Mini-Open Arthroscopically Assisted Bristow-Latarjet Procedure

for the Treatment of Patients With Anterior Shoulder Instability:

A Cadaver Study

Geoffroy Nourissat, M.D., Guillaume Nedellec, M.D., Niamh A. O’Sullivan, M.D.,

Aurore Debet-Mejean, M.D., Christian Dumontier, M.D., Alain Sautet, M.D., and
Levon Doursounian, M.D.

Purpose: The purpose of this study was to evaluate the arthroscopically assisted Bristow-Latarjet
procedure. The aim was to use arthroscopic guidance to assist in positioning of the coracoid bone
block onto the anterolateral aspect of the glenoid. The feasibility of this technique and its efficacy,
reproducibility, and potential neurovascular complications were evaluated. Methods: A minimally
invasive technique was used to harvest the coracoid bone block and the attached coracobiceps
tendon. A portal was created through the subscapularis muscle and, under arthroscopic guidance,
the anterior aspect of the glenoid was cleaned and reamed before the bone block was placed.
Cannulated screws (3.5 mm) were used to fix the vertically oriented bone block to the glenoid. The
size of the bone block, its position on the glenoid, and its relation to the subscapularis tendon and the
musculocutaneous and axillary nerves were recorded. Results: In all 5 cadavers, the bone block was
well positioned and was fixed to the anteroinferior part of the glenoid. No lesions of the cephalic vein or
of the surrounding neurovasculature were observed. Conclusions: This study demonstrated the safe and
effective use of this arthroscopically assisted technique for correct positioning of the coracoid bone block
at the anterolateral aspect of the glenoid in the cadaveric shoulder. Arthroscopy facilitated adequate
reaming of the anterior glenoid and aided in optimal positioning of the bone block. Clinical Relevance:
This cadaveric study highlights the advantages offered by an arthroscopically assisted Bristow-Latarjet
procedure, which optimizes positioning of the block and ensures adequate reaming of the anterior glenoid,
thereby potentially reducing the risks of early nonunion and late arthritis— complications commonly
associated with the classical Bristow-Latarjet technique. Key Words: Shoulder instability—Cadaver
study—Arthroscopic Bristow-Latarjet procedure.

T reatment for patients with recurrent anterior

From the Service de Chirurgie Orthopédique, Hôpital Saint
Antoine Université Paris VII, Paris, France.
The authors report no conflict of interest. Research was per-
formed at Ecole de Chirurgie du fer a Moulin, Paris, France.
Address correspondence and reprint requests to Geoffroy Nour-
issat, M.D., Service de Chirurgie Orthopédique, Hôpital Saint
Antoine Université Paris VII, 184 Rue du Faubourg Saint Antoine,
75012 Paris, France. E-mail: gnourissat@wanadoo.fr
© 2006 by the Arthroscopy Association of North America
0749-8063/06/2210-5470$32.00/0
doi:10.1016/j.arthro.2006.06.016
NOTE: To access the supplementary videos accompanying
this report, visit the October issue of Arthroscopy at
www.arthroscopyjournal.org
shoulder instability has been grouped into 2 sur-
gical categories: soft tissue repair and placement of a
bone block. Soft tissue repair techniques first de-
scribed by Bankart1,2 have since been modified and
include open3-6 and arthroscopic approaches.7-10 Bone
block, most commonly known as Latarjet’s or Bris-
tow’s procedure, presents an alternative avenue of
treatment.11-13 In cases involving bone loss from the
humeral or the glenoid aspect of the shoulder, a bone
block procedure may be indicated.14 This procedure,
which involves placement of a coracoid bone block
with its attached coracobiceps tendon onto the antero-
inferior glenoid, has been traditionally performed as
an open technique.15-24 An average failure rate of less

