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Technicalguideandtipsontheall-arthroscopicLatarjetprocedure

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SHOULDER

Technical guide and tips on the all-arthroscopic Latarjetprocedure

Claudio Rosso • Vito Bongiorno • Gonzalo Samitier •

Guillaume D. Dumont • Gregor Szollosy •

Laurent Lafosse

Received: 1 January 2014 / Accepted: 22 April 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract Shoulder dislocation and subsequent anterior

instability is a common problem in young athletes. The

arthroscopic Bankart repair was originally described by

Morgan et al. in 1987. The procedure has benefited from

many technical advancements over the past 25 years and

currently remains the most commonly utilized procedure in

the treatment of anterior glenohumeral instability without

glenoid bone loss. Capsulolabral repair alone may not be

sufficient for treatment of patients with poor capsular tissue

quality and significant bony defects. In the presence of

chronic anterior glenoid bony defects, a bony reconstruc-

tion should be considered. The treatment of anterior

shoulder instability with transfer of the coracoid and

attached conjoint tendon such as the Latarjet procedure has

provided reliable results. The arthroscopic Latarjet proce-

dure was described in 2007 by the senior author, who has

now performed the procedure over 450 times. The initial

surgical technique has evolved considerably since its

introduction, and this article presents a comprehensive

update on this demanding but well-defined procedure. This

article reviews technical tips to help the surgeon perform

the surgery more smoothly, navigate through challenging

situations, and avoid potential complications. Level of

evidence V.

Keywords Arthroscopic � Latarjet � Instability � Bony

defect � Glenoid bone loss � Arthroscopy � Stabilization �Shoulder dislocation

Introduction

Anterior–inferior shoulder dislocations are common in the

young population, making up 90 % of shoulder disloca-

tions [13]. Multiple soft tissue lesions have been described

in association with anterior shoulder instability, including

the Bankart lesion, anterior labral periosteal sleeve avul-

sion (ALPSA), humeral avulsion of the glenohumeral lig-

ament (HAGL) [2, 5], and bony Bankart. Injured

capsulolabral structures or bony glenoid fragments typi-

cally do not heal anatomically and can result in recurrent

instability manifested by repeat dislocations or sublux-

ations [4, 5, 8]. In addition to soft tissue injury, instability

events often also lead to bony injuries of the humerus

(Hill–Sachs lesion, HAGL with bony flake) or glenoid

(bony Bankart fragment, or erosive bone loss) [4]. In

contrast, patients with generalized hyperlaxity may present

with severe ligament distension and little or no glenoid or

humerus bony defects after numerous recurrent instability

episodes [7].

In the treatment of anterior shoulder instability, two

main categories of surgical treatment exist. The most

common belief is that a soft tissue repair (Bankart) can lead

to restoration of native anatomy and thus restore sufficient

Claudio Rosso and Vito Bongiorno have contributed equally to this

manuscript.

C. Rosso � V. Bongiorno � G. Samitier � G. Szollosy �L. Lafosse

Department of Orthopaedic Surgery, ALPS Surgery Institute,

Clinique Generale, Annecy, France

C. Rosso (&)

Orthopaedic Department, University Hospital Basel and

University of Basel, Basel, Switzerland

e-mail: Claudio.Rosso@unibas.ch

G. D. Dumont

Department of Orthopaedic Surgery and Sports Medicine,

University of South Carolina School of Medicine, Columbia, SC,

USA

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-014-3038-x

stability to the shoulder. Alternatively, a bony reconstruc-

tion can restore stability to the shoulder by means of

augmentation of the deficient anterior glenoid. The

arthroscopic capsulolabral repair (Bankart repair) has been

extensively described and reported on in the past and is still

the preferred surgical treatment modality in most of Eur-

ope, Asia, and North America. However, the Bankart repair

relies on the presence of sufficient anterior glenoid bone

and soft tissue quality. Inferior outcomes have been

reported for this technique in the presence of glenoid bony

defects, HAGL lesions, and engaging Hill–Sachs lesions

[6, 14]. In cases of Bankart failure or any of the above-

mentioned lesions, the arthroscopic or open Latarjet pro-

cedure is a reliable and durable method of treating anterior

instability [1, 4, 11, 16].

