Concept
Transfer of coracoid process through subscapularis
1. Autograft bone block procedure - restore glenoid anatomy
2. Subscapularis tenodesis
- dynamic anteroinferior musculotendinous sling
- when shoulder in vulnerable position abduction and external rotation
Definitions
| Bristow | Latarjet |
|---|---|
|
Larger fragment Secured with two screw |
|
 |
 |
Indications
Critical bone loss > 20%
Subcritical bone loss > 10%
Engaging Hill Sachs
Contact athlete
Failed arthroscopic surgery
Large anterior glenoid deficiency
Large Hill Sachs
Failed arthroscopic stabilization
Bone block positioning
Good results can be correlated with
1. Coracoid process < 5 mm medial to glenoid rim
2. Coracoid positioned inferior to transverse equator of glenoid
3. Bony union develops between coracoid & scapula
4. Fixation screw purchases posterior glenoid cortex
5. Screw does not penetrate articular surface
Latarjet
Technique
Approach
Deltopectoral approach
- divide clavipectoral fascia at lateral edge of conjoint
Coracoid
Identify coracoid
- use fang retractor on superior surface to identify entire coracoid
- strip Coracoacromial ligament off lateral coracoid
- take pectoralis minor off medially
Divide coracoid
- 3 cm long
- use 90o oscillating blade on microsagittal saw 100
- medial to lateral
Prepare coracoid
- release conjoint for length, identify and protect MCN
- pect minor surface will be placed onto glenoid
- remove cortex with burr
- opposite side clear soft tissue with diathermy
- hold coracoid with Kocher forceps
- make 2 indentations with small burr where 2 x drill holes will be
- stops drill spinning off, ensures drill holes are sufficiently far apart
- 2 x 2.5 mm drill holes, tap, countersink
Deep Approach
SSC
- identify 3 sisters inferiorly
A. Divide muscle transversely at inferior 1/3 of SSC
- at muscle is easier to take off capsule
- also want to be inferior
- do so by inserting scissors and opening blades vertical
- use sponge to separate from capsule
- insert fang superiorly / blunt homan medially for view
B. Take down superior half of SSC
- repair later
Capsule
- feel joint line
- 2 x stay sutures 2 ethibond superiorly and inferiorly
- these must be medially over glenoid
- then divide capsule vertically with knife medial to stay sutures
- want maximum amount of capsule length to repair to anterior glenoid
- this prevents IR contracture
Dissect capsule from SSC
- inferiorly
- medially
- will have a free medial edge to repair to anterior edge glenoid
- may be easier to do this after osteotomy coracoid
- use scissors to dissect capsule superiorly
- beware inferiorly as AXN here
Exposure
- remove retractorr
- insert fukuda to expose humeral head, joint, glenoid
- again use fang / blunt homan superiorly and medially for exposure
ORIF Bone Block
Bone block
- clear glenoid 3 - 6 o'clock
- need medial area to place bone
- can use burr
- place bone on glenoid using Kockers to hold
- 2 x drill bits, leave first one insitu
- bone must not overhang medially
- bicortical, tap, typically 30 - 40 mm partially threaded cancellous
Capsule repair
Remove Fucuda
- find capsue with stay sutures
- insert 2 x 3 mm absorbable anchors 3 and 5 o'clock
- pass in mattress formation through capsule
- can use Depuy Mitek Suture grasper
- pass this through capsule lateral to medial, grasp suture
- tie capsule down, ensure knot goes down past bone block to glenoid
Complications
Infection
Nerve injury
Nonunion
Hardware issues
Osteoarthritis
Bone block too medial
Recurrent instability
- too high, can dislocate under bone block
- too low, can dislocate over bone block
