Rockwood Adults CH34

1099

CHAPTER 34 • Glenohumeral Instability

A

B

Figure 34-35.  A: The anterior capsule and rotator interval is shifted up to decrease the capsule volume. B: The subscapularis tenotomy and the rotator interval is closed with no. 2 sutures in an interrupted fashion.

A CT scan with 3D reconstruction must be obtained to evaluate anterior glenoid bone loss. In high demand or contact sport patients, a critical bone loss of > 13.5% resulted in unaccept- able outcome and higher failure rates after arthroscopic Bankart repair in some studies. 209 Recently, Shin et al., 211 in a similar study of both contact and noncontact athletes, reported 17.3% bone loss as the “Critical” value that led to surgical failure and recurrence of instability after arthroscopic repair. In the patient group with less than 17.3% bone loss, failure rate was 3.7% compared with a 42.9% failure rate in the group with over 17.3% bone loss. A critical bone loss greater than 13.5% to 17.3% is an indication for open Latarjet; however, the patient’s activity level, type of sporting (contact vs. noncontact) events, and expectations also factors into the decision-making between arthroscopic repair and open bony reconstruction. Positioning The patient is positioned upright in the beach chair position. An arm holder is placed to allow for different positioning and rotation of the shoulder throughout the case. Surgical Approach A mid-axillary crease approach is used. Technique ✔ ✔ Open Latarjet Procedure: KEY SURGICAL STEPS

❑❑ Peel the subscapularis muscle off the anterior capsule ❑❑ Retract the humeral head posteriorly ❑❑ Expose the labral tear and glenoid bone loss ❑❑ Protect the axillary nerve ❑❑ Release the pectoralis minor muscle from the medial coracoid and the conjoint tendon from the fascia ❑❑ Resect the coracoacromial (CA) ligament from the acromion and preserve the entire length ❑❑ Cut the coracoid at the base from a medial-to-lateral direction ❑❑ Expose and flatten the inferior surface of the coracoid in preparation to transfer to the anterior glenoid rim ❑❑ Drill two holes into the coracoid ❑❑ Expose the anterior glenoid neck ❑❑ Latten the anterior-inferior glenoid in preparation of the coracoid transfer ❑❑ Drill the first hole (2.7-mm drill bit) into the neck of the glenoid about 5 to 6 mm medial to the glenoid surface ❑❑ Fix the coracoid transfer with either a partially or a fully threaded screw to the first hole that was drilled into the neck of the glenoid ❑❑ Drill a second superior hole from the coracoid to the back of the glenoid rim and place another partially or fully threaded screw to complete the final fixation of the coracoid to the anterior glenoid rim ❑❑ Repair the CA ligament to the capsule ❑❑ Repair the subscapularis split ❑❑ Close the deltopectoral interval and keep the skin closed ❑❑ Place the patient in a sling and abduction pillow ❑❑ Follow standard postoperative protocol The incision is centered over the coracoid to the axilla (Fig. 34-36A). Soft tissue is dissected down to identify the cephalic vein which lies between the pectoralis major medially and del- toid laterally. The authors prefer retracting the vein laterally with the deltoid musculature. A linked shoulder retractor (Kol- bel self-retractor) is placed to retract the deltopectoral interval. The clavipectoral fascia is incised to expose the coracoid ( circle ) and conjoint ( arrow ) tendon (Fig. 34-36B). The biceps tendon is

❑❑ Beach chair position with arm holder ❑❑ Examination under anesthesia ❑❑ Mid-axillary crease approach ❑❑ Expose the coracoid and conjoint tendon ❑❑ Horizontal split of the subscapularis at the mid aspect of the muscle belly and tendon