The Latarjet procedure was described in 1954 [10]; the

coracoid is transferred through a horizontal split in the

subscapularis, with the attached conjoint tendon, and fixed

in a vertically oriented position on the anterior glenoid with

two bicortical screws. The conjoint tendon and inferior

portion of the subscapularis create a dynamic ‘‘sling

effect’’ with the shoulder in external rotation and abduc-

tion. This procedure is indicated for treatment of both bony

defects and capsular–ligamentous insufficiency [12].

Recently, a biomechanical study showed that the soft tissue

sling effect is the most significant contributor to stabilizing

the shoulder [15]. The Latarjet procedure relies on the

biomechanics of the so-called triple-block effect [3]. First,

the deficient anterior bony glenoid is augmented by the

coracoid graft. Second, the passage of the coracoid and

conjoint tendon through a split in the subscapularis creates

a dynamic sling effect that prevents anterior translation of

the humeral head. Finally, repair of the capsule/anterior

band of the inferior glenohumeral ligament at the stump of

the coracoacromial ligament on the coracoid graft reten-

sions the antero-inferior capsule. The arthroscopic Latarjet

technique was first performed in late 2003 and its technique

published in 2007 [9]. Since December 2003, over 450

arthroscopic Latarjet procedures have been performed by

the senior author. The technique has constantly evolved

and been refined. Although it remains a challenging pro-

cedure, various modifications have addressed some of its

technical challenges and improved its reproducibility.

In this manuscript, the technique will be reviewed in

detail, noting modifications since the original description.

Technical tips will be discussed to improve the surgeon’s

ability to successfully and safely perform the procedure. In

order to make the steps of this technique more reproduc-

ible, the authors have now described the procedure in 10

steps (vs. the previously published 5 steps) [9]. This pro-

cedure has proven to be a reliable and reproducible tech-

nique in the hands of skilled shoulder surgeons. The

arthroscopic Latarjet procedure does allow for conversion

to open technique at any stage of the surgery, which may

be necessary during a surgeon’s initial attempts at per-

forming it.

Surgical technique

Although the technique does include arthroscopic portions,

the majority of the coracoid preparation is done extra-ar-

ticularly and should be referred to as endoscopic. Patients

receive a combination of general anaesthesia and an in-

terscalene regional block. Cerebral blood flow is monitored

using ultrasound for optimal patient safety. The patient is

placed in the beach chair position with the arm free to

allow movement of the arm during different stages of the

procedure and without any traction to avoid scapula pro-

traction. The surgical field must be draped wide, including

the shoulder but also a major portion of the hemithorax to

permit access through the more medial portals but also to

control swelling (Fig. 1).

The presence of one to two surgical assistants and a

surgical scrub nurse familiar with the instrumentation and

the different stages of the procedure is recommended. The

anaesthesia team provides complete muscular relaxation

and maintains a low, but safe, systemic blood pressure to

improve visualization and thus facilitate the procedure.

Meticulous haemostasis during this largely extra-articular

endoscopic procedure is provided from endoscopic surgical

haemostasis using a radio frequency ablation and electro-

cautery device and by maintaining a balance between the

systemic blood pressure and the arthroscopic pump pres-

sure. Arthroscopic pump pressure is kept low to allow good

visualization, while avoiding excessive swelling of the

shoulder and hemithorax. The balance of the arthroscopic

pump pressure and the patient’s systemic blood pressure is

crucial. The relationship between these two parameters is

critical even in less demanding arthroscopic procedures

and becomes paramount in this more challenging proce-

dure, which requires excellent visualization. In cases of left

shoulders when excessive swelling is noted, for example in

a lengthier procedure or one requiring increased arthro-

scopic pump pressure, cardiac monitoring is advised.

Portal placement

Seven portals are used for this procedure (Fig. 1): The (A)-

portal is the posterior soft spot portal and is used for initial

visualization. The (D)-portal is the antero-lateral portal

positioned adjacent to the antero-lateral acromial angle. It

provides the ability to visualize in line with the superior

border of the subscapularis and is also used for instru-

mentation during coracoid process preparation. The (E)-

Knee Surg Sports Traumatol Arthrosc

123

portal is the classic antero-inferior portal commonly used

for arthroscopic Bankart repair. It allows intraarticular

access through the interval rotator. The (H)-portal is the

superior portal directly superior to the coracoid and is used

for coracoid preparation and to create the coracoid oste-

otomy. The (I)-portal is an axillary portal in line with the

coracoid and is used mostly for visualization during cora-

coid preparation. The (J)-portal is along an arc mid-way

between the (D)- and (I)-portals and is used for visualiza-

tion during the subscapularis split as well as instrumenta-

tion during various stages. The (M)-portal (Fig. 1) is the

most unusual to most arthroscopic surgeons because of its

far medial placement. This portal is safe if the surgeon

remains anterior to the pectoralis minor while creating it.

