TEC HN | QUUSE Latarjet-Bristow Procedure for Recurrent Anterior Instability Gites Watcu, M.D. Clinique Sainte Anne Lumiére Lyon, France PASCAL BOILEAU, M.D. Hopital de VArcher Nice, France ™ HISTORICAL PERSPECTIVE In Burope in 1918, Eden (in 1) suggested the use of a preglenoid bone graft that exhibited much better me- chanical characteristics than capsular flaps, 10 prevent anterior migration of the humeral head. Subsequently. Oudard and Noesske (10) began to use the coracoid pro- cess with two different techniques: Oudard split its hori- zontal portion, in which he embedded a bone gratt ‘whereas Noesske osteotomized the base of the coracoid and sutured its lower tip to the anterior muscles. In 1954, Trillat (14) improved the stability of the osteotomized coracoid by securing the coracoid to the glenoid with a nail; he recommended routine exploration of the joint through an arthrotomy. Also in 1954, Latarjet (7) ratio- nalized the coracoid bone block technique, suggesting that the horizontal limb of the coracoid process be fixed with a serew flush to the anteroinferior margin of the glenoid, making a horizontal incision through the fibers of the subscapularis, English-speaking surgeons more readily refer to the Bristow technique described by Helfet (3), in which the tip of the coracoid process is sutured (0 the capsuloperi- steal elements through a short horizontal incision made in the subscapularis, In 1961, McMurray (9), like Latar- jet, secured the coracoid to the anterior margin of the lenoid with a screw. May (8) explained that the effi- ciency of the coracoid bone block was attributable to the bracing role played by the coracobiceps tendon and the subscapularis tendon in abduction-external rotation, rather than the bone block itself Therefore, the terms “buttress” and “bone block” are hot appropriate; the success of the intervention is ex eee corepes acetal i Sead oD Cis Wale Cl nique Sane fant amie, 85 Cou Alt Thomas, 8003 Lon ae Eval: socoly@tre.e plained by a triple effect. Patte proposed the term “triple blocking” to better describe the efficacy of the procedure 12): ‘© ‘Stable screw fixation of a bone block laid flat in a subequatorial position, flush to the anterior margin of the glenoid; the bone block is the horizontal limb of the coracoid process. © Preservation of the musculotendinous fibers of the inferior third of the subscapularis, ‘© Suturing of the lateral capsular flap to the medial 1 em of the coracoacromial ligament which remains at- tached to the coracoid, ‘The technique we describe in this article is a com- bination of all the advantages of the Latarjet, May, and Bankart procedures, with additional enhancements such as the preservation of the continuity of the subscapularis fibers. This has a dual advantage: first, range of motion exercises in external rotation can be begun immediately after the operation, and second, the integrity of the fibers Of the subscapularis tendon is preserved. Damage to the tendon fibers is precisely what Rowe (13) did not like about bone blocks, because it makes surgical revision (when necessary) more difficult, Furthermore, we have lected to use a fixation method that seems to provide good stability and solid fusion, and avoids secondary osteolysis of the bone graft ™ PREOPERATIVE AND IMAGING S' This procedure is proposed for all eases of traumatic or traumatic recurrent anterior instability (recurrent dislo cation or subluxation) and painful shoulder with bony lesions, attesting that the pain is related to instability and not to another etiology. In the rare case where the liga- mentous lesion is located on the humeral side (HAGL EQUIREME JDIES 256 Teohniques in Shoulder and Elbow SurgeryLatarjet-Bristow Procedure lesion), this procedure is not used and we suture the inferior glenohumeral ligament back to the anatomical neck of the humerus with suture anchors. ‘The reasons for our almost exclusive use of this tech- nigue inelude: © Better results in term of stability and range of motion obtained than with a Bankart-ype repair, in our ex- perience; ‘© Long experience with the procedure that makes it ‘easy, safe, and quick to perform (15); ‘© No need for immobilization or motion limitation dur- ing rehabilitation ‘¢ Faster resumption of activities of daily living and all types of sport more quickly than with a capsular re- pair, Preoperative imaging includes anterior-posterior ‘views in neutral, internal, and external rotation and a comparative Bernageau profile view of the glenoid (1) to detect bony lesions (e.g, Hillsachs, bony Bankart) m PROC! Anesthesia and Patient Positioning ‘The procedure is performed under general endotracheal thesia, The patient is secured in a beach-chair posi- tion with a small pillow behind the scapula to place the zglenoid surface perpendicular to the operating table (Fig. 1), The neck, chest, axilla, and entire arm are sterilized and draped free. DURE Incision for Deltopectoral Approach ‘The skin is incised 4 to 7 em starting under the tip of the coracoid process (Fig. 2). The deltopectoral interval is FIG. 1. Patient positioning: beach-chair position with a small pillow behind the scapula. FIG. 2. Vertical incision under the tip of the coracoid pro- ‘opened and the cephalic vein is taken laterally with the delioid. A sel ig retractor is placed in the delto: pectoral interval and a Homan retractor is placed on the {op of the coracoid process Harvesting of the Bone Block ‘This step requires