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 10 (October), 2006: pp 1113-1118 1113
1114 G. NOURISSAT ET AL.
than 5% has been reported in the literature, similar to
that of the Bankart procedure. Complications most
often associated with this technique include poor po-
sitioning and nonunion of the bone block; these com-
monly result from the interposition of soft tissue be-
tween the glenoid and the block.
In this cadaveric study, the efficacy of an arthro-
scopically assisted Bristow-Latarjet procedure was
evaluated to determine its potential for improving
bone block position while minimizing the complica-
tions classically associated with this technique.
METHODS
Five arthroscopically assisted Bristow-Latarjet pro-
cedures were performed on ethanol/phenol-preserved
cadaveric shoulder specimens. Cadavers were placed
in the beach chair position. The coracoid was pal-
pated, a small incision was made over the bony prom-
inence, and an oscillating saw was used to harvest the
coracoid bone block. The dimensions of the coracoid
and the diameter of the associated coracobiceps ten-
don were recorded (Fig 1). After the coracoid had
been transected, the coracobiceps tendon was freed
bilaterally under direct vision. A 3.5-mm hole was
drilled vertically through the coracoid to accommo-
date the 2.7-mm screw. The harvested bone was in-
troduced inferior to the deltoid muscle and medial to
the deltopectoral groove to protect the musculocuta-
neous nerve.
An arthroscope was employed to facilitate the pro-
FIGURE 1. Minimally invasive harvest of the coracoid bone block
with the attached coracobiceps tendon. The bone block was pre-
pared for fixation with use of a 2.7-mm cannulated reamer and a
k-wire.
FIGURE 2. To facilitate the trans-subscapularis approach, the op-
erator’s finger was placed through the bone block harvest portal to
medially retract and protect the musculocutaneous nerve and the
coracobiceps tendon. The trocar was then advanced through the
subscapularis to the desired position for the bone block.
cedure. The scope was introduced through the con-
ventional posterior soft point (2 cm inferior to the
posterolateral aspect of the acromion). Glenohumeral
exploration allowed visualization of the subscapularis
tendon, the glenoid rim, and the glenohumeral liga-
ments. The scope was positioned over the desired
location for the bone block (the anteroinferior aspect
of the glenoid, at 4 o’clock for the right shoulder and
at 8 o’clock for the left shoulder), and a portal was
created through the subscapularis muscle. Upon cre-
ation of the trans-subscapularis portal, the operator’s
finger was used to medially retract and protect from
the trocar the coracobiceps tendon, the bone block,
and the musculocutaneous nerve. An anterior portal
was then created at a previously described posi-
tion.25,26 The deltoid and its overlying skin were in-
cised, and a 12-mm cannula (Thoracoport; Tyco, Nor-
walk, CT) was introduced through the portal (Fig 2).
Upon arthroscopic visualization of the cannula, the
subscapularis was incised and opened horizontally
with the use of arthroscopic scissors. The anterior
aspect of the glenoid was cleaned and prepped, and
soft tissues were removed with a shaver (Video 1,
available at www.arthroscopyjournal.org). A pin was
then inserted into the anterior surface of the glenoid
with an anterior cruciate ligament (ACL) reconstruc-
tion offset device (Smith & Nephew, Andover, MA)
(Videos 2 and 3). The pin was inserted medial to the
glenoid rim, at a distance that was calculated to equal
the radius of the coracoid, rounded up to the highest
whole millimeter for the offset setting. The pin was
 BRISTOW-LATARJET PROCEDURE FOR SHOULDER INSTABILITY 1115

FIGURE 3. The operative steps: (A) The pin is positioned with use
of an offset device, with the diameter adjusted to half that of the bone
block. (B) The anterior surface of the glenoid is reamed with a
reamer of equal diameter to the bone block. (C) The anterior cannula
is removed, and the bone block is fixed within the joint.

