Arthroscopic Latarjet Using a 3 Anterior Portal Technique

Abstract

Arthroscopic Latarjet is technically challenging with a steep learning curve. Several limitations include the risk of malposition of the coracoid bone block, the risk of screw fixation, such as hardware failure and irritation, and the risk of neurological injury. Initial descriptions of the technique also describe several anterior portals, especially for the subscapularis split. The learning curve is steep, and it is associated with increased risks of complications when compared to the open Latarjet procedure. This technique involves a simplified 3 anterior portal technique, with the portals lateral to the coracoid process and conjoint tendon, reducing the risk of iatrogenic neurovascular injury. Tunnels are created in the glenoid and coracoid process using specific glenoid and coracoid drill guides. This improves coracoid positioning while reducing the risk of neurovascular injury. The coracoid process is also prepared extra‐articularly after osteotomy for better visualization, control and efficiency. This simplified arthroscopic Latarjet technique is safe and reproducible in the treatment of recurrent anterior shoulder dislocations.

The Latarjet procedure is commonly performed in the treatment of recurrent anterior shoulder dislocations. It was first described in 1954, ¹ and has undergone multiple modifications in recent years. This procedure involves the transfer of the coracoid process with its attached soft tissue to the anterior inferior border of the glenoid, using a triple mechanism to stabilize the shoulder. ² The conjoint tendon acts as a sling, the coracoid process acts as a bony block, and the capsule is repaired to the coracoacromial ligament.

The arthroscopic Latarjet technique has become increasingly prevalent with the advancement in arthroscopic techniques. ³ A fully arthroscopic Latarjet technique was first described in 2007 by Lafosse et al., ⁴ using 2 screws for the fixation of the coracoid process to the glenoid. Boileau et al. then described a modification in 2007 and 2010 to the technique, using an arthroscopic coracoid bone block transferred through the subscapularis and fixed to the glenoid by a screw. This was known as the Bristow‐Latarjet procedure. ⁵ However, this arthroscopic approach had several limitations. First, the arthroscopic positioning of the coracoid bone block was technically challenging, leading to the risk of malposition. ⁶ Screw fixation of the coracoid bone block was also noted to have several complications, which included screw breakage, coracoid bone block fracture, graft avulsion, coupled with a 5% to 10% revision rate. ⁷ The creation of a portal medial to the coracoid to facilitate the insertion of screws also led to risks of nerve complications. ⁵ , ⁸  As such, Boileau et al. modified his technique further in 2016 with the use of a guided surgical approach for graft positioning and a cortical button for fixation of the coracoid bone block. ⁹ His technique involved the creation of a standard posterior portal, as well as 5 anterior working portals.

We describe a simplified 3 anterior portal arthroscopic Latarjet technique combined with a Bankart repair with the use of a glenoid drill guide using a single cortical button fixation.

SURGICAL TECHNIQUE

Anesthesia and Patient Positioning

Surgery is performed with the patient under general anesthesia. The patient is placed in the beach chair position with the head resting on the headrest and the arm supported by an arm holder (Spider2 Limb Positioner; Smith & Nephew) with the shoulder in 20° of forward flexion and 20° of external rotation. A trolley towel is folded and placed at the medial border of the scapula to place the scapula in external rotation to reduce the risk of iatrogenic injury of the axillary nerve during the procedure ¹⁰ (Figure 1, Video 1). A 30° arthroscope is used almost entirely throughout the procedure, except for the preparation of the anterior glenoid surface, where a 70° arthroscope is used. The arthroscopic pump is set at 30 mmHg to limit bleeding and to minimize swelling.

FIGURE 1.

Clinical image showing application of a folded trolley towel (labeled) at the medial border of scapula to place the scapula in external rotation. The patient is in a beach chair position.

VIDEO 1.

Download video file ^{(383MB, mp4)}

Narrated video on the 3 portal arthroscopic Latarjet procedure. The patient is placed in a beach chair position and 4 portals are used for the procedure ‐ the posterior, anterosuperior, anterolateral, and anteroinferior portals. The procedure is then divided into 6 steps. Step 1: Diagnostic scope to evaluate the glenohumeral joint. Step 2: Clearing of the rotator interval, coracoacromial ligament, exposure of lateral and inferior coracoid, and identification of the musculocutaneous nerve. Step 3: Exposure of superior coracoid, release of pectoralis minor and osteotomy of coracoid. Step 4: Flattening and decortication of inferior surface of coracoid bone block and passing of suture button. Step 5: Drilling of tunnel on the glenoid, splitting of subscapularis and passing of the bone block. Step 6: Bankart repair and capsular shift. Video content can be viewed at https://doi.org/10.1002/atn2.70147.