repositioning the patient’s arm in a Afferent direction to facilitate exposure: © First, with the arm abducted 90° and externally ro- tated, the coracoacromial ligament is sectioned 1 cm from the coracoid. © The arm is then adducted and internally rotated to release the pectoralis minor insertion from the cora- oid. The base of the coracoid is exposed with a peri- steal elevator in order to see the “knee” of the cor coid process. With an osteotome or preferably a small angulated saw, the coracoid process is osteotomized from medial to lateral at the junction of the horizontal- vertical parts (Fig. 3). ‘© Then the arm is brought again into abduction external rotation and the coracohumeral ligament is released from the lateral part of the coracoid, Preparation of the Bone Block ‘The bone graft is grasped with forceps with teeth and carefully released from its deep attachments. ‘The lateral Vole Tt 27G. Waleh ind P. Boileau part of the conjoined tendon is dissected, avoiding the medial aspect and potential damage to the musculocuta- raft is everted and its deep sur- face is decorticated using a cutting rongeur or a saw Two holes are drilled parallel to each other in the deep afl, using a 3.2-mm drill. After measuring the thickness of the bone graft with a caliper it is positioned under the pectoralis major pending sub- sequent use, and held in place with the self-retaining retractor, which keeps the deltopectoral interval ope neous nerve, The bone surface of the bone Division of the Subscapularis and Exposure With the upper limb in full external rotation, the inferior and superior: ma pularis tendon are identified. The muscle is divided at the superior two thindVinferior one third junction, in line with its i electrocautery and then Mayo scissors. Hemostasis is performed carefully, step by step. Division is slowly carried down to the white capsule, and then is extended 4x 4-inch sponge into the ck the subscapular fossa. Lateally A Homan Capsulotom; sof the subs. medially by insert plane, thus exposin; it is extended as far as the lesser tuberosity retractor is placed in the subscapularis fossa, Placing the upper limb in neutral rotation provides full exposure of the capsule. A 1.S-cm vertical capsu lotomy is made at the level of the anterior-inferior mar- gin of the glenoid, which has been previously identified with an instrument. Placing the arm in full internal rota- tion allows insertion of a humeral head retractor which rests on the posterior margin of the glenoid. The superior two thirds of the subscapularis are retracted superiorly FIG. 3, Harvesting of the bone block that corresponds to the horizontal part of the coracold process, retaining the conjoined coracobrachial tendon and coracoacromial ligament. ‘with a Steinman pin impacted at the superior part of the sapular neck. ‘The inferior part of the subscapularis is retracted inferiorly with a Homan retractor pushed under the neck of the scapula between the capsule and the subscapularis, Exposure of the anterior-inferior rim of the scapula is now complete. It is then possible to inspect the labrum, cartilage, and insertion sites of the glenohu- ‘meral ligaments. The medial capsular flap is resected, along with any damaged portions of the labrum or frac ture fragments, The anterior-inferior margin of the glen- oid is exposed us Ipel, and then decortieated with a curette or an osteotome (Fig. 4). Fixation of the Bone Block with Screws The bone block is inserted through the soft tissue and positioned flush to the anterior-inferior margin of the glenoid, It is easy to check its correct positioning with the limb in internal rotation; whereas lateral overhang must be avoided, a slight medial positioning (no more than a few millimeters) is acceptable. The 3.2-mm drill is sd into the glenoid neck through the inferior hole of ft in an the bone nterior-posterior and superior di It is important to check the orientation of the articular surface and direct the drill parallel to this plane. The bone block is temporarily reflected to allow mea. rection surement of the drilling depth with a depth AO malleolar screw driven into the posterior cortex se- cures the bone block to the glenoid; t ened loosely to allow for easy rotation and proper posi tioning of the superior part of the bone block, which is fixed with a second AO malleolar screw throi Ar is screw is tightLatarjet-Bristow Procedure FIG. 4, The procedure is carried out by horizontal divi- sion the subscapularis (two thirds superior, one third in- ferior; top). The anteriorinferior glenoid rim is exposed (capsuloligament or bone resection in cases of fracture; middle) and decorticated (bottom) superior hole (Fig. 5). Both screws are then firmly tight ence. Closure The remnant of the coracoacromial ligament is repaired to the lateral capsular flap using two interrupted absorb- able sutures (Fig. 5). Suturing is performed with the limb in external rotation. The sponge previously placed in the subscapular fossa is removed, The arm is moved through all ranges of motion for assessment of mobility, The cut surface of the coracoid is coated with bone wax. A sue tion drain is placed and the superficial soft tissue layers are reapproximated and sutured Surgical Recommendations Osteosynthesis is crucial in order to avoid complications: ‘© Put the coracoid process in the “Iying” position rather than in the “standing” position to have a better contact between the bone interface and avoid pseudarth ‘© Use a 3.2mm drill bit for both the coracoid and the scapula © The two screws must be bicortical nd malleolar serews to have good compres. FIG. 5. The bone block is secured bicortcally by two malleolar screws (bottom). The outer capsular flap Is su: {ured to the remainder of the coracoacromial ligament (top). We now use malleolar screws without a washer 59G. Waleh and P, Boileau © Do not use a washer (o avoid impingement with the humeral head. © Never accept a lateral overhang of the coracoid in the joint; itcan lead to rapid degenerative joint disease. If the coracoid is 1 or 2 mm medial, there is no pejora- tive effect. m POSTOPERATIVE MANAGEME! ‘The patient uses a sling during the first 15 days after surgery for activities of daily living, but immediately begins a rehabilitation program twice per day in order to recover full range of motion (elevation, external rotation) fas soon as possible, There are no limitations and we allow a full recovery in elevation and external rotation during the immediate postoperative days After 15 days, the patient is permitted the use of a swimming pool, activities of daily living, complete re covery of motion, progressive strengthening exercises, and can resume working activities After 3 months, the patient can resume all types of sports activity, including contact sports = RESULTS Between 1985 and 1997, we have performed 1,098 ‘Latarjet procedures” in cases of chronic anterior insta- bility, which has allowed us to acquire total confidence when applying the procedure. ‘The series reported here included 160 interventions with an average follow-up of 3 years. Patients had been diagnosed with chronic anterior instability that did not include multidirectional hyperlaxity The study included 126 male patients. Mean age at intervention was 28 years (range 18~40 years). The dom- inant side was involved in 66% of cases; 88% played sports, Instabilities were classified as recurrent disloca- tion (84%), recurrent subluxation (12%), or isolated painful shoulder with signs of instability (4%). Radiographic lesions were demonstrated in 95% of cases, either Malgaigne lesions (Hillsachs; 73%) or glen- oid lesions (fracture or abrasion; 87%). Clinical Results Stability was excellent in 72% of cases, although 22% of patients reported apprehensiveness during sports activity and 5% during activities of daily living. There was 1% Pain was present in 41% of patients, generally during sports activity, seldom during activities of daily living, half was caused by an overhanging coracoid block. Pa tients often suffered from arm fatigue, Rotation was lim ited in 38% of cases, more often in internal (25%) than in external (13%) rotation, but limitation was moderate. Eighty-three percent of patients were able to resume their sports activity at the same level; 9% switched to another type of sport or practiced ata lower level because of their operated shoulder, In total, 81% of patients were very satisfied, 17% were satisfied, and 2% were disappointed, ‘The latter group included patients who had shoulder pain during sports or were apprehensive during activities of daily living. In total, 38% of results were excellent, 38% were good, 17% were fair, and 7% were poor. Radiographic Results Pseudarthrosis represented 2.4% of cases; it was related to the use of unicortical screws but had no influence on the outcome. Fractures of the transferred coracoid pro- cess represented 2.4% of cases: they always occurred within 3 months, and resulted from overtight intraopera- tive screws. In our series, they had no influence on the clinical result, Partial resorption of the coracoid occurred more frequently (9%), with varying extensions. Only those of ever two thirds of the coracoid led to persistence of apprehension and lowering of sports level; the post- tion of the coracoid had no influence on partial resorp- tion, No narrowing of joint space was observed, although an inferior humeral osteophyte was present in 11.6% of the cases (<7 mm). This correlated with an overhanging coracoid. ™ CONCLUSION ‘The present retrospective study confirms that the Latarjet procedure is a reliable operative procedure, as previously reported (2,4,5,11,15). Nine of 10 patients were satistied Pain is reduced by a rigorous technique that avoids over- hanging, which is critical in the avoidance of postopera tive arthritis. The classic reproach about the complexity of the po- tential revision is not justified in our experience. In case of revision, the surgeon must start the dissection at the inferior part of the wound, locate the conjoined tendon and follow it through the subscapularis (which was not ‘cut vertically but split horizontally) to the transferred coracoid process and the joint capsule. m REFERENCES 1) Bemageau J, Patte D. Di ique des Iuxa- tions récivantes de 'épaule, Rev Chir Orthop 1919:65: 101-7. este radiolo 2) Delaunay C, Lord G, Blanchard JP, et al. traitement des luxations récidivantes et des instabilités an \érieures de I'épaule par V'intervention de Latarjet. Ann Chir 1985;39;293-304, ace actuelle du 260 Techniques bx Shoulder and Elbow Surgery3 4 5 6 7 8 Latarjet-Bristow Procedure Helfet AF. Coracoid transplantation for recurring disloca~ tion of the shoulder. J Bone Joint Surg Br 1958;40:198— 202. Hill JA, Lombardo SJ, Kerlan RK, et al The modified Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations. Am J Sports Med 1981:9: 2837. 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