Latarjet Procedure to Restore Glenohumeral Stability in a Patient With a Postage Stamp Fracture

A patient should be considered for a bony anterior stabilization procedure in the setting of a postage stamp fracture in nearly all settings. Factors that may push a surgeon to consider bony stabilization include younger age of the patient, amount of dislocation time, sex, and time from fracture until evaluation. In a situation in which the patient has greater than 15% bone loss, especially in the setting of recurrence, we strongly recommend this surgical procedure. In addition, although glenoid fragment open reduction and fixation can be considered, the timing of this procedure and bone quality often make a fixation procedure less likely to be successful in patients with previous glenoid surgery. In our experience, if we are not able to directly fix this fracture within the first 10 days, the bone quality will not allow for stable fixation. Also, in our experience, computed tomography and magnetic resonance imaging often overestimate the quality of bone and should be viewed with caution when choosing between fracture repair versus other bony stabilization procedure. Finally, previous instrumentation and anchor placement into the anterior glenoid often lead to osteolysis around anchors and resultant decrease in osseous integrity.

In patients who present with postage stamp fractures, even in the setting of subcritical bone loss, we feel that additional soft-tissue stabilization procedures and/or fracture repair pose a significant risk of failure. When considering patients for a Latarjet procedure, it is critical that the surgeon have a clear understanding of the risks of this surgical technique as well as the indications and contraindications. These are outlined in Table 1.

We recommend placing the patient in standard beach-chair position. Adjusting the table into a small amount of reverse Trendelenburg positioning assists with exposure and instrumentation of the inferior glenoid. In addition, bolstering the medial scapular border with nonsterile towels can aid in scapular protraction and visualization. When draping, ensure that draping extends medially to the sternoclavicular joint.

EUA allows the surgeon to qualify the instability without the patient guarding against the examination. It also allows the surgeon to determine whether the shoulder rests in a dislocated position and allows the surgeon to identify the point of maximum instability, which will be critical to incorporate into final coracoid positioning.

A standard posterior arthroscopic portal should be used to view the intra-articular pathology. We prefer to use a 5-mm cannula in our anterior portal to assist with flow and make the portal in line with the planned open approach. The anterior glenoid should be thoroughly evaluated and probed, and bone quality should be recorded. In subacute fractures, the fragment often is encased in soft tissue and callus. A 70° arthroscope is helpful for visualization of a medialized anterior glenoid fragment. All previous anchors and sutures should be carefully debrided and removed (Fig 3). Concurrent intra-articular pathology also should be evaluated and addressed during this portion of the case or after coracoid transfer. Given the medial position of these fragments, we prefer maximizing fragment excision under direct arthroscopic visualization to minimize need for aggressive medial retraction. The anterior glenoid is also prepared initially under direct arthroscopic visualization at this time (Fig 4).

Our incision is made from the tip of the coracoid extending distally along the deltopectoral interval to the superior aspect of the axillary fold, in this case 7 cm. The incision is taken down to the clavipectoral fascia to create full-thickness flaps with the Bovie for hemostasis. The fascia is incised with Metzenbaum's along with the deltopectoral interval and bluntly dissected between the deltoid and pectoralis. The cephalic vein is dissected laterally to minimize transection of bridging veins and risk of hematoma formation. Subpectoral dissection is performed with a Cobb and curved Mayos. A Kolbel retractor is placed between the deltoid and pectoralis major. The red–white stripe of the short head of the biceps and conjoined tendon is identified and the fascia just lateral to the red stripe is incised. Finger dissection is then used to free the posterior adhesions deep to the conjoined. The coracoacromial ligament is then released, leaving a 1-cm cuff of tissue attached to the coracoid for future incorporation into the repair. The coracoid is then exposed to its base, removing lateral and superior adhesions, while maintaining the coracoclavicular ligaments. The pectoralis minor is meticulously released directly off the medial coracoid. At this stage, care is taken to ensure that the trapezoidal ligament, which is 2 to 3 mm anterior to the elbow, is not released. After the coracoid is skeletonized, the planned cut is measured and marked at approximately 25 mm from the tip of the coracoid. We prefer using a 90° sagittal saw from superior to inferior for a majority of the coracoid release, finishing the osteotomy with a 0.5-inch curved osteotome from superomedial to inferolateral.

Following completion of the osseous cut, the coracoid is held at the level of the skin incision with a grasping forceps and the posterior insertion of the coracohumeral ligament is released. The musculocutaneous nerve is palpated, visualized, and gently released free of tension all the way to its insertion into the biceps muscle belly. During these steps, the surgeon should be very mindful of the tension placed on the coracoid to avoid a neural injury. We use a sagittal saw to lightly decorticate the coracoid and prepare the osseous bed for repair to the anterior glenoid. Using the drill guide clamp, 2 drill holes are provisionally drilled in the coracoid piece from the planned anterior surface to the planned deep surface. The coracoid is then tucked into the wound and retracted away for later retrieval.

The arm is then externally rotated to place the subscapularis on tension. The superior and inferior borders of the subscapularis tendon are identified. The fibers of the subscapularis are then split at the 60/40 junction, extending from the lesser tuberosity laterally to the level of the glenoid medially. Mayo scissors are used to develop a plane between the subscapularis and anterior glenohumeral capsule. Gelpi retractors are placed in the subscapularis split and identified the anterior glenohumeral capsule. At the level of the glenoid, the capsular split is then extended straight inferiorly. The superomedial corner of the capsule of the inferior capsule is tagged for later identification during capsular repair. With a Bovie and Cobb elevator, the anteroinferior labrum is further dissected subperiosteally off the glenoid. The soft tissues are dissected off the anterior glenoid neck and remnant deep hardware removed. The fracture bed is prepared and contoured to accept the coracoid transfer (Fig 5).

The coracoid is retrieved from within the wound and secured along the glenoid neck, flush with the glenoid laterally. The optimal position of the coracoid is confirmed using digital palpation and held in place with a K-wire (Fig 6). An additional K-wire is placed outside the planned screw trajectory, and drill holes are placed through the coracoid into the glenoid using a 3.5-mm drill. The 4.0 mm, fully threaded, noncannulated bicortical screws are then inserted with suture washers (Fig 7). In our case, a small step off is noted between the coracoid and the glenoid. This is contoured using a high-speed burr to smooth the lateral prominence of the coracoid graft.

With the arm placed approximately at 45° of external rotation, the capsule is repaired using #2 FiberWire (Arthrex, Naples, FL) suture preloaded on the suture washers. The remaining stump of the coracoacromial ligament is incorporated in the capsule repair. Using a SutureTape (Arthrex), the subscapularis is then repaired carefully to avoid incarceration of the long head of the biceps at the lateral aspect of the repair. After completion of the repair of the capsule and the subscapularis, the conjoined tendon will be found medially exiting between the superior and inferior split of the subscapularis tendon (Fig 8).

At this point, the wound is closed per surgeon preference. Postoperatively, we place the operative arm into a padded abduction sling for 6 weeks. External rotation is restricted to 30° for the first 3 weeks. The full rehabilitation protocol is outlined in Table 2.