Portal Placement

Four portals are used for this procedure. First, a standard posterior portal (P) is created in the soft spot, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Second, an anterosuperior portal (AS) is created just lateral to the coracoid and anterior to the acromioclavicular joint. Third, an anterolateral portal (AL) is created 1 cm inferior and 1 cm lateral to the anterolateral corner of the acromion. Lastly, an anteroinferior portal is created 3 cm inferior to the tip of the coracoid, in line with the conjoint tendon (Figure 2). All 3 anterior portals are created under direct arthroscopic visualization and there is no portal medial to the coracoid to reduce the risk of iatrogenic nerve injury. This procedure can be divided into 6 steps.

FIGURE 2.

Clinical image showing placement of arthroscopic anterior portals. The AS, AL, and AI portals are labeled. (AI, anteroinferior; AL, anterolateral; AS, anterosuperior.)

Step 1: Diagnostic Scope

The 30° arthroscope is introduced in the posterior (P) portal, and instruments are introduced in the AS portal. A diagnostic scope of the glenohumeral joint is systematically performed to evaluate soft tissue and bony injuries such as labral tear, glenoid bone loss, and Hill‐Sachs lesion.

Step 2: Clearing of Rotator Interval, Coracoacromial Ligament, Exposure of Lateral and Inferior Coracoid, and Identification of Musculocutaneous Nerve (MCN)

A radiofrequency ablation (RFA) device (Werewolf Flow 90; Smith & Nephew) is introduced via AS, and the rotator interval is debrided. The lateral border of the conjoint tendon is identified. The coracoacromial ligament is divided and the lateral surface of the coracoid is exposed. The RFA device is used to mark the 4‐o'clock position on the glenoid surface, which serves as a landmark for the drill guide later.

A 70° arthroscope is then introduced via the P portal. The anterior capsulolabral complex is elevated from 3‐ to 6‐o'clock position using a combination of liberator and RFA device until the muscle fibers of the subscapularis are visualized. The anterior glenoid surface is burred and rasped until a bleeding bony surface is observed (Figure 3).

FIGURE 3.

Arthroscopic image of the final exposure showing the glenoid surface, muscle fibers of the subscapularis, capsulolabral complex and the humeral head.

An 18‐gauge spinal needle is used to check the placement and working trajectory of the AL portal, aiming to be parallel with the upper border of the subscapularis tendon, before making the stab incision. With the RFA device through AL portal, the inferior surface of the coracoid is exposed until the knuckle, just anterior to the attachment of the coracoclavicular ligaments. With the 70° arthroscope, the space anterior to the subscapularis and lateral to the conjoint tendon is exposed as well.

Step 3: Exposure of Superior Coracoid, Release of Pectoralis Minor and Osteotomy of Coracoid

A 30° arthroscope is introduced via AL portal and RFA device via AS portal. The superior surface of the coracoid is exposed until the knuckle and attachment of the coraco‐clavicular ligaments. Pectoralis minor is released from the medial border of the coracoid. The coracoid is inspected to ensure no remnant soft tissue is attached to the planned osteotomy site.

The anteroinferior portal portal is created under direct visualization to be just adjacent to lateral border of conjoint tendon, at the level of upper 2/3 and lower 1/3 of subscapularis tendon. This is done prior to osteotomy of the coracoid to ensure native anatomy is not distorted to reduce the risk of nerve injury.

The osteotomy of the coracoid is performed with a reciprocating saw from medial to lateral via AS portal, just distal to the attachment of the coraco‐clavicular ligaments to maximize the length of the bone block (Figure 4). Bleeding from bone is usually encountered after completion of osteotomy at coracoid base. Bone wax is applied with the McDonald dissector to maintain arthroscopic visualization. The bone block is then delivered extra‐articularly via AS portal with a coracoid clamp for further preparation.

FIGURE 4.

Arthroscopic image showing the sawing from the medial border of the coracoid process (labeled) via the AS portal. (AS, anterosuperior.)

