LATARJET Open Surgical technique

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2 LATARJET Open Surgical technique Steps A. Exposure B. Preparation of coracoid holes C. Cutting the coracoid D. Fixing the Double Cannula to the coracoid E. Exposure of both sides of Subscapularis F. Split of Subscapularis G. Passing the Coracoid Process through the Subscapularis split H. Positioning of the shoulder and positioning the Double Cannula I. Fixing the coracoid process to the glenoid 2

3 1. Exposure This is NOT a standard pectoral approach but more medial one finger breadth inferior and medial to the coracoid, to the anterior axillary crease. This is a vertical incision. Dissect laterally to the cephalic vein which is then protected and retracted laterally with the deltoid muscle. The coracoid process is then exposed with the Pec Minor located medial, the CA ligament located lateral, and the conjoint tendon presents inferiorly. The anterior lateral border of the CA ligament end of the conjoint tendon is separated from the deltoid facia. Homan retractor is placed as far superior on the coracoid as possible. The arm is positioned in anterior flexion to access easily the upper border of the coracoid. The Pec Minor is dissected free from the medial border of the conjoint tendon. This will allow the Pec Minor inferior border to be identified. The surgeon should be aware that the musculocutaneous nerve is just below, posterior to the pectoralis minor. This is why the detachment of the Pec Minor must be performed along the medial border of the coracoid. There are several strategies for manageing the CA ligament. The CA ligament may or may not be used to attach to the anterior capsule in the open approach at the end of the transfer. Once the surgeon has determined his preference for managing the CA ligamet and it is released, attention is then directed towards the prepared the coracoid. 2. Establishing the Coracoid Holes 2a Coracoid drill guide (Cat # ) 2a. Introduce the Coracoid Drill Guide (#285365) Place the Coracoid Drill Guide flush on top of the Coracoid. The guide is parallel to the coracoid, between the medial 1/3 and the lateral 2/3 of the bone 2b. Introduce the Coracoid K wires (#285260) thru the α and β holes The αlpha distal hole should be 1 cm away from the tip of the coracoid process. The end of the K -Wire should be seen after its exit. 2c. Locate the final position of the β hole relative to the α axis and drill the Coracoid K. Wire through the Coracoid Drill Guide in the β position. 2d. Check position of both K- Wires and do not hesitate to replace them if needed 2e. Remove the Coracoid Drill Guide (leave the Coracoid K- Wires in the α and β holes) 2f. Drill the αlpha hole, over the Coracoid K. Wire, down to the depth stop using the Coracoid Step Drill (#285240). 2b 2f 150mm K wires (Cat # ) Image shows 150mm K wires through the Coracoid drill guide Coracoid Step Drill (Cat# ) 3

4 CONTINUED 2g. Remove the Coracoid Step Drill and Coracoid K. Wire from the αlpha hole and remove the K- Wire. 2. Establishing the Coracoid Holes 2h 2j Instrumetnts Coracoid Step Tap (Cat# ) 2h. Drill the β hole over the Coracoid K- Wire to the depth stop in the same manner. 2i. Thread the Coracoid Step Tap (#285245) inside the αlpha hole and then the β hole - Put Top Hats in Alpha and Beta holes - 2k. Screw in the Top Hats using the Top Hat Screw Driver in the αlpha hole and β hole. 2k Top Hat Screwdriver (Cat# ) Screws and Top Hats (Cat# , , , , ,285135,285140) 3. CUTTING THE CORACOID Cut the Coracoid using a 90 Degree oscillating saw blade. 4. The Subscap Split Place the coracoid medially (cover with sterile sponge) to optimize exposure for the subscap spilt. 4a. Locate the superior and inferior border of the subscap. Locate the bicipital groove which marks the lateral border of the subscapularis. Locate and protect the axillary nerve. 4b. Find the The three Sisters (anterior humeral circumflex, and the associated two veins). This will determine the location of the subscap split: 2/3 superior and 1/3 inferior 4c. With the curved mayo scissor, initiate the split and use a sponge to develop the plane between the subscap and capsule. 4d. Place the curved Gelpi retractor into the subscap split. 4e. Make a 1.5 to 2cm VERTICAL capsulotomy at the level of the glenohural joint Not laterally. Introduce the Fekuda retractor to displace posteriorly the humeral head and expose the anterior border of the glenoid. This will decrease the ante version of the glenoid which is essential for optimal screw placement/direction 4f. Remove a trapezoidal segment of the labrum at the level of the coracoid transfer site. The trapezoidal segment should be at least as large as the bony component of the coracoid transfer. Decorticate the bone at the transfer site. The inferior level of the graft should be at the 5 o clock position. 4