The (M)-portal is initially used for preparation of the

medial coracoid, to perform the subscapularis split and to

introduce the double-barrel cannula from the Latarjet kit

(DePuy Synthes Mitek, Raynham, MA, USA), which is

used for coracoid handling and final fixation. Whatever

portal is used, the proximity of the plexus to the coracoid

process creates a potential source of risk to structures of the

brachial plexus: the musculocutaneous nerve, which travels

into the conjoint tendon and most importantly the axillary

nerve, which crosses immediately inferior to the subscap-

ularis muscle. Figure 3b shows the musculocutaneous

nerve; Fig. 6a shows the proximity to the axillary nerve.

Surgical stages

In order to facilitate its reproducibility, the initial 5-step

technique is now described in 10 surgical stages.

First stage: joint evaluation

Pertinent anatomic landmarks (acromion, clavicle, cora-

coid process), skin portals, and the glenohumeral joint axis

are marked (Fig. 1). One assistant initially provides for-

ward traction of the arm. The entry point for the posterior

(A)-portal is confirmed with a needle to ensure it is parallel

with the glenoid, allowing the antero-posterior axis of the

joint to be identified and drawn on the skin. A thorough

joint evaluation is performed, including the glenoid and

humeral chondral surfaces, the rotator cuff, glenoid labrum,

and glenoid or humeral bony defects. Soft tissue injuries,

including anterior and posterior labral lesions, ALPSA

lesions, and HAGL lesions and SLAP tear, are noted.

Posterior labral tears can be repaired prior to performing

the arthroscopic Latarjet procedure, while lesions including

the ALPSA, HAGL, anterior Bankart, or bony Bankart are

included in the indications for arthroscopic Latarjet and

need not be specifically addressed. The thickness and

quality of capsule and ligaments is often compromised,

precluding adequate soft tissue repair. The presence and

size of a Hill–Sachs lesion is assessed. The extent of gle-

noid bone loss can be difficult to evaluate initially from the

posterior (A)-portal prior to resection of the scarred,

injured capsulolabral tissues on the anterior glenoid. Gle-

noid defects are more effectively assessed later from the

(E)-portal after resection of the anterior capsule and lab-

rum. Engagement of the Hill–Sachs lesion with the anterior

glenoid is assessed by abduction and external rotation of

the shoulder. This step is identical to previous reports.

In the case of previous anterior Bankart repairs, the

capsuloligamentous complex is removed including the

sutures as outlined in stage two of the surgical steps. In the

case of metal anchors, it is tried to extract them. If this is

not possible, their location should be evaluated with respect

to the future coracoid graft placement.

Second stage: intraarticular joint preparation

The anterior labrum and capsule from the 2 to 5 o’clock

position, along with the attached middle glenohumeral liga-

ment (MGHL) and anterior band of the inferior glenohumeral

ligament (IGHL), are resected using radio frequency ablation

through the (E)-portal. The resection should expose the

posterior aspect of the subscapularis muscle (Fig. 2). The 2

and 5 o’clock positions are marked for precise graft posi-

tioning near the end of the procedure. With the rotator interval

then widely open, a needle is inserted parallel to the superior

edge of the subscapularis to orient the (D)-portal. This step is

identical to previous reports.

Third stage: coracoid preparation

The antero-lateral (D)-portal is now used for instrumenta-

tion. The coracoacromial (CA) ligament is detached from

Fig. 1 The most important landmarks including the anterior portals

are marked on the skin. Note the medial placement of the (M)-portal

at the height of the axillary fold and in line with the glenoid version

Knee Surg Sports Traumatol Arthrosc

123

the coracoid, and the lateral conjoint tendon released from

the deltopectoral fascia (Fig. 3a). Care should be taken not

to damage the conjoint tendon.

