How can I improve exposure of the glenoid side for coracoid transfer in an open Latarjet procedure?

Improving Glenoid Exposure During Open Latarjet Procedure

To improve exposure of the glenoid side for coracoid transfer in an open Latarjet procedure, a systematic approach to soft tissue releases is recommended, which can increase glenoid exposure from 57% to 93% of the surface area. 1

Systematic Approach to Glenoid Exposure

Step 1: Initial Exposure (57% visibility)

• Position the patient properly in beach chair or lateral decubitus position
• Make an adequate deltopectoral approach
• Identify and protect the axillary nerve and brachial plexus

Step 2: Long Head of Biceps Release (increases to 69%)

• Release the long head of biceps tendon
• This is particularly important as it improves visualization of the anterior glenoid rim
• Consider tenotomy or tenodesis based on the tendon quality

Step 3: Pectoralis Major Tendon Release (increases to 83%)

• Partially release the superior aspect of the pectoralis major tendon
• This significantly improves the working space and visualization
• Take care to avoid excessive release which could lead to functional deficits

Step 4: Inferior Capsule Release (increases to 93%)

• Perform a systematic release of the inferior capsule
• This is a critical step that dramatically improves inferior glenoid exposure
• Maintain careful identification of the axillary nerve during this step

Step 5: Posterior Capsule Release (if needed, up to 100%)

• Only necessary in severe cases with significant scarring or revision cases
• Provides complete exposure but increases risk of posterior instability

Technical Considerations

Coracoid Preparation

• Ensure complete exposure of the inferior pole of the coracoid
• Prepare the coracoid meticulously before osteotomy
• Drill the coracoid before osteotomy to prevent fracture during drilling 2

Graft Positioning

• Proper positioning of the coracoid graft is essential to avoid failure
• Common technical errors include inferior graft malposition and inadequate fixation
• Use two screws rather than single-screw fixation to prevent hardware failure and graft nonunion 1

Fixation Technique

• Consider using specialized fixation devices like low-profile wedge plates that ensure better load distribution between coracoid graft and glenoid 3
• Ensure screws are perpendicular to both the graft and the glenoid neck and parallel between them 4

Special Considerations for Revision Cases

• In revision cases, exposure becomes even more challenging due to:

  • Distorted anatomy
  • Obliterated soft-tissue planes
  • Adhesive scar tissue
  • Increased risk to adjacent neurovascular structures 1

• In these cases, consider:

  • More extensive soft tissue releases
  • Potential need for extended approaches
  • Heightened vigilance for neurovascular structures

Avoiding Complications

• Inadequate exposure is a major contributor to technical errors during the Latarjet procedure
• Surgeon experience is critical - the American Academy of Orthopaedic Surgeons recommends that surgeons performing shoulder procedures should maintain a high volume to minimize complication rates 5, 1
• Careful identification and protection of neurovascular structures throughout the procedure is essential
• Ensure proper graft positioning and fixation to prevent recurrent instability, which ranges from 0.3% to 4.8% with proper technique 2

By following this systematic approach to soft tissue releases, you can significantly improve glenoid exposure during the open Latarjet procedure, which is critical for accurate coracoid graft placement and ultimately leads to better patient outcomes.