LUtarjet-limit unique coracoid osteotomy Latarjet (With video)

Abstract

Background: The Latarjet procedure is an effective technique for the treatment of recurrent anterior shoulder dislocation with glenoid bone loss. However, the inevitable destruction of the coracoacromial arch may result in humeral head translation. The aim of the study is to introduce a modified Latarjet technique with coracoacromial arch preservation as well as its short term clinical outcomes.

Methods: We propose a novel individualized flexible arthroscopic suture button fixation Latarjet technique called `LUtarjet' with video. Precise measurements of the coracoid process, glenoid deficiency and osteotomy plane were made preoperatively. Only three arthroscopic portals were needed and limit unique coracoid osteotomy was performed with coracoacromial arch preservation. The mini window splitting of the subscapularis was performed from the posterior to the anterior direction and the split window was as small as 8-10 mm in length.

Results: A total of 27 patients (25.6 ± 5.4 years) were included in the study. The average surgical duration was 55.6 ± 6.3 min and the mean follow-up time was 8.1 ± 1.5 months. The functional score was significantly improved at the last follow-up. Radiologic evidence showed that the bone graft healing was placed in the desired position. No complications were found.

Conclusions: We present a fast, easy, accurate, safe arthroscopic 'LUtarjet' technique called FEAST that can simplify the arthroscopic Latarjet process and achieve a satisfactory bone graft position and satisfactory short-term clinical outcomes.

Level of evidence: IV, case series.

Keywords: Coracoacromial archBackground; Glenoid bone loss; Latarjet; Recurrent anterior shoulder dislocation; Suture button fixation.

Figure 1.

Schematic animation of the surgery. (a) The height and length of limit unique coracoid osteotomy can be individualized according to the size of the glenoid defect arc. (H, Height of the limit unique coracoid osteotomy; L, length of the limit unique coracoid osteotomy). (b) Coracoid bone block with anti-rotation and fixation bone tunnels and sutures. (c) The coracoid process is transferred, passed through the subscapularis and fixed on the anterior neck of the scapula with two cortical buttons and a 4-strand suture. (d) Schematic diagram of the principle of surgery on a cadaveric specimen. CAL Coracoacromial ligament, CP coracoid process, CT conjoined tendon, GN glenoid

Figure 2.

Preoperative measurement and design. (a) Injury side glenoid with GBL. The blue area represents the glenoid defect arc. Circles represent the optimal outer fitting circle (OFC). (b) Normal side glenoid. Circles represent the optimal OFC. (c) Measurements of length, width and thickness of the coracoid process and design of the limit unique coracoid osteotomy plane. (d) Surgical approaches in a right shoulder. AP Anterior portal, ALP anterolateral portal, PP posterior portal, GBL glenoid bone loss

Figure 3.

Limit unique coracoid osteotomy and bone block preparations. (a) Measurement of the coracoid process. (b) Marking of the limit unique coracoid osteotomy plane. (c) Limit unique coracoid osteotomy using an oscillating saw. (d) Central tunnel creation. (e) Anti-rotation tunnel creation. (f) Bone block preparation with sutures

Figure 4.

Localization of glenoid deficit arc, bone tunnel and anti-rotation anchor, and the plane of subscapularis split. (a) Location in 3D computed tomography en face view. (b) Anterior glenoid under arthroscopy. The blue arrow shows the center of the glenoid height. The yellow arrow shows the bone tunnel outlet. (c) Plane of subscapularis split. A Anti-rotation anchor positioning, D projection position of bone tunnel outlet, GN glenoid, HH humeral head, RF radiofrequency, S split subscapularis plane

Figure 5.

Bone tunnel positioning and drilling. (a) A microfracture awl marking the outlet of the bone tunnel. (b) Guide suture placement. (c) Polydioxanone suture guidance of the high-strength suture from the bone block passing the bone tunnel. (d) Anatomical relationship among the subscapularis split window, axillary nerve and guide suture. GN Glenoid, RF radiofrequency, SS subscapularis, HH humeral head

Figure 6.

Mini window splitting of the subscapularis. (a) Visualizing the muscular membrane in front of the subscapularis. (b) Splitting the subscapularis window laterally ~8–10 mm. (c) Anterior view of the subscapularis split window and axillary nerve. AN Axillary nerve, GN glenoid, RF radiofrequency, SS subscapularis

Figure 7.

Bone block transfer and fixation. (a) The fixation suture and anti-rotation suture were pulled to the rear and the bone block was placed in front of the subscapularis. (b) The bone block and subscapularis split window were adjusted to the vertical position. (c) The bone block was pulled into the glenohumeral joint. (d) The anti-rotation line was adjusted to flush the bone block to the glenoid articular surface. (e) A knotless suture anchor was fixed to the glenoid to prevent rotation of the bone block. (f) The bone block was fixed to the glenoid. GN Glenoid, RF radiofrequency, SS subscapularis, HH humeral head

Figure 8.

Postoperative MRI shows the integrity of the CAL, indicating preservation of the coracoacromial arch. CAL Coracoacromial ligament, CP coracoid process, MRI magnetic resonance imaging

Figure 9.

Computed tomography images of one representative case that underwent the individualized flexible fixation Latarjet procedure (en face view of the glenoid). (a) Preoperative mirror image of the normal side. (b) Injury side with glenoid bone loss preoperatively. (c) Injury side immediately after surgery. (d) Injury side at 6 months after surgery. The circle indicates the outer fitting circle