Step 4: Flattening and Decortication of Inferior Surface of Coracoid Bone Block and Passing of Suture Button

The bone block is held with a graft preparation tool, and the inferior surface is flattened and decorticated using a right‐angled saw to maximize the contact between the bone block and anterior glenoid surface. A 2.7 mm drill is used to create the hole for passing of the Osteoconnect endobutton (Smith & Nephew). The endobutton is then passed and ensured that the post of the endobutton is fitted completely into the drill hole (Figures 5, 6, 7).

FIGURE 5.

Clinical image of the coracoid bone block being held with graft preparation tool, and the inferior surface flattened and decorticated using a right‐angle saw. The coracoid process is delivered via the AS portal. (AS, anterosuperior.)

FIGURE 6.

Clinical image of a 2.7 mm drill (labeled) being used to create the hole for passing of the endobutton. The coracoid process is being held by the graft preparation tool and is delivered via the AS portal. (AS, anterosuperior.)

FIGURE 7.

Clinical image of the endobutton being passed into the drill hole made in the coracoid process (labeled). The coracoid process is being held by the graft preparation tool and delivered via the AS portal. (AS, anterosuperior.)

Step 5: Drilling of Tunnel on the Glenoid, Splitting of Subscapularis, and Passing of the Bone Block

A 30° arthroscope is reintroduced via AL portal for visualization of anterior glenoid surface in the glenohumeral joint. A posterior glenoid drill guide with 5 mm offset is introduced via P portal to hook on the anterior glenoid surface at 4‐o'clock. Care is taken to ensure the drill guide is parallel to the articular surface of glenoid. A 2.8 mm drill with sleeve is used to create the tunnel, and the subscapularis muscle is retracted anteriorly off the glenoid surface to avoid over‐penetration of the drill bit (Figure 8). Once the sleeve is seen on the anterior glenoid surface, the drill bit is retracted, leaving the sleeve in for shuttling of sutures later.

FIGURE 8.

Arthroscopic image of the drilling of the tunnel for the suture button. A posterior glenoid drill guide with 5 mm offset (labeled) is introduced via posterior portal to hook on the anterior glenoid surface at 4‐o'clock. Care is taken to ensure the drill guide is parallel to the articular surface of glenoid. A 2.8 mm drill with sleeve is used to create the tunnel and the subscapularis muscle is retracted anteriorly off the glenoid surface to avoid over‐penetration of the drill bit.

A Wissinger rod is passed from posterior to anterior via P portal to tent the subscapularis muscle fibers at 4‐o'clock position, parallel to the drill sleeve and medial to the capsulolabral complex. The advancement of the Wissinger rod needs to be done under direct visualization and in a controlled manner to avoid injury to the axillary nerve anterior to the subscapularis. Once the tip of the Wissinger rod is visualized on the anterior surface of the subscapularis muscle, the subscapularis is split lateral to the Wissinger rod using an RFA device until the anterior glenoid surface is seen. The Wissinger rod is then swapped to a subscapularis spreader through the P portal to hold the split muscle fibers apart to facilitate the passing of the sutures and bone block (Figure 9).

FIGURE 9.

Arthroscopic image of the subscapularis spreader holding the split muscle fibers apart to facilitate passing of the sutures and bone block. A Wissinger rod is passed from posterior to anterior via the posterior portal to tent the subscapularis muscle fibers at 4‐o'clock position, parallel to the drill sleeve and medial to the capsulolabral complex. Once the tip of the Wissinger rod is visualized on the anterior surface of the subscapularis muscle, the subscapularis is split lateral to the Wissinger rod using RFA device until the anterior glenoid surface is seen. The Wissinger rod is then swapped to a subscapularis spreader through the posterior portal to hold the split muscle fibers apart to facilitate passing of the sutures and bone block. (RFA, radiofrequency ablation.)

A shuttling monofilament is passed through the drill sleeve and retrieved via AS portal. The shuttling suture is used to pass the sutures of the endobutton from anterior to posterior. As the sutures are pulled posteriorly, the bone block is delivered through the subscapularis split. A coracoid clamp is introduced via an anteroinferior portal portal to control the bone block to ensure optimal position is achieved. Once the placement of the bone block is satisfactory, a posterior Endobutton is applied and tightened 3 to 4 times with a tensioning device at 100 Newtons (Figure 10).

FIGURE 10.

Arthroscopic image of the bone block placement after application and tightening of the posterior endobutton. A shuttling monofilament is used to pass the sutures of the endobutton from anterior to posterior. As the sutures are pulled posteriorly, the bone block is delivered through the subscapularis split. A coracoid clamp is introduced via AI portal to control the bone block to ensure optimal position is achieved. Once the placement of the bone block is satisfactory, a posterior endobutton is applied and tightened 3 to 4 times with a tensioning device at 100 Newtons. (AI, anteroinferior.)

