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Keys to perform a Latarjet with a modified open Bankart repair
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In my experience, performing an open Latarjet with a modified open Bankart repair will maximize stability in collision athletes. There are several key steps: 1) attention to an extensile approach is necessary thoroughly developing the deltopectoral interval; 2) meticulous exposure of the coracoid process and using a 90° oscillating saw blade to obtain 22 mm to 25 mm of length; 3) freeing the coracoid process and conjoint tendon to the level of the musculocutaneous nerve to minimize tension on this structure after the coracoid is transferred; 4) splitting the subscapularis for the approach will permit retention of subscapularis function; 5) performing the medial vertical capsulotomy with the arm in external rotation to maximize return of range of motion; 6) proper positioning and fixation of the coracoid along the scapular neck; 7) performing a Bankart repair along the glenoid margin placing the coracoid and hardware in an extra-articular position; and 8) early protected range of motion.
Figure 1. The skin incision extends distally from the coracoid.
Figure 2. The coracoacromial ligament is incised with the coracoid exposed.
Figure 3. The pectoralis minor is exposed medial to tip of coracoid.
Figure 4. The base of the coracoid is exposed on medial side in preparation for osteotomy.
Images: Arciero RA
For this technique, the skin incision will start at the coracoid and extend distally (Figure 1). This is significantly more proximally than the open traditional Bankart incision is made, more distal near the anterior axillary fold. We find the deltopectoral interval, and I think that the key to any surgery and particularly for instability cases, is to open up the deltopectoral interval from the clavicle all the way distal to the pectoralis major tendon. These two muscles are freed and mobilized so that they can be easily retracted and the deltopectoral interval opened thoroughly (Figure 2). This facilitates an easier deeper exposure.
Using a self-retaining retractor to retract the deltoid and pectoralis major muscles is helpful. The next important anatomic landmark is to identify the fleshy fibers of the short head of the biceps. Incise lateral to this muscle to open the clevipectoral fascia, and this will minimize bleeding. Proceed proximally and release the coracoacromial (CA) ligament, which will be necessary to transfer the coracoid. Then, proceed distally. I routinely release the falciform ligament just proximal to the pectoralis major tendon as this improves inferior exposure.
To isolate the coracoid process, attention is turned to the medial side of the coracoid. The fat stripe between the pectoralis minor attachment on the medial side of the coracoid and the conjoint tendon at the tip of the coracoid marks an easy way to separate these structures (Figure 3). Electrocautery is used to release the pectoralis minor off the medial aspect of the coracoid and all soft tissues are released from the medial and inferior aspect of the coracoid with an elevator. This will expose the entire medial and inferior aspect of the coracoid to the base of this process (Figure 4). Mark a distance of 25 mm from the tip of the coracoid to the base to ensure that after osteotomy the length of the coracoid process is of sufficient length. A 90° oscillating saw is a key tool to perform a proper and efficient coracoid osteotomy. I typically will begin the osteotomy from the medial aspect of the coracoid to lateral and protect the medial neurovascular structures with a blunt elevator medially.
Expose the musculocutaneous nerve
After the coracoid is cut, the coracohumeral ligament will need to be released from the lateral aspect of the coracoid to begin mobilization of the coracoid. One of the most critical maneuvers is to release the coracoid process and attached conjoint tendon distally to the level of the musculocutaneous nerve (Figure 5). There are numerous fascial bands that will require release to fully mobilize the coracoid process and conjoint tendon. This will minimize tension on the musculocutaneous nerve when it is subsequently transferred to the scapular neck.
Preparation of the coracoid is the next step, and this begins by delivering the coracoid out of the wound and exposing the inferior surface. The coracoid will need to be flattened and this is done with a saw or burr to obtain a fine petechial bleeding surface. Then two 3.5-mm drill holes are made approximately 10 mm apart. The coracoid can be then placed behind the self-retaining retractor.
Figure 5. The coracoid osteotomy is completed and released distally until the musculocutaneous nerve is exposed.
Exposure of the glenoid is initiated thru a split in the subscapularis between the upper and lower thirds of the muscle immediately medial to the tendon. Using blunt scissors and elevators, it is easily possible to separate the muscle from the underlying capsule. A sponge can be used to “push” the muscle off the capsule medially and develop this plane. Often, a suture in placed in the sponge itself for later retrieval as it can become lodged quite medial and difficult to retrieve at the end of the procedure. Continue to split the subscapularis out laterally so that when a 90° blunt Gelpi retractor is placed, the subscapularis split is a wide interval. Dissection inferior to the tendinous attachment of the subscapularis will maximize functional return of this important muscle.
