How can I improve exposure of the glenoid side for coracoid (coracoid process) transfer during shoulder surgery?

Improving Glenoid Exposure for Coracoid Transfer During Shoulder Surgery

To improve exposure of the glenoid side for coracoid transfer, perform sequential soft tissue releases including the long head of biceps, pectoralis major tendon, and inferior capsule, which can increase glenoid exposure from 57% to 93% of the surface area.

Anatomical Challenges and Exposure Techniques

When performing a coracoid transfer procedure (such as the Latarjet procedure), adequate exposure of the glenoid is critical for proper graft positioning. Limited exposure can lead to technical errors that may result in recurrent instability and need for revision surgery.

Sequential Soft Tissue Releases

Based on cadaveric research, a systematic approach to soft tissue releases significantly improves glenoid exposure 1:

1. Initial exposure: Before any releases, only about 57% of glenoid surface area is typically visible
2. Long head of biceps release: Increases exposure to 69%
3. Pectoralis major tendon release: Further increases exposure to 83%
4. Inferior capsule release: Achieves 93% exposure
5. Posterior capsule release: Can provide complete (100%) exposure, though rarely necessary

Approach Selection

The deltopectoral approach is most commonly used for coracoid transfer procedures 2:

• Advantages:

  • Enables extensive inferior glenohumeral release
  • Provides access to the inferior apex of the glenoid (critical for proper implant positioning)
  • Can be implemented in complex cases
  • Preserves deltoid muscle integrity

• Disadvantages:

  • Risk of postoperative shoulder instability
  • Limited access to posterior glenoid in cases of significant retroversion
  • Uncertain subscapularis healing

Technical Considerations for Coracoid Transfer

Critical Positioning

Proper positioning of the coracoid graft is essential to avoid failure. Common technical errors leading to revision include 3:

• Inferior graft malposition: Placing the graft inferior to the 5-o'clock position on the glenoid face
• Inadequate fixation: Single-screw fixation is associated with higher rates of hardware failure and graft nonunion compared to two-screw techniques

Special Considerations for Revision Cases

In cases where a previous coracoid transfer has been performed, exposure becomes even more challenging due to 4:

• Distorted anatomy
• Obliterated soft-tissue planes
• Adhesive scar tissue
• Increased risk to adjacent neurovascular structures

In such cases, a conjoint tendon tenotomy technique may be considered to minimize neurovascular injury while leaving the well-healed coracoid bone graft in place.

Surgeon Experience Factor

The surgeon's experience level is an important consideration. Complication rates are higher when shoulder arthroplasty is performed by surgeons who perform fewer than two shoulder arthroplasties per year 5.

Patient-Specific Guides for Complex Cases

For cases with severe glenoid defects, patient-specific positioning guides can significantly improve:

• Glenoid component positioning
• Screw positioning accuracy
• Total intraosseous screw length (89% of ideal length with guide vs. 52% without) 6

Common Pitfalls to Avoid

1. Inadequate exposure: Failing to perform necessary soft tissue releases, leading to poor visualization and improper graft positioning
2. Single-screw fixation: Associated with higher rates of hardware failure and graft nonunion
3. Inferior graft placement: Positioning below the 5-o'clock position increases failure risk
4. Neurovascular injury: Particularly when working with distorted anatomy in revision cases

By following a systematic approach to glenoid exposure through appropriate soft tissue releases and proper surgical technique, you can significantly improve visualization for accurate coracoid transfer, which is essential for successful outcomes in shoulder instability surgery.