ICR-Nice.
Pan Am Clinic.
Arthroscopy. 2021 Feb;37(2):477-479. doi: 10.1016/j.arthro.2020.12.177.
The all-arthroscopic Latarjet is gaining popularity among shoulder surgeons, although the procedure is technically demanding and potentially dangerous, placing the brachial plexus and axillary vessels at risk when using screws for fixation of the bone block from the front. Matsen once wrote that "lateral to the coracoid is the safe side, while medial to the coracoid is the suicide." However, creation of a portal medial to the coracoid during arthroscopic reconstruction of the glenoid is needed to permit accurate positioning of the screws (parallel to the glenoid surface) and coracoid bone block (flush to the glenoid surface). Our own clinical experience with the arthroscopic Latarjet over the last decade has shown us that the safety of the arthroscopic medial transpectoralis portal depends on 3 technical considerations: (1) the portal should always be established in an outside-in fashion from anterior to posterior; (2) passing through the pectoralis major muscle with a relatively superficial trajectory, using a switching stick oriented with a 45° orientation toward the tip of the coracoid; and (3) under visual control of the anterior extra-articular subdeltoid space to end up lateral to the coracoid process. If these conditions are respected, surgeons should not worry: medial to the coracoid can also be a safe side! An inside-out technique (introducing a switching stick from posterior to anterior) is forbidden, as this would end up piercing the neurovascular structures. Once the coracoid has been osteotomized and the conjoint tendon retracted distally, all instruments passing though the transpectoral portal are directly in contact with the neurovascular structures. This is why working through the medial transpectoralis portal should be done only with the help of a cannula or half-pipe. Ideally, the transpectoral portal should not be used as a "working portal" but as a "protecting portal" instead, placing a stick or spreader to protect the neurovascular structures. To avoid working through the anterior medial portal, we have proposed a much safer alternative that consists of drilling the glenoid from posterior to anterior (using a guide and remaining inside the glenohumeral joint) and using cortical-buttons (instead of screws) for coracoid fixation. In this modern technique, the transpectoral portal makes the arthroscopic safe as it allows the introduction of a spreader to retract the subscapularis muscle and protect the neurovascular structures during transfer and fixation of the coracoid bone block.
全关节镜下 Latarjet 术式在肩关节外科医生中越来越受欢迎，尽管该手术技术要求高且存在潜在风险，从前侧使用螺钉固定骨块时，可能会损伤臂丛神经和腋血管。Matsen 曾写道：“喙突外侧是安全侧，而喙突内侧是自杀侧。”然而，在关节镜下重建盂肱关节时，需要在前侧创建喙突内侧关节镜入路，以允许准确放置螺钉（与盂肱关节面平行）和喙突骨块（与盂肱关节面齐平）。我们在过去十年中进行关节镜下 Latarjet 术的临床经验表明，关节镜下喙突内侧经胸肌入路的安全性取决于 3 项技术考虑因素：（1）入路应始终从前向后以由外向内的方式建立；（2）使用与喙突尖端成 45°角的切换棒，以相对较浅的轨迹穿过胸大肌；（3）在关节外前肩下空间的可视控制下，最终位于喙突外侧。如果满足这些条件，外科医生就不必担心：喙突内侧也可以是安全侧！禁止使用由后向前的内-外技术（引入切换棒），因为这会导致神经血管结构被刺穿。一旦喙突被截骨，联合肌腱被向远端牵拉，通过经胸肌入路的所有器械都直接与神经血管结构接触。这就是为什么通过内侧经胸肌入路进行操作只能借助套管或半管完成的原因。理想情况下，经胸肌入路不应作为“工作入路”，而应作为“保护入路”，放置棒或撑开器以保护神经血管结构。为了避免通过前内侧入路进行操作，我们提出了一种更安全的替代方案，即从后向前钻盂肱关节（使用导针并保持在盂肱关节内）并使用皮质螺栓（而不是螺钉）固定喙突。在这种现代技术中，经胸肌入路使关节镜手术更安全，因为它允许引入撑开器来牵拉肩胛下肌，并在转移和固定喙突骨块时保护神经血管结构。
