Woodmass Jarret M, Wagner Eric R, Solberg Muriel, Hunt Tyler J, Higgins Laurence D
Boston Shoulder Institute, Boston, Massachusetts.
Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada.
JBJS Essent Surg Tech. 2019 Sep 25;9(3):e31. doi: 10.2106/JBJS.ST.18.00025. eCollection 2019 Jul-Sep.
Anterior glenohumeral instability is common, with 21.9 first-time dislocations per 100,000 individuals per year. Recurrent instability is more likely to occur in patients who are younger, of male sex, and have bone defects or ligament laxity. The open Latarjet procedure is effective for the treatment of recurrent anterior glenohumeral instability and is preferred over arthroscopic Bankart repair in the presence of glenoid bone loss. The Latarjet procedure involves transferring the coracoid to the anterior aspect of the glenoid in the following steps. Step 1: Preoperative planning includes an assessment of glenoid deformation and the integrity of the rotator cuff. The degree of bone loss is measured with use of the circle-line method. Step 2: The patient is in the beach-chair position with the arm in a pneumatic arm holder. A parallel drill guide system with 3.75-mm cannulated screws is utilized. Step 3: A 5-to-6-cm incision is made along the anterior axillary line. The deltopectoral interval is established, and the cephalic vein is mobilized laterally. The coracoacromial ligament is transected 15 mm lateral to the coracoid to allow later repair to the anterior capsule. The pectoralis minor is released subperiosteally off the medial coracoid. A 90° oscillating saw is used to transect the coracoid medially to laterally. The coracohumeral ligament is released. Step 4: Two 4.0-mm drill-holes are made 1 cm apart through the coracoid. The undersurface is decorticated. Step 5: The subscapularis is split at the junction of the upper two-thirds and lower one-third. A longitudinal capsulotomy is performed parallel to the glenoid. Step 6: Soft tissue, including the capsule and labrum, is removed from the anterior aspect of the glenoid. The bone is decorticated with an osteotome and a rasp. Step 7: The coracoid is positioned flush or 1 mm recessed relative to the glenoid. Two 1.6-mm guidewires are placed with use of a parallel drill guide followed by a cannulated reamer and two 3.75-mm cannulated screws. Step 8: The coracoacromial ligament is repaired to the capsule. Step 9: The subscapularis split is repaired laterally. The deltopectoral interval and skin are closed in a standard fashion. A standardized rehabilitation protocol is employed postoperatively. The Latarjet procedure results in significantly lower rates of recurrent glenohumeral instability and revision compared with the arthroscopic Bankart procedure (3% and 1% compared with 28.4% and 21%, respectively); however, complication rates as high as 30% have been reported, as well as a risk for nerve injury. The videos included in this article highlight the critical steps required to optimize outcomes and minimize complications when performing the Latarjet procedure.
肩肱关节前侧不稳很常见，每年每10万人中有21.9例首次脱位。复发性不稳更易发生于年轻男性患者，以及存在骨缺损或韧带松弛的患者。开放性Latarjet手术对于治疗复发性肩肱关节前侧不稳有效，在存在肩胛盂骨质丢失的情况下，比关节镜下Bankart修复术更可取。Latarjet手术包括按以下步骤将喙突转移至肩胛盂前侧。步骤1：术前规划包括评估肩胛盂变形情况及肩袖完整性。采用环线法测量骨质丢失程度。步骤2：患者取沙滩椅位，手臂置于气动臂托中。使用带有3.75毫米空心螺钉的平行钻孔导向系统。步骤3：沿腋前线做一个5至6厘米的切口。建立三角肌胸大肌间隙，将头静脉向外侧游离。在喙突外侧15毫米处切断喙肩韧带，以便稍后修复至前关节囊。在喙突内侧骨膜下松解胸小肌。用90°摆动锯从内侧向外侧切断喙突。松解喙肱韧带。步骤4：在喙突上相隔1厘米钻两个4.0毫米的钻孔。对其下表面进行去皮质处理。步骤5：在肩胛下肌上、中三分之一与下三分之一交界处劈开。平行于肩胛盂进行纵向关节囊切开术。步骤6：从肩胛盂前侧清除包括关节囊和盂唇在内的软组织。用骨刀和锉刀对骨质进行去皮质处理。步骤7：将喙突相对于肩胛盂放置成齐平或内陷1毫米。使用平行钻孔导向器放置两根1.6毫米导丝，随后用空心扩孔钻和两根3.75毫米空心螺钉。步骤8：将喙肩韧带修复至关节囊。步骤9：从外侧修复劈开的肩胛下肌。按标准方式闭合三角肌胸大肌间隙和皮肤。术后采用标准化康复方案。与关节镜下Bankart手术相比，Latarjet手术导致复发性肩肱关节不稳和翻修率显著降低（分别为3%和1%，而关节镜下Bankart手术为28.4%和21%）；然而，据报道并发症发生率高达30%，还有神经损伤风险。本文中的视频突出了在进行Latarjet手术时优化手术效果和将并发症降至最低所需的关键步骤。
