Advertisement

The Shoulder Trans-pectoralis Arthroscopic Portal Is a Safe Approach to the Arthroscopic Latarjet Procedure: A Cadaveric Analysis

Published:October 03, 2020DOI:https://doi.org/10.1016/j.arthro.2020.09.044

      Purpose

      To assess the proximity of neurovascular structures in a layered approach during medial portal placement and determine standardized measurements for establishing a portal medial to the coracoid used in arthroscopic Latarjet-type procedures.

      Methods

      Twelve shoulders (6 right and 6 left) in 6 fresh frozen cadaveric torsos were mounted in the modified beach-chair position. A standard posterior portal and 3 anterior portals—central, lateral, and medial—were used. A long spinal needle was placed along the path of the medial portal to the lateral tip of the coracoid, superficial to the conjoined tendon and pectoralis minor. A second long spinal needle was directed toward the medial base of the coracoid, penetrating the pectoralis minor. Superficial and deep plane dissections were performed, and distances to surrounding neurovascular structures were recorded.

      Results

      In the superficial plane, the cephalic vein and lateral pectoral nerve were located a mean distance (± standard deviation) of 4.6 ± 1.9 mm and 9.4 ± 2.6 mm from the spinal needle, respectively. In the deep plane, the axillary nerve was 24.9 ± 7.4 mm from the needle; the lateral cord of the brachial plexus, 25.5 ± 8.1 mm; the axillary artery, 34.1 ± 6.0 mm; and the musculocutaneous nerve, 42.2 ± 9.2 mm. The portal was consistently established 45.0 to 50.0 mm distal and 30.0 to 35.0 mm medial to the coracoid, which was a minimum distance of 10 mm to the lateral pectoral nerve.

      Conclusions

      In a cadaveric model, the creation of a medial trans–pectoralis major portal used in the arthroscopic Bankart-Bristow-Latarjet procedure can avoid compromise of vital neurovascular structures, alleviating concerns of creating a portal medial to the coracoid. Portal placement 45.0 to 50.0 mm distal and 30.0 to 35.0 mm medial to the palpable tip of the coracoid process may be a safe approach to perform the arthroscopic Bankart-Bristow-Latarjet procedure.