Step 6: Bankart Repair and Capsular Shift

The 30° arthroscope is then reintroduced via P portal, and a standard Bankart repair and capsular shift is performed with 2 to 3 suture anchors to exteriorize the bone block.

Postoperative Rehabilitation Regime

Patient is immobilized in an arm‐sling in neutral rotation for 3 weeks, followed by passive forward flexion and abduction, and limitation of external rotation to neutral for 3 weeks. The patient is allowed for full range of motion as tolerated from 6 weeks onward. The patient's computed tomography scan 8 weeks postoperatively is shown in Figure 11.

FIGURE 11.

(A‐C) Computed tomography scan 8 weeks postoperatively showing the glenoid (labeled) and coracoid bone block (labeled).

Ethical Statement

Informed consent was taken from this patient for the annonymised details to be added into this technical note.

DISCUSSION

Arthroscopic Latarjet procedure has become increasingly popular. ¹¹ Its advantages are multifold, including decreased stiffness and faster rehabilitation time. ¹¹ , ¹² Its minimally invasive nature also may lead to faster recovery times and decreased pain. ¹² Vuletic et al. in 2024 compared the existing research between arthroscopic and open Latarjet procedures, and found that both were equally efficacious in treating shoulder instability, ¹³ with arthroscopic Latarjet having a faster recovery time. There have also been studies showing similar short and mid‐term clinical results for arthroscopic Latarjet compared to open surgery. ¹⁴ , ¹⁵ , ¹⁶

However, arthroscopic Latarjet is technically challenging, and the learning curve is steep. There is an increased risks of coracoid graft malposition, screw complications and injury to surrounding neurovascular structures.

The accuracy of placement of the coracoid bone block is necessary to reconstruct the anteroinferior glenoid. A medially placed bone block can lead to recurrent instability, whereas a laterally placed bone block can increase the risk of early osteoarthritis. ⁶ Russo et al. in 2017 noted that patients with an open Latarjet procedure had better bone block positioning than the arthroscopic group. ¹⁷ However, it can be argued that the arthroscopic technique enables visualization of the complete glenoid articular surface, reducing the risk of coracoid graft malposition. ⁴ Other studies have shown satisfactory positioning of the coracoid bone block with arthroscopic technique. ⁷ , ¹⁸ , ¹⁹ In this technique, we have used a guided approach described by Boileau et al. in 2016, with glenoid and coracoid drill guides, reducing the risk of medialization or lateralization of the coracoid bone block. ⁹ This enables a fixed distance between the drill bit's exit point and the glenoid rim, as well as the drill hole and borders of the coranoid process. In addition, the extra‐articular preparation of the coracoid bone block in our technique allows more effective flattening and decortication of its curved undersurface for better fitting to the flat anterior glenoid. This method of preparation is easier with more controlled when compared to the technique described by Valenti et al. in 2018, where flattening of the deep surface of the coracoid was difficult after the coracoid osteotomy, due to the strands of the cortical buttons being passed. ²⁰

The use of a single cortical button has been described by Boileau et al. with good union results ⁹ and is also described in our technique. It avoids the complications of screw fixation, such as hardware failure (migration, breakage, or loosening) or irritation. ²¹  A biomechanical study by Manfredi et al. in 2023 reported that both screws and suture buttons showed comparable loads at failure and final displacement, making suture buttons a good alternative to screws. ²² Further studies have shown a good union rate with the use of suture button fixation. ²³ , ²⁴  As in this technique, the use of a single cortical button is preferred as the size of the coracoid bone block in Asian populations is often smaller ²⁵ to accommodate double cortical buttons.

This technique combines the Latarjet procedure with a Bankart repair and capsular plication. The concomitant Bankart repair places the coracoid graft in an extra‐capsular position. This provides increased stability, reduces the risk of arthritis by reducing the risk of humeral head contact with the coracoid bone block and preserves the labral proprioceptive receptors. ⁹ , ²⁰ , ²⁶

Neurologic complications are also reduced using our technique. The use of a specific glenoid drill guide, with a posterior to anterior direction of glenoid drilling, reduces the risk of injury to the anterior neurovascular structures. This also allows a more ideal alpha angle to avoid suprascapular nerve injury. ²⁷ This technique, using a cortical button, also avoids the need for screw insertion near the anterior neurovascular structures, where a much more medial portal is required to accommodate the trajectory of the screw.

