Arthroscopic Latarjet Procedure

Arthroscopic Latarjet Procedure

Laurent Lafosse, Dipit Sahu and Wade Andrews

Chapter Synopsis

• Failure of Bankart repair has led many surgeons to perform a Latarjet procedure for recurrent instability. Open Latarjet repair has shown good long-term results. The arthroscopic Latarjet procedure combines the advantages of an open Latarjet procedure with the advantages of an arthroscopic approach.

Important Points

• Indications include instability with bone loss, complex soft tissue injury, humeral avulsion of the glenohumeral ligaments (HAGL lesions), high-risk activity (e.g., in throwing athletes), and revision of failed Bankart repair.

Clinical and Surgical Pearls

• The technique progresses through the following steps:

– Intra-articular preparation

– Coracoid exposure

– Subscapularis split

– Coracoid harvesting

– Coracoid transfer

– Coracoid fixation

Clinical and Surgical Pitfalls

• The pectoralis minor tendon should be completely erased from the coracoid.

• The coracoid graft should be given enough freedom from all adhesions and bursa to allow it to be displaced to the level of the glenoid.

• The subscapularis split should be wide enough to allow easy passage of the graft to the glenoid.

• Final position of the graft should be checked from three different portals.

Several options exist for the surgical treatment of anterior glenohumeral instability. Although the Bankart procedure has been shown to have reliably favorable results, there exist certain conditions (e.g., glenoid fracture, engaging Hill-Sachs lesion, inferior ligament hyperlaxity) that can signal a potentially suboptimal outcome.1,2 The open Latarjet procedure, transfer of the coracoid such that its inferior surface abuts the anterior glenoid, has been reported by several authors to return a high rate of good to excellent results in long-term follow-up studies.^3–9 Mid-range stability is increased by the additional bone stock increasing the effective surface area of the glenoid. End-range stability is aided by the sling effect of the transferred short head of the biceps; as the arm is brought into increasing abduction, this tendon is brought under increasing tension, resisting anterior translation of the humeral head. The goal of this procedure is to recreate the open Latarjet procedure through an all-arthroscopic approach. This allows not only the reproduction of a reliable procedure, but also enhanced ability to address concomitant pathology, as well as accelerating patient mobility.

Preoperative Considerations

It is important to determine the functional use of the shoulder by the patient’s age, sport (type and level), work, and level of danger in case of instability (e.g., climbers, carpenters). It is also desirable to know any modifications to activity or change in level of performance caused by the instability.

Pertinent history includes a description of the initial instability event, including the mechanism of injury and method of reduction. The number and quality (subluxation versus dislocation) of subsequent instability episodes should be investigated, as well as any aggravating factors or positions. Particular attention must be paid to the exact definition of dislocation or instability; this determination is easy when diagnosis is via a radiograph showing a dislocated position, but more difficult if no radiograph was obtained before reduction. Other pertinent details include the exact mechanism of injury, the time elapsed before relocation, and whether the relocation was performed by a physician or by someone else. Occasionally it is not possible to determine if the episode was a subluxation or an actual dislocation, and the final diagnosis of instability will depend on secondary bony or soft tissue lesions from radiologic investigations.

Symptoms

The classic anterior instability patient will report apprehension or frank instability when the affected arm is brought into increasing amounts of abduction and external rotation. Patients may also describe pain, catching sensations, weakness, and inability to perform at previous levels in their sport.

Physical Examination

In the case of an acute injury, it is important to evaluate a radiograph before physical examination, to exclude any fracture (e.g., glenoid fracture, great tuberosity fracture). The physical examination should begin with the patient being asked to demonstrate his or her range of motion and any positions that are known to cause apprehension. Some patients may be able to demonstrate intentional subluxation or even dislocation. With the patient in a standing position, both shoulders are taken through a passive range of motion as comfort allows. End range is measured in flexion, abduction (Gagey test), internal and external rotation, and extension (retropulsion). Apprehension tests are performed at 0, 90, and 140 degrees of abduction. One should remember to perform a complete examination including assessment for other possible pathologies. Posterior instability can be examined with either a jerk or a drawer test. The rotator cuff strength should be examined and the acromioclavicular joint evaluated for tenderness. Finally, one should remember to test for a sulcus sign and look for other signs of ligamentous laxity.

