill guide.
    I will use an Arthrex 2.9 bio–pushlock bio–composite anchor and take the relevant 2.9 drill bit.

    Drill the first anchor hole.

    Leave the drill guide in position, remove the drill bit and clean the end of the drill bit with a gauze swab.

    In patients with hard bone sometimes a gauze swab is not enough to clear the drill. It may be necessary to remove the bone fragments using a pair of fine forceps.

    Re-drill the same first hole.
    This ensures that there are no bone fragments and debris within the first drill hole. This is important to prevent anchor breakage.

    Here the first anchor drill hole can be seen on the edge of the native glenoid at the level of the lower screw which is projectional in this picture, as the drill hole is actually between the two screws.

    Repeat process to drill second anchor hole.

    Final position of two anchor drill holes. Here the second drill hole can be seen at the superior tip of the graft on the edge of the native glenoid.

    Remove the Fukuda retractor from the glenohumeral joint.

    Take the first anchor.
    Here I use an Arthrex bio-composite 2.9mm Biopushlock anchor.

    Remove the clip from the traction stay sutures on the anterior capsular labral structures, the pair of sutures are separated.

    Load the first anchor.
    Here the two limbs of the first suture are being passed through the wire loop for passage of the sutures through the eyelet of the anchor.

    Here it can be seen the lower stay suture is loaded through the eyelet of the first anchor. Both limbs of the no. 2 Vicryl suture have been passed through the eyelet of the anchor.

    Load the second anchor.
    Here both limbs of the second stay suture are being passed through the eyelet of the second Biopushlock anchor.

    Slide the anchor down the first stay suture.

    Position the anchors into the drill holes between the screws on the graft. Pull tightly on the sutures to reduce the capsulolabral soft tissues down to the edge of the native glenoid.Position the anchor into the first inferior drill hole between the screws on the graft. Pull tightly on the sutures to reduce the capsulolabral soft tissues down to the edge of the native glenoid.

    Using a small mallet gently tap the edge of the anchor introducer to advance the anchor into it’s drill hole, keeping the tension on the sutures in the left hand and the introducer steady. A change in the pitch of the noise from the mallet indicates the anchor is fully engaged in the bone.

    Operation – 6


    Unscrew the anchor introducer.

    Take arthroscopic suture cutter.
    Here the Arthrex closed suture cutter is being loaded with the two limbs of suture from the first stay suture which is now attached to the anterior glenoid with the first anchor.

    Slide suture cutter down suture to cut flush with capsule and remove redundant suture material.

    Insert the second superior anchor. Here the anchor has been introduced to the drill hole at the superior position at the tip of the coracoid graft.

    Insert a second anchor in the same manner as the first.

    Remove handle from second anchor.
    This is achieved by unscrewing the purple handle. Cut the sutures as with first anchor using arthroscopic suture cutters

    Final position showing capsule re-attached on the inside of the coracoid bone graft leaving the graft extra-articular.

    Gentle external rotation of the arm confirms that there is minimal tension on the repaired anterior capsule. With gentle abduction from this position the conjoint tendon through the subscapularis split can be observed tightening across the lower aspect of the muscle producing the tenodesis sling effect mimicking the anterior band of the inferior glenohumeral ligament.

    Remove subscapularis spreader retractor.
    Here can be seen the final position of the conjoint tendon through the split of subscapularis.

    I place a single no. 2 Ethibond stitch into the lateral edge of the split in subscapularis. This not only repairs the lateral edge of the split in the tendon but leaving the suture relatively long will allow this to act as a marker if ever revision surgery was required. This will identify the position of the split in subscapularis and hence guide the approach to the coracoid bone graft.

    Final position of the subscapularis Ethibond stitch seen here. At this stage wash-out the wound with saline and ensure haemostasis using diathermy if necessary.

    Remove all retractors and repair the superficial fascia and fat.
    Allow deltopectoral interval to fall back together.

    Use 3/0 monocryl running suture to repair the skin in the subcuticular layer.Pull the ends of the continuous monocryl skin suture to ensure that skin edges are opposed.

    . Wound is further covered with removable paper steri-strips

    Standard adhesive dressing is applied.

    This AP x-ray shows the position of the bone graft on the anterior glenoid and the position of the two screws.