5 5. FIXING THE DOUBLE CANNULA TO THE CORACOID 5a Insert the 2 Coracoid 3.5mm Screws in the two sleeves of the double cannula 5b. Thread the Coracoid 3.5mm Screw over the 2 Top Hats through the Double Cannula into the α and β holes 5c. Screw the Coracoid 3.5 Screws thru the α and β holes of the Coracoid until the screws end will be seen on the distal side of the Coracoid Process. Coracoid 3.5mm Screws (Cat# ) Double Cannula (found in Cat# , disposable kit) 5d Abrade and flatten the posterior aspect of the coracoid transfer to match the recipient site. 6. CORACOID TRANSFER THROUGH THE SUBSCAPULARIS Positioning of the shoulder and positioning of the double cannula 6a Fullly expose the glenoid neck. Mobilize the coracoid process and make sure the CT (Conjoint Tendon) is fully released from the PM (Pec Minor). 6b.Transfer the Coracoid Process through the split of the subscapularis. Place the Coracoid Process in its desired position on the anterior rim of the Glenoid. Verify the location is at the 5 O clock position. The coracoid should be flush to the glenoid surface 6c. The assistant should pull the scapula backward with the Fukuda in order to decrease the glenoid ante-version and internally rotate the humeral head to decrease the tension of the subscapularis muscle. 6d. The surgeon pushes the entrance of the Double Cannula medially to get a good axes for the screws, as parallel to glenoid surface as possible. 5

6 7. CORACOID GLENOID FIXATION Glenoid K-Wires (found in Cat# , disposable kit) 7a. Start from the αlpha hole: Insert a long Glenoid K-Wire (Found in Cat# , disposable kit) through the Coracoid 3.5mm Screw and drill across the glenoid. The Glenoid K- Wire should exit the skin and be firmly clamped on the posterior side of the shoulder. It is essential at this stage to be at a maximum of 20 degrees angulation based on the glenoid plain. 7b. Drill the β Glenoid K-Wire and check that they are parallel 7.a 7c. Remove the Coracoid 3.5mm Screw from the αlpha hole. 7.b 7 d. Drill the Glenoid thru the αlpha hole using the Glenoid 3.2mm Drill (Cat# ) over the Glenoid K- Wire and through the Coracoid Positioning Cannula. Once the Glenoid 3.2mm Drill has gone across the the Glenoid, use the scale that is marked on the Glenoid 3.2mm Drill to determine the length of the required Screw. 7.d Glenoid 3.2mm Drill (Cat# ) Measurement markings will be both on the distal and proximal ends of the drill bit 6

7 CONTINUED 7. CORACOID GLENOID FIXATION Bristow-Latarjet Cortical Screws (Cat# , , , , ,285135,285140)) 7.e 7e. Thru the alpha hole, load the Latarjet Cortical Screw over the Glenoid K- Wire and insert into down thru the cannula. 7f. Thread the screw into the glenoid using the 2.5mm Cannulated Screwdriver (Cat# ). Do not over tighten the Screw. 7.f 2.5mm Cannulated Screw Driver (Cat# ) Repeat all 6 steps for the β hole (from 7.a to 7.f) and check from different portals good placement of the graft 7g. Remove both Glenoid K. Wires by pulling them from the posterior part of the shoulder. 7.i 7h. Remove the Double Cannula. 7i. Tighten both Bone Screws using the Solid Screwdriver (Cat# , red handle). 2.5mm Solid Screw Driver (Cat# ) 7

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