Although the learning curve for an arthroscopic Latarjet procedure remains high, the use of a simplified 3 portal technique is less technically demanding. Lafosse et al. in 2007 used 7 portals when describing the first arthroscopic Latarjet procedure. ⁴ There was also the use of a medial portal. This technique describes 3 anterior portals—anterosuperior, anteroinferior and anterosuperior, which are created under direct arthroscopic visualization. There is no portal medial to the coracoid to reduce the risk of iatrogenic nerve injury.

This technique however, does have limitations. The use of a single cortical button instead of 2 buttons may not provide adequate rotational stability during the fixation of the coracoid graft. This theoretically may decrease the healing of the bone block to the glenoid. However, this is mitigated with meticulous preparation of undersurface of coracoid bone block and anterior glenoid surface. While Valenti et al. in 2018 suggested for the use of 2 cortical buttons in an alternative arthroscopic Latarjet procedure, ²⁰ there have been good bony unions noted by Boileau et al. in 2024 with the use of a single cortical button. ²⁸ The pearls and pitfalls of the 3‐portal arthroscopic Latarjet technique are summarized in Table 1, and the advantages and disadvantages summarized in Table 2.

TABLE 1.

Pearls and Pitfalls of the 3 Portal Arthroscopic Latarjet Technique

Pearls	Pitfalls
Arthroscopic Latarjet enables visualization of the complete glenoid surface, reducing the risk of malposition	Inaccurate placement of the bone block can lead to recurrent instability (medially placed) or early osteoarthritis (laterally placed)
The use of glenoid and coracoid drill guides reduces the risk of malposition
Extra‐articular preparation of the coracoid bone block allows for effective flattening and decortication which allows better fitting to the flat anterior glenoid	If flattening of the deep surface of the coracoid is done after strands of cortical buttons are passed, it may prove more difficult
The use of a single cortical button has good union results and avoids complications of screw fixation	Screw fixation of the coracoid bone block may lead to hardware failure or irritation
The use of a specific glenoid drill guide with a posterior to anterior direction of glenoid drilling reduces the use of injury to anterior neurovascular structures. This also allows a more ideal alpha angle to avoid suprascapular nerve injury	There is a risk of neurologic complications and injury with drilling
The use of a cortical button avoids the need for screw insertion near the anterior neurovascular structures	Screw fixation of the coracoid bone may require a more medial portal (nearer anterior neurovascular structures) to accommodate the trajectory of the screw
The use of 3 anterior portals created under direct arthroscopic visualization means that there is no portal medial to the coracoid, reducing the risk of iatrogenic nerve injury

TABLE 2.

Advantages and Disadvantages of the 3 Portal Arthroscopic Latarjet Technique

Advantages	Disadvantages
Decreased stiffness	Technically challenging
Faster rehabilitation time	Steep learning curve
Decreased pain	Increased risk of coracoid graft malposition, screw complications and injury to surrounding neurovascular structures
Equally efficacious as open Latarjet procedures in treating shoulder instability	Single cortical button may not provide adequate rotational stability and may theoretically decrease the healing of the bone block to the glenoid. This can be mitigated by meticulous preparation of the undersurface of the coracoid bone block and anterior glenoid surface
Similar short and mid‐term clinical results for arthroscopic Latarjet compared to open surgery
Concomitant Bankart repair and capsular plication with arthroscopic Latarjet procedure places the coracoid graft in an extra‐capsular position, increasing stability. It also reduces the risk of arthritis by reducing the risk of humeral head contact with the coracoid bone block. This also preserves the labral proprioceptive receptors

Arthroscopic Latarjet procedure provides the benefits of less extensive surgical wounds and faster rehabilitation time. In addition, its arthroscopic nature allows a concomitant Bankart procedure and capsular plication to be done, improving stability and proprioception. This simplified 3 portals technique, with the use of a single cortical button aims to reduce the learning curve for a complex and advanced arthroscopic procedure, at the same time avoiding the risk of neurological injury without the need for a medial portal. In addition, the use of specific glenoid and coracoid guides decreases coracoid malposition. As such, this arthroscopic Latarjet technique is safe and reproducible in the treatment of recurrent anterior shoulder dislocations.

DISCLOSURES

The authors (C.M.P.T., T.W.W.T., J.Z.C.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.