    Post-operative lateral x-ray.
    This image confirms the position of the bone graft on the anteroinferior edge of the glenoid with good position of the two parallel screws.

    Post-operative axillary view of the shoulder
    This confirms the position of the bone graft on the anterior glenoid with good position and length of the two screws.

    Post Operative

    Surgery is usually preformed as a day case. Patient is discharged with a sling including body belt, waterproof dressing, oral analgesia and physiotherapy instructions for early mobilisation.
    Wound should be checked and the end of the absorbable sutures trimmed at 2 weeks. Postoperative xrays (ideally 3 views AP, lateral and modified axillary) should be performed at 3-4 weeks as the sling is weaned.
    Further set of 3 view Xrays should be performed at 4 months postop to ensure position of screws and graft maintained and with good clinical progress graft healing can be confirmed.
    Physiotherapy regimen for Anterior Stabilisation (bony procedure) – The aims of rehabilitation are to protect the repair in the early stages and to maximise function.
    General Points
     Do not push through pain – remember pain inhibits rotator cuff control
     Do not sacrifice quality of movement for ROM
     Do not overstretch into combined abd/ER Immobilisation
     Patient to wear sling with waistband for 3 weeks 24 hours a day, only removing for physiotherapy exercises
     At 3 weeks, gradually wean out of sling but to continue wearing at night for a further 3 weeks
     Total sling usage – 6 weeks Post operative
    0-6 weeks: Pendular exercises; Active assisted – ER to neutral only (handshake position); Active assisted – elevation as comfort allows– consider use of table slides or walk backs
    At 3 weeks: Gradually wean out of sling – light activities only (weight of a cup of tea within the field of vision, short lever)
    From 6 weeks: Increase range of ER –gradually increase elevation as comfort and ER allows. Progress active assisted through to active. Isometric rotator cuff in available range
    8 weeks: Resisted work through available range
    12 weeks: Sports Specific Rehabilitation – for throwing, important to regain ROM into abd/ER, but needs dynamic control into this range (including eccentric control)
    Functional Milestones:
    CV fitness including running & static bike – Depending on patient can be from 0 weeks within sling
    Cycling (Road non competitive) – 8-12 weeks
    Swimming – 12 weeks +
    Racquet Sports/ Golf – 12 weeks+
    Contact Sport e.g. rugby, football, mountain biking, hockey, climbing – 4-6 months

