After a thorough diagnostic shoulder arthroscopic evaluation is performed with the arthroscope inserted through the A portal, the E portal is created, and the rotator interval is completely removed to gain access to the capsulolabral complex, coracoid process, and conjoint tendon. Care should be taken to preserve the biceps pulley. The coracoacromial ligament is detached from the lateral aspect of the coracoid process. Should any intra-articular abnormality is found, it should be corrected before proceeding with the Latarjet procedure, with the exception of anterior capsulolabral or glenoid injuries. Engagement of the Hill–Sachs lesion with the anterior glenoid is assessed by abduction and external rotation of the shoulder. The extent and characteristics of bony anterior glenoid injuries are much better evaluated later visualizing from anterior D to E portals.

The labrum is carefully peeled off from the anterior glenoid with a radiofrequency probe, and a cleavage plane between the anterior capsule and the posterior articular aspect of the subscapularis developed until the capsule is completely independent of the subscapularis from two to six o’clock positions. Then the labrum is transected at the two o’clock position and the capsulolabral complex fully retracted inferiorly and hidden into the axillary pouch to allow free passage of the graft through the subscapularis at a later stage.

With the rotator interval widely open, a needle is inserted just above and parallel to the superior edge of the subscapularis to orient the D portal. The lateral and inferior aspects of the coracoid can be skeletonized using a radiofrequency probe or a shaver inserted through the D portal.

After glenohumeral joint preparation, the arthroscope is moved into the D portal, allowing the inferolateral J portal to be created under direct visualization. A shaver or a radiofrequency probe is inserted through the J portal to remove any soft tissue remaining in the lateral and inferior aspect of the coracoid. It is also used to dissect the lateral border and anterior aspect of conjoint tendon as well as the superior aspect of the coracoid making sure that any soft tissue is cleared to the origin of the coracoclavicular ligaments. It is recommended to release the lateral border of the conjoint tendon as inferiorly as possible reaching the insertion of the pectoralis major tendon to facilitate later coracoid graft mobilization. The mobility of the coracoid process should be tested while it is released. This is especially important in revision cases where scar tissue might preclude soft tissue mobilization. The arthroscope is then moved to this J portal and the M portal created to begin with the coracoid harvesting process. During all the process of coracoid dissection and harvesting, we found it very useful to use switching sticks inserted through the D and E portals to elevate the deltoid and pectoralis major in order to create additional working space and improve visualization in the anterior extra-articular region of the shoulder.

The coracoid harvesting process is performed visualizing from the I portal, which allows a frontal view of the tip of the coracoid. The pectoralis minor is resected from the coracoid using a radiofrequency probe inserted through the M portal. While performing this step, the brachial plexus and the musculocutaneous nerve may be at risk. To prevent any inadvertent damage of nerves, it is recommended to use the probe always facing superiorly. Once the coracoid is completely exposed, an additional portal (H) is created above the coracoid in order to gain access for pre-drilling the coracoid osteotomy. Coagulation of a branch of the cephalic vein can help avoid potential bleeding when creating this superior portal. A commercially available cannulated ∝ß drill guide has been developed to aid in the coracoid harvest process. The guide is inserted through the H portal and should be accommodated between the middle and medial third of the width of the coracoid process (two-thirds lateral and one-third medial) and at minimum of 7 mm posterior to the coracoid tip to avoid lateral or anterior screw placement. The drill guide aids in the insertion of two (∝ and ß) K-wires that perforate the coracoid process superiorly to inferiorly (Fig. 16.2). Once the coracoid is drilled, the guide is removed and the position of the wires 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.

Attention is now turned toward coracoid osteotomy. The osteotomy is started on the superior, lateral, and medial surfaces of the coracoid process creating a through with a forefoot cutting drill bit power tool inserted through the superior H portal. A minimal 4 mm security distance between the osteotomy line and the posterior is recommended to avoid fracture of the graft. Once the coracoid base is osteotomized at the superior, medial, and lateral cortical bone, the osteotomy is performed from the H portal using the curved osteotome. The coracoid is then retracted medially and inferiorly to expose completely the anterior aspect of the subscapularis.

Before starting the split of the subscapularis, the connective tissue covering the anterior aspect of the subscapularis tendon and muscle is fully resected using a shaver. The ideal level of the split should be established between the middle third and inferior third of the tendon. To define this level, it is helpful to insert a Wissinger rod through the posterior portal that will pierce the subscapularis at the four o’clock level of the glenoid. After verification of correct level through various portals, a split in the subscapularis is created using radiofrequency probe inserted either through the M or I portals. It is advised to extend the subscapularis split as wide as possible to facilitate the passage of the graft into the joint. The lesser tuberosity and the axillary nerve delineate the lateral and medial limits of the split, respectively. The axillary nerve should be visualized with caution (Fig. 16.3). Placing the dull large trocar through the muscle and onto the glenoid can complete the split and externally rotating the shoulder with the arm adducted.

