Modification of the Traditional Open Latarjet Technique with the Use of Sutures and Cortical Buttons Instead of Screws

Abstract

In this article we describe a modification of the open Latarjet technique, using sutures and cortical buttons, for the fixation of the coracoid. The transfer of the coracoid to the anterior glenoid is a popular technique used for complex shoulder instability. The technique is proven to be effective with consistently good results but complications have been reported related to the screws used for the fixation of the coracoid. Recent studies confirm that the suture-button technique for the fixation of the coracoid is biomechanically comparable to the screw fixation. The proposed technique combines the advantages of the open approach and avoids the use of metal screws, potentially minimizing hardware-related complications.

Introduction

The Latarjet procedure has been proven to be an effective and reliable treatment for recurrent anterior shoulder instability and in cases with glenoid bone loss [1–3]. Walch and Boileau [4] reported on 2000 cases treated with Latarjet with 98% excellent or good results and only 1% recurrence instability rate. In 2007 Burkhart et al. [5], reported 4% recurrence rate in 102 patients with anterior instability and significant bone loss, treated with a modified Latarjet.

The procedure, as popularised by Walch [6] relies on 2 parallel malleolar screws for the fixation of the coracoid on to the glenoid. However, the use of screws has been related to complications such as nonunion (9.4–10.1%), resorption of the bone block (1.6%), intraoperative and postoperative fracture (1.1–1.5%) as well as screw avulsion, twisting, or breakage and impingement with the humeral head (2.4–6.5%) [7, 8]. LeBus et al. [9] in 2017 reported 46% hardware-related complications in a small number of NFL players. Griesser et al. [7] in a systematic review that included 45 studies, reported 7% reoperation rate, 35% of which consisted of removal of symptomatic metalwork.

In 2016 Gendre et al. [10] demonstrated an excellent rate of bone union in arthroscopic Latarjet using a suture-button fixation system. Seventy patients underwent arthroscopic coracoid transfer (Bristow or Latarjet) using suture buttons instead of screws. They reported bone union in 83% of the cases (58/70) with 74% bone union in the Bristow group and 91% in the Latarjet group. The coracoid position was considered to be ideal in 93% of the cases with the graft below the equator and tangential with the glenoid surface. No hardware complications were reported at a mean follow-up of 14 months.

In a more recent cadaveric biomechanical study, Provencer et al. [11] compared screw to suture fixation for the Latarjet procedure in sixteen male cadaver shoulders. The mean failure load (yield load) for screw fixation was 226 ± 114 N (95% CI), compared to 266 ± 73 N (95% CI) for suture-button fixation. There was no significant difference in failure load between the two groups (P = 0.257). The mean strain at failure for screw fixation was 63 ± 21% (95% CI) of the measured gauge length, compared with 86 ± 26% (95% CI) of the measured gauge length for suture button. The most common mode of failure for the screw fixation method was a fracture through the bone drill holes, while for the suture-button construct was rupture through the muscle at the clamp-muscle interface.

We propose a modified open Latarjet technique using suture-button fixation avoiding the use of screws.

Technique

Patient Positioning

The patient is placed on a shoulder table in the beach chair position. The arm is draped free and placed into an arm support device (Trimano, ARTHREX).

Approach

The limited deltopectoral approach is used with a nearly vertical skin incision from the tip of the coracoid towards the axillary fold. The cephalic vein is taken laterally and a self-retaining retractor is used between the deltoid and pectoralis major. The arm is positioned in abduction and external rotation and a Hofmann retractor is placed on top of the coracoid process.

Coracoid Preparation

The coracoacromial (CA) ligament is exposed and divided 1 cm from the coracoid attachment, with the arm kept in external rotation. Then with the arm in adduction and internal rotation the pectoralis minor is released exposing the medial side of the coracoid.

The coracoid is osteotomised at about 2.5 cm from its tip, using an angular 90° oscillating saw, with direction from medial to lateral and from superior to inferior in a perpendicular fashion. The coracoid is mobilised and extra care is taken to avoid traction injury of the musculocutaneous nerve.

The undersurface of the coracoid is flattened using the saw. Two 1.6 mm Kirschner wires are used to drill the coracoid (Fig. 1). They are placed 1 cm apart and 6 mm from the medial edge of the coracoid. This can be done either with a freehand technique or using a glenoid offset parallel drill guide (Arthrex).

Fig. 1.

Coracoid process preparation: a, b coracoid prepped and measured in length and width, c, d coracoid drilled with 2 Kirschner wires (1.6 mm) 6 mm from its medial edge and 1 cm apart

Glenoid Exposure

The arm is placed in adduction and external rotation and the subscapularis is exposed. The superior and inferior borders of the tendon are identified and a horizontal split is made at the junction between superior 2/3 and inferior 1/3 of the muscle–tendon junction. The split is made with Mayo scissors, in line with the muscle fibres extending laterally to the lesser tuberosity.

Following blunt dissection, a Hohmann retractor is placed in the subscapularis fossa against the glenoid neck. A self-retaining Gelpi retractor can be used to maintain the subscapularis split open. The capsule is incised vertically at the level of the joint and a Fukuda type of retractor is inserted in the joint improving the exposure of the anterior glenoid.

Glenoid Preparation

The anterior labrum is debrided and an osteotome is used to decorticate and flatten the anterior glenoid neck area. Then two parallel Kirschner wires (1.6 mm) are inserted to the glenoid in position 4 and 5 o’clock using the ARTHREX 6 mm glenoid offset guide. A 3.2 mm cannulated drill bit is used to drill 2 parallel tunnels in the glenoid over the Kirschner wires, with direction from anterior to posterior, going through both cortices. Then the Kirschner wires are removed (Fig. 2).