passed through the posterior cortex of the glenoid, as
described by Caspari.7 A 2.7-mm drill was passed
over the pin with no drilling of the posterior cortical
bone. The cortical bone was then drilled to sufficient
dimensions to receive the bone block (a diameter
equal to that of the coracoid and 2 mm thick) (Fig 3).
The drill diameter was adjusted to match that of the
bone block, and a drill depth of 2 mm was marked on
the drill with a line, such that it could be seen through
the arthroscope.
After the cannula had been removed, the bone block
was introduced through the subscapularis and was
fixed to the debrided glenoid with a 2.7-mm cannu-
lated screw (Depuy, Warsaw, IN) (Video 4). In the
absence of a customized device, screw length was
calculated by the addition of an arbitrary 2 cm to the
measured length of the coracoid block. The area of
contact between the coracoid and the glenoid was
visualized arthroscopically (Video 4). The shoulder
was then examined, and internal and external rotation
of the joint was carried out to ensure correct position-
ing of the bone block through a full range of motion of
the subscapularis (Video 5). In cases in which the
range of motion was restricted, the subscapularis in-
cision was enlarged horizontally to free the joint and
permit full range of motion.
After the procedure had been completed, a dissec-
tion was performed. The size and location of the bone
1116 G. NOURISSAT ET AL.
block, its position relative to the glenoid, its distance
from the axillary nerve, the width of its surface of
contact, and the absence of interposition tissue be-
tween the bone block and the glenoid were noted.
Evidence of traction on the musculocutaneous nerve
and its relation to the subscapularis were also recorded
(the landmarks used were the biceps groove and the
superior edge of the tendon).
RESULTS
The procedure was performed on 3 right and 2 left
cadaveric shoulders. The average time taken to com-
plete the procedure was 82 minutes (range, 60 to 100
minutes). The average length of the incision made for
harvesting the coracoid was 20 mm (range, 18 to
22 mm. The diameter of the bone block was 8 mm in
3 cases and 10 mm in 2 cases; the length of the block
was 16 mm in 4 cases and 22 mm in 1. The diameter
of the coracobiceps tendon was 8 mm in all but 1 case,
in which it was 7 mm. The musculocutaneous nerve
was not visualized with this approach.
The trans-subscapularis portal was located 10 mm
inferior to the upper margin of the subscapularis ten-
don in 3 cases, and at 14 mm and 20 mm in the other
2 cases. The bone block was located at the anteroin-
ferior aspect of the glenoid in all cases—at the 4
o’clock position in all of the right-sided glenoids and
at 8 o’clock in the left glenoids. Introduction of the
12-mm cannula through the subscapularis was com-
plicated in only 1 case, in which a partial tear existed
on the humeral aspect superior one fourth of the
tendon. For placement of the central pin, the offset
device was adjusted to 4 mm for the 8-mm-diameter
bone blocks and 5 mm for the 10-mm-diameter bone
blocks. Cannulated screws used were 40 mm long in 3
cases and 35 mm and 45 mm long in the other cases.
Arthroscopic positioning and fixation of the bone
block were considered satisfactory in all 5 cases
(Video 2).
Before dissection was performed, the anterior por-
tals were found to be perfectly aligned in 4 of 5 cases.
Movement of the specimen resulted in portal mis-
alignment in a single case; this was later corrected.
Both incisions could be enlarged, if required, to permit
a deltopectoral approach (Fig 4). In 3 cases, portals
were located on either side of the cephalic vein; in the
other cases, they were located lateral and proximal to
it. The trans-subcapularis portal was located in the
superior third of the tendon (in 3 cases), in the supe-
rior quarter (1 case), and in the superior two thirds of
the tendon (1 case). Subscapularis incisions were at
FIGURE 4. Skin incisions are positioned in such a way that they
can be modified, if required, to facilitate a deltopectoral approach.
25, 25, 30, 35, and 40 mm from the bicipital gutter.
The axillary nerve was located 20 mm medial from the
portal in 1 case, 25 mm in another, and 30 mm in 3
cases. The surface of contact between the anterior part
of the glenoid and the bone block was 60% of the
surface area of the bone block in the first 2 cases, 80%
in the next 2 cases, and 100% in the last case. No
evidence was found of soft tissue interposition be-
tween the coracoid and the glenoid. The musculocu-
taneous nerve was located at least 3 cm from the
insertion of the coracobiceps tendon in all cases. The
nerve did not appear injured, severed, or under trac-
tion. The bone block was located at the 4 o’clock
position on the glenoid in all right-sided shoulder