For coracoid transfer, the subscapularis split is opened by retracting the superior two-thirds of the tendon with the Wissinger rod inserted through the joint and the inferior third with an additional rod inserted thorough the I portal. The coracoid is fixed to a transparent double-barrel cannula inserted through the medial M portal that will be used to drive the graft. Two long coracoid-holding screws are passed through the bores of this cannula and the top hats into the bone. The coracoid can now be fully mobilized with the remainder of soft tissue attachments released. Before transferring the coracoid to the glenoid, the undersurface of the coracoid and the anterior glenoid rim are decorticated using a motorized arthroscopic burr without suction. This burr can be inserted either through the lateral D or superior H portals for the coracoid and through the J or I portals for the glenoid.

To facilitate the mobilization of the coracoid graft toward the glenoid, the scapula is retracted posteriorly, and the arm placed in internal rotation and forward flexion, thereby releasing the conjoint tendon and opening the subscapularis split. The double-barrel cannula is now used to joystick the coracoid graft into proper position on the glenoid, while usually visualizing from a J portal. Optimal positioning is about 1–2 mm medially to the cartilage in the axial plane and inferiorly to the glenoid equator in the sagittal plane surface ensuring bony congruence. Once the graft is satisfactorily positioned, two long K-wires are used to drill through the graft, glenoid, and finally through the posterior shoulder skin. We recommend drilling first the inferior wire to ensure bony contact. Once the graft is stabilized on the glenoid surface with these two long K-wires, the long screws that fixed the graft to the double-barrel cannula are removed and two holes drilled with a 3.2 mm cannulated drill driven by the K-wires starting with the inferior hole. Screw length measurement is carried out using the laser marks on the drill bit when the posterior glenoid cortex is perforated (usually 28–34 mm). The inferior screw is then inserted and the process repeated for the superior screw. Care must be taken to alternately tighten the screws to provide adequate compression without fracturing the graft. The final graft position is checked through J, D, and posterior A portals and any prominences gently abraded with a burr. Once it is confirmed that the coracoid position is adequate, the K-wires are removed posteriorly and the cannula retrieved anteriorly. It is also important to check that the subscapularis muscle is completely anterior to the coracoid graft permitting full excursion in external rotation. In addition, the head of the screws should not interfere with the humeral head during internal rotation.

Glenohumeral osteoarthritis at long-term follow-up has been reported as complication of the Latarjet procedure. Bouju et al. have recently reported a lower incidence of osteoarthritis (8.5%) compared to previously published series with a minimum 10-year follow-up [14]. In this investigation, the strictly extracapsular situation of the bone block appeared as an important factor in limiting long-term osteoarthritis, and capsule reinsertion seemed to alleviate the radiologic complications. Based on these findings, we consider that the capsulolabral complex should be reconstructed unless the capsular tissue is in a poor condition.

In this last step of the procedure, a forceps is inserted through the E portal to grasp the capsulolabral complex from the inferior axillary pouch and reduce it back to the anterior glenoid rim visualizing the joint from the conventional posterior A portal. The labrum is reattached to the anterior glenoid rim using conventional anchors, and in this manner, the graft is left outside the joint. The anchor located at two o’clock position should be inserted first and the upper part of the labrum reattached to stabilize the labrum in its anatomic position. Then the labrum is sutured superiorly to inferiorly to the six o’clock position. All suture anchors are recommended to avoid impaction of the anchors with the coracoid screws.

Long-term studies of the open Latarjet procedure have confirmed its efficacy in terms of safety for the patient and stability of the joint. It provides excellent results and patient satisfaction with an overall recurrence rate of 0–8% [4, 15–17]. However, literature regarding the long-term results of all-arthroscopic Latarjet is still scarce. As mentioned before, the rationale for arthroscopic Latarjet is that it would combine the excellent results obtained by means of the open technique with the advantages that arthroscopy provides. The main concern about the arthroscopic procedure is the learning curve with the neurovascular risk that it implies [18]. Arthroscopic Latarjet offers potential advantages: firstly, the avoidance of a diagnostic previous shoulder arthroscopy in order to evaluate the soft tissue quality and bony defect and need to reconversion to an open surgery; secondly, the visual control of the joint during coracoid placement that could avoid malpositioning of the graft and screw prominence [19, 20]; thirdly, the possibility to detect and treat other intra-articular lesions such as superior or posterior tears as well as cartilage defects; and lastly, a faster recovery based on diminished postoperative pain, scar tissue, and stiffness [21].