The capsulotomy is the next step. Place the arm in maximal external rotation and place a posterior force on the humeral head. This will delineate the level of the glenoid margin quite well. Incise the capsule vertically along the bony rim of the glenoid. This will maximize capsular length and minimize loss of motion with subsequent Bankart/capsular repair. A scapular neck retractor is placed medially and a Fukuda retractor into the joint to retract the humeral head (Figure 6). Superiorly, it is sometimes advantageous to place a Steinmann pin into the upper scapular neck to act as an additional retractor of the upper portion of the subscapularis muscle belly.
Figure 6. Humeral head retractor is placed exposing the glenoid and anteroinferior bone loss.
Figure 7. The inferior coracoid fixation drill hole is made at the 5 o’clock position approximately 7 mm to 8 mm medial to the edge of the glenoid (This represents half the width of the coracoid process to insure proper positioning).
Figure 8. The superior fixation drill hole is created using the proximal hole in the coracoid as a “drill-guide.”.
Figure 9. Coracoid fixation is completed.
Preparation of the scapular neck for placement of the coracoid is next done with a burr. The area prepared would correspond to the 2 o’clock to 6 o’clock position on a right shoulder for the width of the coracoid. We prefer to place the inferior portion of the coracoid along the scapular neck. The scapular neck is drilled with a 2.5-mm drill at about the 7 o’clock or 8 o’clock position, parallel to the glenoid fossa and thru the posterior cortex. This drill hole is made about 7 mm to 8 mm medial to the edge of the glenoid rim to minimize lateral overhang after securing the coracoid (Figure 7). Most coracoid processes are 14 mm to 16 mm in diameter and the 3.5-mm lag drill hole previously placed in the center of the coracoid will make the lateral edge of the coracoid transfer adjacent to the glenoid rim. We measure the length of the drill hole of the hole placed at the 7 o’clock position, add it to the thickness of the coracoid and this will provide the length of the initial 3.5-cortical screw necessary (typically 30 mm to 36 mm). The selected screw is then placed into the inferior most hole in the coracoid and then fixed into the drill hole at the 7 o’clock position on the scapular neck. Delivering the screw through the coracoid at least 15 mm to 20 mm will make it much easier to find the corresponding drill hole in the scapular neck. While tightening the screw, proper rotation of the coracoid is checked.
The superior drill hole in the coracoid process can be used as a drill guide for the second more proximal hole in the scapular neck (Figure 8). Drill the 2.5-mm drill through the coracoid acting as a drill guide and through the scapular neck and posterior cortex, measure the length of 3.5-mm cortical screw and complete fixation of the coracoid.
The CA ligament, attached laterally, will drape over the lateral edge of the coracoid and make it difficult to see if the coracoid is fixed flush at the articular margin. We routinely will reflect a small portion of the CA ligament off the lateral aspect of the coracoid to inspect the glenoid-coracoid interface and ensure no lateral overhang, and be sure that the graft is flush with the glenoid fossa (Figure 9).
Additional stability
Figure 10. The Bankart repair is secured making the coracoid transfer extra-articular.
Finally, we will place three anchors along the glenoid margin and perform a modified Bankart repair. These sutures are passed through the medial edge of the capsule. With subsequent knot-tying, the capsule is repaired directly to the edge of the glenoid, rendering the coracoid transfer in an extra-articular location (Figure 10.) This may add additional stability, places the hardware outside the joint and may minimize the risk of osteoarthritis as long as motion is preserved.
The postoperative rehabilitation is critical. The young athlete is protected in an immobilizer for 3 weeks to 4 weeks, but immediate motion is initiated with forward flexion to 140° and external rotation to 30°. Full motion is permitted at 6 weeks and return to sports allowed at 5 months to 6 months.
Reference:
Arciero RA. Surgical Spotlight: How I do a Latarjet — Pearls, pitfalls and outcomes. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 10-13, 2014; Seattle.
For more information:
Robert A. Arciero, MD, can be reached at UConn Health, 263 Farmington Ave., Farmington, CT 06030; email: arciero@nso.uchc.edu.
Disclosure: Arciero is on the speakers bureau for and receives institutional support from Arthrex.