The arthroscope is then moved into the (D)-portal,

allowing the (I)- and (J)-portals to be created under direct

visualization using two spinal needles. The medial (M)-

portal is created carefully. One of two methods can be

utilized to create the (M)-portal: a switching stick can be

placed in the posterior (A)-portal, through the glenohu-

meral joint, to identify the orientation of the glenoid at its

inferior level (where the subscapularis split level will be) or

by direct visualization with the arthroscope facing medially

and looking at the interval anterior to the pectoralis minor

tendon and posterior to the pectoralis major muscle. The

(M)-portal can also be located at the intersection of a

horizontal line at the level of the axillary fold and an an-

tero-posterior line overlying the plane of the glenoid.

With the arthroscope in the (I)-portal facing the tip of

the coracoid, the medial aspect of the coracoid process can

be accessed with instrumentation through the (M)-portal.

The pectoralis minor is detached using radio frequency

ablation (RFA) (Fig. 3b). It is important to orientate the

RFA to the bone to avoid damage of the brachial plexus. A

switching stick is placed in the (D)-portal to lift up the

anterior deltoid, thus creating additional working space and

improved visualization. The medial aspect of the conjoint

tendon is dissected from adjacent soft tissues using a

combination of blunt dissection and intermittent, cautious

use of RFA to avoid injury to the musculocutaneous nerve,

which lies in close proximity inferomedial to the conjoint

tendon.

Soft tissues are cleared from the superior aspect of the

coracoid process, to its base as defined by visualization of

the coracoclavicular ligaments. Coagulation of a branch of

the cephalic vein during this step can help avoid potential

bleeding when creating the superior (H)-portal. Finally, the

undersurface of the coracoid is cleared of soft tissues.

Certain points are emphasized for this stage, which were

not found in previous reports, including emphasis on lateral

orientation of the RFA during detachment of the pectoralis

minor tendon from the coracoid and consistent coagulation

of the branch of the cephalic vein superiorly.

Fourth stage: coracoid harvesting

The shoulder is positioned in retropulsion without arm

traction, with the arthroscope still in the (I)-portal. The (H)-

portal is localized with a needle and then created to

accommodate the double coracoid drill guide. The tip of

the coracoid is identified with a long K-wire to avoid

excessively distal placement of the drill guide.

Two 1.5-mm K-wires are inserted using the coracoid

drill guide, with the most distal wire approximately 5 mm

proximally to the tip of the coracoid. The wires should be

placed between the middle and medial third of the width of

the coracoid process (2/3 lateral and 1/3 medial) to avoid

lateral screw placement. The drill guide is removed and the

position of the wires is evaluated on the superior and

inferior aspects of the coracoid. The holes are then drilled

using the cannulated coracoid step drill bit and then tapped.

A ‘‘Top Hat’’ washer is inserted into each hole with the

K-wire still in place as a guide (Fig. 4). A circumferential

stress riser is created at the base of the coracoid using a 5.5-

mm burr from the medial (M)-portal (2–6 o’clock), the

lateral (D)-portal (6–11 o’clock), and the superior side (H)-

Fig. 2 Part of stage 2: Marking of the 2 o’clock position before

capsulectomy. View from the (A)-portal

Fig. 3 Stage 3: coracoid

preparation. a shows the lateral

view from the (D)-portal while

b shows the (I)-portal view

before pectoralis minor

detachment. Note the

musculocutaneous nerve (MCN)

in the background of b

Knee Surg Sports Traumatol Arthrosc

123

portal (11–2 o’clock), keeping one K-wire in the proximal

coracoid hole as a point of reference for the stress riser.

Care is taken not to burr into the drilled whole. Once the

cortical bone at the coracoid base is burred circumferen-

tially, the osteotomy is performed from the (H)-portal using

the curved osteotome (Fig. 5). The coracoid is mobilized

medially and inferiorly to fully expose the anterior sub-

scapularis as it is done in open surgery. This stage has only

been slightly modified: the burr is now introduced first in

the (M), (D), and then the (H)-portals in order to create a

symmetrical stress riser. The wire (CHIA) is not used

anymore as the osteotomized graft can easily be found and

retrieved without the wire.

