Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Arthroscopic latarjet procedure
OVERVIEW
Chapter synopsis
-
Bipolar bone loss or 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 shoulder instability with bone loss of the glenoid, humerus, or both, complex soft tissue injury, humeral avulsion of the glenohumeral ligaments (HAGL lesions), high-risk activity (e.g., in throwing or contact sport athletes), and revision of failed Bankart repair.
Clinical and surgical pearls
-
The technique progresses through the following steps:
-
Intra-articular preparation
-
Coracoid harvesting
-
Subscapularis split
-
Coracoid transfer
-
Coracoid fixation
-
Clinical and surgical pitfalls
-
Visualization without excessive swelling and minimal bleeding is the key to success. This requires an understanding and communication with anesthesia for perfect operating conditions and efficiency as the procedure progresses.
-
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.
-
The 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. , The open Latarjet procedure, transfer of the coracoid such that its inferior surface abuts the anterior glenoid, has been reported by several authors to produce a high rate of good to excellent results in long-term follow-up studies. 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 postoperatively.
Preoperative considerations
History
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 changes in the 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 the diagnosis is via a radiograph showing a dislocated position but more difficult if no radiograph was obtained before reduction. In some instances, the direction of instability is unknown, and it is important to determine whether the direction of instability is anterior, posterior, and/or multidirectional. 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 the 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. The hyper extension-internal rotation (HERI) examination test is interesting because it assesses the inferior glenohumeral ligament (IGHL) and inferior capsule complex without causing apprehension for patients in more than 90% of anterior instability cases.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here