specimens and at 8 o’clock in all left-sided specimens.
In the first case, the coracoid bone block was 4 mm
medial to the glenoid rim. In the other cases, it was
located at 2, 0, 1, and 0 mm, respectively. A distance
of 0 mm from the glenoid rim was found to be the
optimal position for the bone block (Fig 5). No later-
alization of the bone block was observed. In the first 2
cases, the screw was at a slight tangent to the glenoid
surface, but it lay parallel in the other 3 cases.
DISCUSSION
Arthroscopic surgery for anterior shoulder instabil-
ity classically derives from the Bankart procedure and
consists of soft tissue reinsertion and rim reconstruc-
tion.7-10 Excellent results have been reported in the
literature and in many cases match those reported for
open surgery.27-30 The indications for arthroscopic
repair are limited, however, by a number of clinical
 BRISTOW-LATARJET PROCEDURE FOR SHOULDER INSTABILITY
FIGURE 5. Dissection of the first cadaveric specimen shows the
coracoid and harvest zone (CH), the glenoid surface (GL), and a
4-mm medialized bone block (BB) with the attached coracobiceps
tendon (CB). To expose the glenoid, the subscapularis (SS) was
sectioned distal to the bone block.
criteria. Contraindications to arthroscopic repair typi-
cally include youth at the time of initial dislocation,
engagement in contact sports, hyperlaxity, and a his-
tory of recurrent dislocations.10,30 Radiologic contra-
indications include the presence of large Hill-Sachs or
large bony Bankart lesions.10,14,30 In such cases, a
(Bristow) Latarjet procedure is recommended. First
described by Latarjet in 1954, this procedure has
since undergone many modifications.11 In his ap-
proach, Latarjet horizontally incised the subscapu-
laris and fixed the coracoid into the glenoid in a
horizontal orientation. In 1958, Helfet12 reported a
variation on this technique—the Bristow procedure, in
which a bone block was fixed vertically to the glenoid
with the use of simple sutures through a vertical
incision of the subscapularis. In 1970, May13 de-
scribed a modified Bristow procedure, wherein the
subscapularis was incised along the lines of the mus-
cle fibers, and the bone block was secured with screw
fixation. Vertical incisions of the muscle and larger
incisions have since been associated with an increased
rate of fatty degeneration of the subscapularis.31-33
The Latarjet procedure has been criticized for restrict-
ing both internal31 and external rotation.32 In addition,
a decrease in the strength of external rotation has been
1117
reported following this repair.32 Two major complica-
tions of this procedure are nonunion and poor position
of the bone block. In the literature, the reported rate of
nonunion is highly variable, ranging from 0% to
50%.15,16,20,21,24 Many authors have reported an asso-
ciation between nonunion and poor outome. Guity
et al.17 associated nonunion with pain, Hovelius16
believes it increases the rate of postoperative instabil-
ity, and Wymenga33 found that nonunion was associ-
ated with a reduction in the quality of mobility. In a
retrospective study, Allain et al.20 reported a bone
block lateralization rate of 56% and a medialization
rate of 5% for the open Latarjet procedure. In a
computed tomography control study, Cassagnau15 re-
ported a lateralization rate of 10% for bone blocks.
Hovelius16 reported that 36% of bone blocks were
positioned too high on the glenoid and that 6% were
medialized. Lateralization of bone blocks is related to an
increased risk of arthritis.15,16,19-24. Medialized bone
blocks have been held responsible for some cases of
recurrent shoulder dislocation.16,19
At the date of publication, this is the first report in
the literature of an arthroscopically assisted bone
block procedure. This study has shown that arthros-
copy can be successfully used to facilitate positioning
of the bone block at the anteroinferior aspect of the
glenoid. The technique produced reproducible results
and reduced lateralization of the bone block. In the
first case, the bone block was medialized, but this
happens in the absence of a customized device. The
trans-subscapularis portal should be positioned di-
rectly above the desired position for the bone block.
Neurovascular damage in the area can be avoided by
manual medial retraction of the biceps tendon and the
musculocutaneous nerve by the surgeon. In all cases,
the bone block avoided the surrounding neurovascu-
lature.
CONCLUSIONS
Given that the efficacy of the arthroscopically as-
sisted Bristow-Latarjet procedure has been confirmed,
it is our intent to conduct a clinical study. It is essen-
tial that this technique should be evaluated clinically
before it is clinically applied on a large scale.
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