Fifth stage: anterior subscapularis preparation and split

The anterior bursa of the subscapularis is removed with a

shaver to visualize the entire subscapularis muscle, and the

anterior humeral circumflex artery and its two veins (three

sisters), which mark the inferior border of the subscapu-

laris. The medial limit is delineated by the axillary nerve,

which should be visualized with caution. While viewing

through the (J)-portal, the split is now performed at the

junction of the inferior 1/3 and superior 2/3 of the tendon,

using the radio frequency ablation device via the (M)-

portal: move laterally towards the insertion into the lesser

tuberosity (using external and internal rotation of the arm

to better view and expose the muscle and tendon, Fig. 6a).

The axillary nerve is at potential risk of injury during this

step. It is crucial to visualize the nerve during this step.

Special attention must be paid to avoid approaching the

nerve with the radio frequency ablation device. The split is

completed by placing the dull large trocar through it and

onto the glenoid, and externally rotating the shoulder with

the arm adducted (Fig. 6b). A switching stick from the (A)-

portal in line with the dull trochar is used to lift the superior

2/3 of the tendon through the split (Fig. 6b). This stage has

been modified to its original description: the location of the

split was previously identified by placing a switching stick

through the posterior (A)-portal, piercing it through the

subscapularis and using it to retract the brachial plexus

medially while the split was performed through the (J)- and

(I)-portals. The split is now performed under direct visu-

alization from the (M)-portal. Care is taken to orient the

electrocautery laterally during this step to protect the

axillary nerve.

Sixth stage: glenoid exposure and preparation

The bony bed of the glenoid is now prepared from ante-

riorly [arthroscope in (I)-portal, instruments in (E)-portal]

using radio frequency ablation and a burr. The bony bed

should show capillary bleeding and have a flat surface. No

change has been implemented in this stage.

Seventh stage: coracoid retrieval

The double cannula, with its plastic blue trocars, is inserted

via the (M)-portal (Fig. 7a). The two plastic trocars are

removed together to minimize loss of pressure by fluid loss,

and the long 3.5-mm coracoid holding screws are inserted

and used to engage the previously drilled holes and secure

the coracoid to the double cannula (Fig. 7b). The coracoid

can now be completely mobilized and any remaining soft

tissue tethers released.

The inferior aspect of the graft is further decorticated

with a burr to ensure a flat surface to match the anterior

glenoid neck. A surgical assistant holds the arthroscope

in (I)-portal, while the surgeon moves the graft using the

double cannula over the stationary 5.5-mm burr for better

control, with no suction through the burr (see Technical

Tips #6). This step has changed from its original

description. The coracoid graft is being retrieved using

the double cannula and the long 3.5-mm coracoid holding

screws. The double cannula and attached graft are now

Fig. 4 Stage 4: placed ‘‘Top Hats’’ in the coracoid. Note the posterior

K-wire which is maintained during the performance of the stress riser.

View from the (I)-portal

Fig. 5 Stage 4: coracoid osteotomy with the curved osteotome (white

arrow). View from the (I)-portal

Knee Surg Sports Traumatol Arthrosc

123

moved, while the burr is held still, facilitating burring of

the coracoid.

Eighth stage: coracoid placement

Before coracoid fixation, the scapula often has to be

retracted posteriorly as the thorax can get in the way of the

(M)-portal when trying to be in line with the glenoid plane.

This can be done by screwing a 5.5-mm tap into the cor-

acoid osteotomy site through the (J)-portal and using it as a

joy stick to retract the scapula. A drill is used prior to

inserting the tap to avoid coracoid base fracture (Fig. 8a).

The arm is then placed in internal rotation and slight

forward flexion in order to relax the conjoint tendon and

open the subscapularis split, thus facilitating correct

placement of the graft.

The double cannula is then used to manipulate the graft

through the subscapularis split and into position on the

glenoid. The switching stick from the posterior (A)-portal

is used to open the split allowing passage of the graft

(Fig. 8b). The switching stick is also used to ensure there is

no prominence of the graft with respect to the glenoid rim.

Optimal positioning is about 1–2 mm medially to the car-

tilage surface ensuring bony congruence.

