25 Modified Open Latarjet: The “One-Screw” Technique

10.1055/b-0039-167674

25 Modified Open Latarjet: The “One-Screw” Technique

Philippe Landreau

Abstract

Michel Latarjet described, in 1954, a coracoid bone block technique to prevent anterior shoulder dislocation and suggested that the horizontal limb of the coracoid process be fixed to the anterior margin of the glenoid with a screw. Today, the concept of the triple-blocking effect remains the same: the sling effect, the bone effect, and the capsular repair effect. This technique provides excellent results for the treatment of anterior traumatic shoulder instability, especially in cases of bone loss. However, there are some potential technical issues that can lead to complications. This chapter describes a modification of the open Latarjet technique. The procedure uses only one screw for fixation, in order to minimize the risk of coracoid fracture and to preserve more cancellous bone in contact with the scapular neck to improve the chance of healing. Additionally, the joint capsule is opened horizontally, which allows for more versatility for the final capsule suture. There are no specific instruments required, as this surgery can be done with the usual instrumentation that can be found in any operating theater. The coracoid preparation and the glenoid exposure are critical steps. A specific trick is described to accurately position the coracoid process without the use of a special guide. The two main potential mistakes that should be avoided are clearly highlighted: overhanging of the coracoid graft and capsular suture in internal rotation.

25.1 Goals of Procedure

Michel Latarjet was a French surgeon who described, in 1954, a coracoid bone block technique to prevent anterior shoulder dislocation and suggested that the horizontal limb of the coracoid process be fixed to the anterior margin of the glenoid with a screw. ¹ Later, in 1985, Patte et al developed the concept of “triple-blocking” effect ² :

The conjoint tendon sling effect. ³ When the arm is placed in abduction and external rotation position, the conjoint tendon, in its new position, acts as a reinforcement of the inferior subscapularis and anterior inferior capsule; it lowers the distal part of the subscapularis.
The bone effect by increasing or restoring the glenoid anteroposterior (AP) diameter.
The capsular repair effect (or Bankart effect). The repair of the capsule and inferior glenohumeral ligament to the stump of the coracoacromial ligament provides a third mechanism of stability to the glenohumeral joint. Even after all these years, the concept of the Latarjet procedure, open or arthroscopic, remains the same ( Fig. 25.1 ).

**Fig. 25.1** The concept of “triple-blocking” effect: conjoint tendon sling effect, bone effect, and capsule repair effect.

The capsule is repaired with the arm in full external rotation in order to avoid any postoperative limitation of motion during the physiotherapy protocol. The bone-to-bone fixation allows an earlier and more aggressive postoperative rehabilitation than in a Bankart procedure. The time to return to sport activities is usually 3 months for noncontact sports and 4 months for contact sports.

The surgical technique that we currently use is derived from the technique that Walch and Boileau already described. ⁴ We have modified some technical points that we believe have made the surgical procedure easier and simpler.

25.2 Advantages

In comparison with the “two-screw” technique, the procedure is simpler, with less risk of coracoid fracture. More cancellous bone is in contact with the scapular neck, allowing a better chance of consolidation. The horizontal capsulotomy allows a better versatility for further capsule suture.

There is no specific instrumentation. This surgery can be done with the usual instrumentation that can be found in any operating theater ( Fig. 25.2 ). If the Bateman retractor is not available, a Hohmann retractor can be used. If no Fukuda retractor is available, use a spoon or a Hohmann retractor at the inferior part of the joint.

**Fig. 25.2** Simple instrumentation used for the modified “one-screw” Latarjet technique.

25.3 Indications

The indications of Latarjet are still controversial. This procedure can be used for any case of anterior traumatic shoulder instability, as the outcomes are excellent and superior to the arthroscopic Bankart procedure. ⁵ However, this is not an anatomic procedure and the risk of complications is higher than that for the Bankart procedure. ⁶ Therefore, we recommend performing a Latarjet when there is a significant bone loss (glenoid bone loss or Hill–Sachs lesion not amenable to remplissage procedure) and in cases of contact/collision sport participation by the patient.

25.4 Contraindications

The Latarjet procedure is not indicated in case of multidirectional instability. In the rare situation of coracoid nonunion after previous coracoid fracture, we recommend assessing the quality and the size of the distal coracoid using a CT scan. We have performed some cases with success when the coracoid was usable. Otherwise, it is preferable to move to the Eden–Hybinette procedure knowing that the procedure will miss the sling effect of the coracobrachial.

25.5 Patient Preparation/Positioning

25.5.1 Preoperative Imaging

The usual preoperative imaging assessment comprises X-rays with AP views in three rotations, Bernageau incidence, and MRI. The MRI will detect any associated lesion (cuff tear, superior labral anterior and posterior [SLAP]) that will be treated arthroscopically before the open procedure, if needed. We do not perform a CT scan routinely, except if the bone loss needs a more accurate assessment.

25.5.2 Patient Positioning

After the usual preoperative preparation to prevent surgical site infection, a general anesthesia is administered. We do not routinely perform any interscalene block as this surgery is usually well tolerated and results in less postoperative pain. The patient is situated in a beach-chair supine position ( Fig. 25.3 ). Elevating the head of the table 30 to 45 degrees is usually enough to minimize bleeding and to allow the surgeon to work comfortably. Position the patient slightly toward the operative side until the lateral part of the shoulder is off of the operating room table. The arm should be stabilized with an arm holder. It should leave enough space for the surgeon to be close to the table, facing the shoulder. The assistant should be on the lateral side. A folded sheet or a sandbag is placed under the medial border of the scapula to push the affected side forward and tilt the scapula, allowing the arm to fall backward, opening the deltopectoral space and placing the coracoid process more laterally.