    Recommended Reading

    Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder.
    J Alliance, D Goutallier, C Glorion. JBJS 80A June 1998: 841-852
    95 shoulders between 1969-1983
    58 reviewed mean follow up 14.3 yrs (10-23)
    No redislocations, 6 apprehension
    88% good/excellent; 9% fair; 3% poor
    Traumatic glenohumeral bone defects and their relationship failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill Sachs lesion. SS Burkhart & JF de Beer. Arthroscopy. 2000 October;16(7):677-694
    Two surgeons with identical technique of Arthroscopic Bankart repair using suture anchors
    Identification of the bare spot for arthroscopic quantification of glenoid bone loss.
    194 cases of arthroscopic Bankart repairs for traumatic anterior instability – 101 contact athletes (96 rugby players)
    Average follow-up: 27 mo. (14-79 mo.)
    Recurrent postoperative instability: 21 cases (11%) – 14 of these 21 had bony defect; 3 “engaging Hill- Sachs” and 11 “inverted pear” Bankarts
    The group with no bone defects (173): 7 recurrences (4 percent)
    The group with bone defects (21): 14 recurrences (67 percent)
    Contact athletes without bone defects: 6.5% recurrence
    Contact athletes with bone defects : 89% recurrence
    Reasons for failure after surgical repair of anterior shoulder instability. M Tauber, H Resch, R Forstner, M Raffl, J Schauer. JSES. 2004 May/June:279-285
    41 pts presenting with failure after surgical stabilisation
    35 arthroscopic, 6 open Bankart repairs
    56% defect in anterior bony glenoid rim
    One hundred and eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study 1 – clinical results. L Hovelius, B Sandstrom, K Sundgren, M Saebo. JSES Sept/Oct 2004: 509-516
    1980-2001: 15 year follow up (14.3-20.8)
    8 surgeons (97 cases, 9, 6 surgeons x(1-3))
    At 2yrs: 1 redislocated, 98% satisifed
    At 15 yrs: 1 revision, 1 pt 1 dislocation, 1 pt 3 episodes 3 yrs postop nil since
    76% very satisfied, 22% satisfied, 1 don’t know, 1 dissatisfied
    Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. P Boileau, M Villalba, J-Y Hery, F Balg, P Ahrens, L Neyton. JBJS 88A; Aug 2006: 1755-1763
    91 pts, age 26+/-5, 71 male, 79 sports, 40 risky
    Mean FU 36months – 15% recurrence
    Risk: bone defect glenoid or humerus (p=0.01); hyperlaxity inferiorly (p=0.03) anteriorly (p=0.01)
    Glenoid loss and inferior hyperlaxity 75% recurrence (p<0.001)
    Do the traditional and modified Latarjet techniques produce equivalent reconstruction stability and strength? J Giles, G Puskas, M Welsh, J Johnson, G Athwal. Am J Sports Med. 2012. Vol 40 Issue 12 pp 2801-2807
    The Congruent-Arc results in significantly poorer fixation stability as compared with the Classic technique but did more closely reproduce intact joint contact, which may yield more favorable long-term outcomes.
    Care must be taken in balancing the consideration of initial fixation stability and joint contact for the Congruent-Arc and Classic Latarjet, as these factors have opposing implications for each of the two reconstructions’ outcomes.
    The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair. S Schmid, M Farshad, S Catanzaro, C Gerber. JBJS Am. 2012. 94 (11). e75.
    retrospective case series of 49 consecutive cases
    coracoid transfer as described by Latarjet can effectively restore anterior glenohumeral shoulder stability if previous operation(s) have failed to do so
    if recurrence is associated with chronic pain, the pain is likely to persist and compromise the subjective outcome.
    BESS/BOA Patient Care Pathways: Traumatic anterior shoulder instability. P Brownson, O Donaldson, M Fox, J Rees, A Rangan, A Jaggi, G Tytherleigh-Strong, J McBirnie, M Thomas, R Kulkarni. Shoulder & Elbow. 2015. Vol 7 (3) 214-226.
    Current British best practice evidence based guidelines for the management of traumatic anterior shoulder instability.
    Excellent clearly written document describing all aspects of traumatic anterior shoulder instability including the surgical recommendations for bone loss instability to use the Latarjet technique.
    Long-term outcomes of the Latarjet procedure for anterior shoulder instability: A systematic review of studies at 10-year follow-up. E Hurley, S Jamal, Z Ali, C Montgomery, L Pauzenberger, H Mullett. J Shoulder & Elbow Surg. Feb 2019. 28 (2). e33-e39.
    The Latarjet procedure for anterior shoulder instability results in excellent functional outcomes at long-term and a high rate of return to sport among athletes.
    However, varying rates of recurrence, residual pain, and progression of instability arthropathy are still of concern.
    The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair. S Schmid, M Farshad, S Catanzaro, C Gerber. JBJS Am. 2012. 94 (11). e75.
    BESS/BOA Patient Care Pathways: Traumatic anterior shoulder instability. P Brownson, O Donaldson, M Fox, J Rees, A Rangan, A Jaggi, G Tytherleigh-Strong, J McBirnie, M Thomas, R Kulkarni. Shoulder & Elbow. 2015. Vol 7 (3) 214-226.
    Current British best practice evidence based guidelines for the management of traumatic anterior shoulder instability.
    Excellent clearly written document describing all aspects of traumatic anterior shoulder instability including the surgical recommendations for bone loss instability to use the Latarjet technique.
    Long-term outcomes of the Latarjet procedure for anterior shoulder instability: A systematic review of studies at 10-year follow-up. E Hurley, S Jamal, Z Ali, C Montgomery, L Pauzenberger, H Mullett. J Shoulder & Elbow Surg. Feb 2019. 28 (2). e33-e39.
    The Latarjet procedure for anterior shoulder instability results in excellent functional outcomes at long-term and a high rate of return to sport among athletes.
    However, varying rates of recurrence, residual pain, and progression of instability arthropathy are still of concern.

    Reference

    • orthoracle.com

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