Fig. 6 Stage 5: subscapularis

tendon split. a depicts the

medial extension and the

proximity to the axillary nerve

while b shows the condition

after the split. The white arrow

shows the switching stick with

the blunt trocar in the

background. Cameral view is

from (J)-portal

Fig. 7 Stage 7: coracoid

retrieval. The coracoid is

retrieved with the Double-

Barrel Cannula and the blue

pins inserted (a). The coracoid

screws are then inserted into the

‘‘Top Hat’’ washers

Fig. 8 Stage 8: joystick and graft placement. The white arrow marks the drilled coracoid base. The black arrow shows the switching stick

inserted from the (A)-portal

Knee Surg Sports Traumatol Arthrosc

123

With the graft in place and aligned with the previously

placed marks at the 2 and 5 o’clock position, the inferior

K-wire is inserted through the long cannulated screw: it is

only advanced approx. 2 mm into the glenoid in order to (1)

ensure bony contact and (2) being able to rotate around it to

optimize graft placement. Once the desired position is

achieved, both K-wires are advanced through the graft and

the glenoid (Fig. 8c), perforating the skin of the shoulder

posteriorly. The K-wires are firmly held posteriorly with

clamps to ensure they remain in place during drilling for the

cannulated screws and graft fixation. Looking from above

the shoulder, the two K-wires should diverge from the

switching stick (alpha angle) by 10� (two fingers between

the switching stick and the K-wires) and be parallel to each

other in order to avoid divergent screws. New to this step is

the initial advancement of the inferior K-wire of approxi-

mately 2 mm into the glenoid bone in order to create a

fulcrum to still allow the ability to reorient the graft.

Ninth stage: coracoid fixation

The inferior hole is drilled first to ensure good positioning

of the screw in bone. The inferior (alpha) cannulated

holding screw is removed and the hole drilled with a 3.2-

mm cannulated drill. Screw length measurement is taken off

the drill bit when the posterior glenoid cortex is perforated

(usually 26–32 mm). The inferior screw is then inserted and

the process is repeated for the superior screw (Fig. 9a). The

screws are then alternatively tightened to ensure symmet-

rical compression of the graft onto the glenoid neck

(Fig. 9b). Over-tightening may fracture or medialize the

graft and should be avoided. This stage has not been

changed, but care is taken not to have an excessively long

screw all while ensuring posterior cortical purchase.

Tenth and final stage: dynamic final joint evaluation

The graft position is checked from anterior (I)- and (J)-

portals and the posterior (A)-portal. It is ideally positioned

between 2 and 5 o’clock. The K-wires are then removed

posteriorly prior to removal of the cannula anteriorly. This

ensures that the K-wires do not damage the brachial plexus

during removal or accidentally pull out the screw if the

wire is bent. Mild graft prominence can be corrected with

the burr. The surgeon should verify that the screw heads are

directed away from the humeral head (this is dependent on

accurate wire guide placement and drilling of the coracoid

process during the harvesting phase, See Technical Tips

#3). The sling effect can be immediately observed with the

arm in abduction and external rotation (Fig. 10). This stage

has not been changed as graft placement is still visualized

from different portals in order to ensure a good placement.

Technical tips

1. Correct placement of the graft is crucial: Therefore,

after initial joint assessment, the graft position on the

glenoid rim is marked using the radio frequency ablation

device (a burr can also be used). This must be done with

the arthroscope in the (A)-portal keeping the camera par-

allel to the glenoid and oriented downward in order to have

a view with minimal optical distortion. If the graft position

is marked later in the operation through a superior or an-

tero-lateral portal, the angle of vision of the 30� arthro-

scope makes it more difficult to accurately identify correct

positioning on the glenoid. Be sure to create a clearly

visible mark as it can wash off during the procedure and

thus be difficult to find when it is time to place the graft.

2. (M)-Portal placement: An inadequately placed (M)-

portal will make the subscapularis split and correct graft

placement very difficult. Usually, when misplaced, the

(M)-portal is too lateral. It is definitely safe to go medial as

long as you stay anterior to the conjoined tendon and the

pectoralis minor to avoid brachial plexus injury. As stated

above, there are two ways of determining the (M)-portal.

When commencing to perform this procedure, the switch-

ing stick option is preferred (switching stick through the

(A)-portal and aligning it with the glenoid plane). Looking

from above and aside the shoulder, the switching stick

gives the precise direction and height in which the (M)-

portal should be placed on the thorax. Make sure not to

Fig. 9 Stage 9: graft fixation.