Fig. 2.

Glenoid preparation: a anterior glenoid exposed and prepped, b 6 mm offset glenoid guide from Arthrex, c two parallel pins inserted in the glenoid using offset glenoid guide, d, e the glenoid is drilled with 3.2 mm cannulated drill bit, f drill bit and Kirschner wires are removed

Coracoid Fixation

We load onto a cortical button (2.6 × 10.9 mm) (pectoralis repair button, Arthrex), a fibre wire suture folded in half, so in one end we have a closed-loop and in the other end we have two free suture ends. The button which is mounted on a threaded inserted (Arthrex), is passed into the glenoid tunnel until it exits through the back. The inserter is then released and whilst still in the glenoid tunnel, the button is flipped over the posterior cortex of the glenoid by pulling on the fibre wire. The inserter is then removed. The same procedure is repeated for the other glenoid tunnel using the same equipment (Fig. 3).

Fig. 3.

Ante grade insertion of suture buttons through the glenoid: a proximal biceps tenodesis cortical button (Arthrex) attached to its handle, loaded with looped fibre wire so in one end we have a closed-loop and in the other tow free suture ends. b The button and sutures passed through the glenoid drill holes with direction from front to back. c The safety pin of the handle is released to allow the button flip at the back of the glenoid. d Gently pulling on sutures to make sure that the button is flipped and secure. e Checking that the sutures are sliding through the button. f The same procedure is repeated for the other drill hole

We pass all four sutures of the inferior button through the inferior coracoid drill hole which is closer to the conjoint tendon insertion entering first the decorticated side of the bone. We repeat the procedure for the sutures of the superior button through the other coracoid drill hole. The sutures of each button are loaded through a Dog Bone (Arthrex) in a way that the closed-loop goes through one slot and the two free suture ends through the other. The coracoid is placed on to the glenoid, making sure that there is good surface apposition and contact and the coracoid is flush with the glenoid surface. A sliding NICE knot is used to tighten the buttons sequentially on to the coracoid. We use a suture tensioner up to 100 N, to tension the construct which is finally secured with 3 half-hitches (Fig. 4).

Fig. 4.

Coracoid fixation with suture buttons. a–c Fibre wire sutures loaded through the coracoid drill holes. d Dog Bone (Arthrex) buttons applied to allow for the sutures to slide. e A NICE knot is performed for each button and the coracoid is placed against the anterior glenoid. f The suture tensioner is applied (Arthrex). g The position of the coracoid is adjusted to avoid overhang and the sutures are sequentially tensioned to 100 N (Arthrex suture tensioner). h The knots are further secured with 3 half-hitches and the use of a knot pusher

The capsule is reattached to the CA ligament stump and the lateral side of the coracoid using absorbable interrupted sutures. The wound is closed in layers. A drain is typically not used.

Postoperative Rehabilitation

Following this procedure we still use our standard rehabilitation protocol for a Latarjet procedure.

Discussion

The use of screws for the fixation of the coracoid on to the glenoid has been related to complications including screw loosening, prominence and irritation or breakage. Gendre et al. [10] were the first to describe the arthroscopic Latarjet procedure with the use of suture buttons for the fixation of the coracoid reporting no hardware complications and a union rate at least as good as the rate achieved with cortical screws. Recent studies confirm good outcomes and lower complications rate with the use of suture-button fixation, with similar biomechanical properties and no significant differences in the maximal load to failure comparing to screw fixation [12–14].

In 2019 Xu et al. [15] reported clinical and radiological results on 128 patients who underwent arthroscopic Latarjet with a single suture-button fixation. The patient outcomes were satisfactory and the graft demonstrated excellent remodelling to a new concentric circle with the humeral head analogous to the original glenoid. They also noticed that the grafts positioned laterally did not cause arthropathy of the joints within the 3 years to follow-up period.

Conclusion

The latarjet procedure is a proven technique for managing the anterior shoulder instability but it has hardware-related complications.

It has been already shown that the use of suture buttons in arthroscopic Latarjet using a posterior guide can result in excellent rates of bone union. A similar type of fixation can be used in open Latarjet coracoid transfer avoiding the use of screws and potential associated complications.

We present a modification of the open Latarjet technique without the use of screws (Fig. 5). We do thing that this is a simple and reproducible technique offering the benefits of the traditional fixation (Fig. 6), potentially minimizing hardware-related complications.

Fig. 5.

Step by step open technique for the fixation of the coracoid to the glenoid with sutures and buttons (Arthrex): a the fibre wire is loaded on the button, attached to its threaded inserter, and inserted through the glenoid bone tunnel with direction from front to back. b The button exits at the back of the glenoid, released from its handle and flipped. c The sutures are passed through the coracoid drill holes. The sutures then are passed through the Dog-bone (Arthrex) in a way that through one slot we have a closed-loop and through the other 2 free ends. The same is repeated for the other Dog-bone button. d We push the dog bone down and the coracoid is paced in position. e A sliding NICE knot is performed for each button. f The position of the coracoid is checked and the knots are tightened at 100 N using the suture tensioner device (Arthrex). Each knot is then secured with 3 half-hitches

Fig. 6.

CT scan of the left glenoid 6 months following open Latarjet using sutures and cortical buttons. This imaging is from our first patient treated with this technique. a Axial view of the shoulder demonstrating optimal position with no overhang of the coracoids. b, c Sagittal CT scan view of the glenoid demonstrating good bone integration and low-profile metalwork

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.