Imaging

High-quality imaging studies are of paramount importance in accurate evaluation of patients with instability. Plain radiographs with five views of both shoulders are obtained: true anteroposterior (AP) views in neutral and internal and external rotation, Y-lateral view, and Bernageau glenoid profile view or axillary view if fluoroscopy is not available. It is critical that the Bernageau view be performed with the x-ray beam aligned parallel to the long axis of the scapula (from superior to inferior). Furthermore, this relationship must be maintained when the uninvolved shoulder is imaged. This should produce images that show the glenoid in near-identical profiles, allowing an accurate assessment of bone loss in the AP plane. If radiographs show clear proof of dislocation, such as a large Hill-Sachs lesion or an inferior glenoid fracture, further investigation may not be necessary. However, for clear definition of soft tissue to be achieved, radiography is often supplemented with either computed tomography (CT) or magnetic resonance arthrography (MRA). Although magnetic resonance imaging (MRI) does show more soft tissue detail, it is the senior author’s (L.L.) preference to obtain a CT arthrogram for increased detail of bony lesions.

Indications

• Instability with glenoid, humeral, or combined bone loss

• Complex soft tissue injury, humeral avulsion of the glenohumeral ligaments (HAGL lesions)

• High-risk activity—for example, in throwing athletes, contact athletes (American football, rugby), overhead athletes (rock climbing, swimming), manual laborers

• Numerous episodes of instability

Contraindications

• Absence of coracoid (previous Latarjet procedure)

• Voluntary and intentional dislocators

• Multidirectional instability with pronounced ligamentous laxity

Surgical Technique for Arthroscopic Latarjet Procedure after a Failed Bankart Procedure

Anesthesia and Positioning

General anesthesia with a regional nerve block is the preferred technique.

The patient is prepared as for a normal shoulder arthroscopic procedure, with care taken to have a wider area exposed medially for the most medial portal (Fig. 19-1). The patient is placed in the beach chair position.

Figure 19-1 Lateral view of portals used in the Latarjet procedure.

The following technical tips are important and specific for this procedure:

• The arm should be free (without any traction).

• The medial border of the scapula should be supported by a back support. This helps to act as a hinge on which the scapula can be rotated posteriorly with the help of switching sticks (as described later) to make the glenoid face more laterally. Supporting the shoulder on its back at the level of the spinal edge of the scapula maintains it in an external rotation position and facilitates the fixation of the bone graft to the glenoid.

Surgical Landmarks, Incisions, and Portals

Seven portals are used, denoted by the letters A, D, E, H, M, I, and J (Figs. 19-1 and 19-2).

Figure 19-2 Portals M, I, and J are used specifically for the arthroscopic Latarjet procedure.

Portals A and E are the starting portals, and the rest are introduced as the surgery proceeds.

The three portals that are used specifically in this surgery are as follows:

• Portal M: This is the most medial portal, through which the double-barrel cannula is introduced to control the coracoid graft.

• Portal I: This portal is in direct line with the axis of coracoid.

• Portal J: This is used as a viewing portal for the subscapularis muscle.

Specific Steps

Specific steps for this procedure are outlined in Box 19-1.

Box 19-1 Surgical Steps

1. Intra-articular preparation

Inspect the glenohumeral joint through portals A and E

Remove the labrum

Remove the capsule

2. Coracoid exposure

Create the rotator interval opening

Conjoint tendon

Visualize the axial nerve

3. Subscapularis split

Establish the inferior I and inferolateral J portals

Determine the level of subscapularis split

Create portal M

Subscapularis split

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Tags: Surgical Techniques of the Shoulder Elbow and Knee in Sports

Sep 11, 2016 | Posted by admin in SPORT MEDICINE | Comments Off

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