The inferior screw is inserted

first. The white arrow marks the

graft

Knee Surg Sports Traumatol Arthrosc

123

advance the switching stick anteriorly through the sub-

scapular muscle as one can damage the brachial plexus. In

women, the (M)-portal can be placed more laterally in the

breast fold since skin and subcutaneous tissue are often

more elastic, avoiding uncomfortable scars or possible

damage to breast implants.

3. Avoid a proud graft: It is important to not have a

proud coracoid graft or proud screws that can damage the

humeral head. Therefore, when inserting the K-wires on

the coracoid, the authors take care to place them at the

junction of the medial 1/3 and lateral 2/3 of the bone so that

later the screws will be far medial to the glenoid articular

surface and at a safe distance from the humeral head.

4. Coracoid preparation: This step is time-consuming

and requires special attention at different phases. When

detaching the pectoralis minor tendon, mind the musculo-

cutaneous nerve, which is distally and slightly medial to the

tip of the coracoid. Before the creation of the circumfer-

ential stress riser around the coracoid, adequate liberation of

the coracoid from its surrounding soft tissue must be per-

formed especially along the inferior and medial aspects in

order not to have any excessive bleeding after the osteot-

omy. The inferior part of the coracoid is especially a site of

potential bleeding. A switching stick through the (D)-portal

can lift the deltoid muscle and help to create more space.

One must also take care to liberate the conjoint tendon well

from its adhering tissue on the lateral and anterior side

creating a well-mobilized graft. Care must be taken not to

harm the musculocutaneous nerve when liberating the

conjoined tendon medially. The inferior stress riser has to

be extended proximally into the body of the scapula to not

only avoid any remaining spike after the osteotomy, but also

to gain extra length of the coracoid graft.

5. Subscapularis split: (Fig. 6) The split must be made

at the junction of the lower 1/3 and upper 2/3 of the muscle

in order not to restrict external rotation. The authors prefer

the option with direct anterior visualization as described

above. The surgeon must be cautious during this stage to

avoid harming the axillary nerve. The axillary nerve should

be visualized initially and the surgeon should be aware of

its position at all times when performing the split. Addi-

tionally, the radio frequency ablation device should always

be directed laterally to avoid damage the axillary nerve.

6. Graft radius adjustment: After the graft is harvested,

the authors keep it on the guide and use the burr to adjust

the inferior radius of the graft to make it flat/coplanar with

the glenoid neck and to address any remaining irregulari-

ties. It is safer to the surrounding neurovascular structures

and technically simpler to move the graft with the attached

double cannula while keeping the burr still than to move

the burr on the graft. Suction on the burr should be off to

avoid soft tissue injuries. The vicinity to the brachial

plexus and its branches should always be appreciated.

7. Scapular retropulsion: In order to properly position

the graft and place the screws parallel to the glenoid plane

(thus ensuring the screw heads are not proud), it is helpful

to retract the scapula. If this cannot be achieved by simple

retropulsion, the authors screw an anchor 5.5-mm tap

through the (J)-portal into the base of the coracoid at the

osteotomy site (Fig. 8a). This is used as a joystick to lever

and retract the scapula and facilitate correct screw place-

ment. Traction on the arm should be avoided when per-

forming the arthroscopic Latarjet procedure as this will pull

forward the scapula and inevitably increase the angle

between glenoid plane and the screws.

8. Graft placement: The authors use a switching stick

through the (A)-portal along the glenoid plane to guide

accurate placement of the graft in the medial–lateral plane.

A lateral graft will hit against the tip of the switching stick.

Placement can easily be corrected by using the switching

stick to push the graft more medially. It is recommended to

temporarily advance the inferior wire just 2 mm in order to

stabilize the graft in and verify its position. This allows the

adjustment of the direction and rotation to define the best

position before the inferior wire is completely advanced.

This manipulation allows medial adjustment without losing

the correct height.

9. To ensure that the graft is not too low: The inferior

screw hole should be drilled first (Fig. 9a). This allows the

surgeon to feel whether the drill is within the glenoid bone.

A too inferiorly placed graft may cause recurrence of

anterior dislocation above the graft.

10. Reasons for a limitation of postoperative external

rotation: If the extent of subscapularis split was not medial

enough, external rotation can be limited. Maximal external

rotation of the shoulder, with the arm at the side, while a

switching stick is held through the subscapularis split will

avoid this limitation. Also, if the graft is positioned too

superior on the glenoid, the conjoint tendon is over ten-

sioned. Post-operative arthrofibrosis can also lead to

stiffness.

Fig. 10 Stage 10: final dynamic joint evaluation. Depicted is the

sling effect of the subscapularis tendon and muscle (SSC)

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Conclusion

The Arthroscopic Latarjet Procedure is a safe, reliable, and

reproducible procedure in the hands of experienced and

skilled arthroscopic surgeons. The technique is constantly

evolving with fine tuning of its steps and modern instru-

mentation that allows for a logical sequence of steps and

avoidance of errors. The authors recommend heeding the

above technical tips to safely and reproducibly perform the

procedure within a reasonable operative time while

achieving good results. Converting to the open technique

can be accomplished at any of the above stages of the

procedure.

References

1. Bhatia S, Frank RM, Ghodadra NS, Hsu AR, Romeo AA, Bach

BR Jr, Boileau P, Provencher MT (2014) The outcomes and

surgical techniques of the Latarjet procedure. Arthroscopy

30(2):227–235

2. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ,

Mow VC (1992) Tensile properties of the inferior glenohumeral

ligament. J Orthop Res 10(2):187–197

3. Boileau P, Mercier N, Old J (2010) Arthroscopic Bankart-Bri-

stow-Latarjet (2B3) procedure: how to do it and tricks to make it

easier and safe. Orthop Clin North Am 41(3):381–392

4. Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L

(2006) Risk factors for recurrence of shoulder instability after

arthroscopic Bankart repair. J Bone Joint Surg Am

88(8):1755–1763

5. Bui-Mansfield LT, Banks KP, Taylor DC (2007) Humeral avul-

sion of the glenohumeral ligaments: the HAGL lesion. Am J

Sports Med 35(11):1960–1966

6. Burkhart SS, De Beer JF (2000) Traumatic glenohumeral bone

defects and their relationship to failure of arthroscopic Bankart

repairs: significance of the inverted-pear glenoid and the humeral

engaging Hill–Sachs lesion. Arthroscopy 16(7):677–694

7. Johnson SM, Robinson CM (2010) Shoulder instability in

patients with joint hyperlaxity. J Bone Joint Surg Am

92(6):1545–1557

8. Jost B, Koch PP, Gerber C (2000) Anatomy and functional

aspects of the rotator interval. J Shoulder Elbow Surg

9(4):336–341

9. Lafosse L, Lejeune E, Bouchard A, Kakuda C, Gobezie R,

Kochhar T (2007) The arthroscopic Latarjet procedure for the

treatment of anterior shoulder instability. Arthroscopy

23(11):1242–1245

10. Latarjet M (1954) Treatment of recurrent dislocation of the

shoulder. Lyon Chir 49(8):994–997

11. Schmid SL, Farshad M, Catanzaro S, Gerber C (2012) The La-

tarjet procedure for the treatment of recurrence of anterior

instability of the shoulder after operative repair: a retrospective

case series of forty-nine consecutive patients. J Bone Joint Surg

Am 94(11):e75

12. Schulze-Borges J, Agneskirchner JD, Bobrowitsch E, Patzer T,

Struck M, Smith T, Wellmann M (2013) Biomechanical com-

parison of open and arthroscopic Latarjet procedures. Arthros-

copy 29(4):630–637

13. Simonet WT, Melton LJ III, Cofield RH, Ilstrup DM (1984)

Incidence of anterior shoulder dislocation in Olmsted County,

Minnesota. Clin Orthop Relat Res 186:186–191

14. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S

(1995) Arthroscopic stabilization for recurrent anterior shoulder

dislocation: results of 59 cases. Arthroscopy 11(2):173–179

15. Yamamoto N, Muraki T, An KN, Sperling JW, Cofield RH, Itoi

E, Walch G, Steinmann SP (2013) The stabilizing mechanism of

the Latarjet procedure: a cadaveric study. J Bone Joint Surg Am

95(15):1390–1397

16. Yamamoto N, Muraki T, Sperling JW, Steinmann SP, Cofield

RH, Itoi E, An KN (2010) Stabilizing mechanism in bone-

grafting of a large glenoid defect. J Bone Joint Surg Am

92(11):2059–2066

Knee Surg Sports Traumatol Arthrosc

123