      Clinical Relevance

      Creation of a portal medial to the level of the coracoid may pose a risk to neurovascular structures. This cadaveric study establishes a working zone for medial trans-pectoralis portal placement, which avoids vital neurovascular structures, and provides standardized measurements for establishing this portal for use in the arthroscopic Bankart-Bristow-Latarjet procedure.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Burkhart S.S.
        • De Beer J.F.
        Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted pear glenoid and the humeral engaging Hill-Sachs lesion.
        Arthroscopy. 2000; 16: 677-694
        • Boileau P.
        • Villalba M.
        • Héry J.Y.
        • Balg F.
        • Ahrens P.
        • Neyton L.
        Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.
        J Bone Joint Surg Am. 2006; 88: 1755-1763
        • Boileau P.
        • Saliken D.
        Editorial Commentary: The wake of the dragon: Will the orthopaedic community adopt the shoulder arthroscopic Latarjet procedure as we adopted the arthroscopic rotator cuff repair?.
        Arthroscopy. 2017; 33: 2139-2143
        • Lubowitz J.H.
        • Brand J.C.
        • Rossi M.J.
        • Provencher M.T.
        Shoulder problems motivate innovative solutions.
        Arthroscopy. 2016; 32: 1737-1739
        • Matzkin E.
        Editorial Commentary: In a world of endless options, is there a single solution? Management options for failed anterior instability surgery in athletes.
        Arthroscopy. 2018; 34: 1428-1429
        • Moezzi D.
        Editorial Commentary: The ever-revealing role of the arthroscope-arthroscopic Latarjet procedure.
        Arthroscopy. 2017; 33: 543-544
        • Tibone J.
        Editorial Commentary: Not for the faint of heart: The arthroscopic Latarjet procedure, a North American experience.
        Arthroscopy. 2016; 32: 1971-1972
        • Verma N.N.
        Editorial Commentary: Arthroscopic Latarjet: Is it ready for prime time?.
        Arthroscopy. 2019; 35: 1062-1063
        • Lafosse L.
        • Boyle S.
        Arthroscopic Latarjet procedure.
        J Shoulder Elbow Surg. 2010; 19 (suppl): 2-12
        • Lafosse L.
        • Lejeune E.
        • Bouchard A.
        • Kakuda C.
        • Gobezie R.
        • Kochhar T.
        The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability.
        Arthroscopy. 2007; 23: 1242.e1-1242.e5
        • Boileau P.
        • Mercier N.
        • Old J.
        Arthroscopic Bankart-Bristow-Latarjet (2B3) procedure: How to do it and tricks to make it easier and safe.
        Orthop Clin North Am. 2010; 41: 381-392
        • Boileau P.
        • Mercier N.
        • Roussanne Y.
        • Thélu C.È.
        • Old J.
        Arthroscopic Bankart-Bristow-Latarjet procedure: The development and early results of a safe and reproducible technique.
        Arthroscopy. 2010; 26: 1434-1450
        • Boileau P.
        • Saliken D.
        • Gendre P.
        • et al.
        Arthroscopic Latarjet: Suture-button fixation is a safe and reliable alternative to screw fixation.
        Arthroscopy. 2019; 35: 1050-1061
        • Cerciello S.
        • Corona K.
        • Morris B.J.
        • Santagada D.A.
        • Maccauro G.
        Early outcomes and perioperative complications of the arthroscopic Latarjet procedure: Systematic review and meta-analysis.
        Am J Sports Med. 2019; 47: 2232-2241
        • Horner N.S.
        • Moroz P.A.
        • Bhullar R.
        • et al.
        Open versus arthroscopic Latarjet procedures for the treatment of shoulder instability: A systematic review of comparative studies.
        BMC Musculoskelet Disord. 2018; 19: 255
        • Hurley E.T.
        • Lim Fat D.
        • Farrington S.K.
        • Mullett H.
        Open versus arthroscopic Latarjet procedure for anterior shoulder instability: A systematic review and meta-analysis.
        Am J Sports Med. 2019; 47: 1248-1253
        • Malahias M.A.
        • Fandridis E.
        • Chytas D.
        • Chronopulos E.
        • Brilakis E.
        • Antonogiannakis E.
        Arthroscopic versus open Latarjet: A step-by-step comprehensive and systematic review.
        Eur J Orthop Surg Traumatol. 2019; 29: 957-966
        • Ekhtiari S.
        • Horner N.S.
        • Bedi A.
        • Ayeni O.R.
        • Khan M.
        The learning curve for the Latarjet procedure: A systematic review.
        Orthop J Sports Med. 2018; 6 (2325967118786930)
        • Athwal G.S.
        • Meislin R.
        • Getz C.
        • Weinstein D.
        • Favorito P.
        Short-term complications of the arthroscopic Latarjet procedure: A North American experience.
        Arthroscopy. 2016; 32: 1965-1970
        • Butt U.
        • Charalambous C.P.
        Arthroscopic coracoid transfer in the treatment of recurrent shoulder instability: A systematic review of early results.
        Arthroscopy. 2013; 29: 774-779
        • Griesser M.J.
        • Harris J.D.
        • McCoy B.W.
        • et al.
        Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review.
        J Shoulder Elbow Surg. 2013; 22: 286-292
        • Hamada H.
        • Sugaya H.
        • Takahaski N.
        • et al.
        Incidence of axillary nerve injury after arthroscopic shoulder stabilization.
        Arthroscopy. 2020; 36: 1555-1564
        • Kordasiewicz B.
        • Kiciński M.
        • Małachowski K.
        • Boszczyk A.
        • Chaberek S.
        • Pomianowski S.
        Arthroscopic Latarjet stabilization: Analysis of the learning curve in the first 90 primary cases: Early clinical results and computed tomography evaluation.
        Arthroscopy. 2019; 35: 3221-3237
        • Leuzinger J.
        • Brzoska R.
        • Métais P.
        • et al.
        Learning curves in the arthroscopic Latarjet procedure: A multicenter analysis of the first 25 cases of 5 international surgeons.
        Arthroscopy. 2019; 35: 2304-2311
        • Shah A.A.
        • Butler R.B.
        • Romanowski J.
        • Goel D.
        • Karadagli D.
        • Warner J.J.
        Short term complications of the Latarjet procedure.
        J Bone Joint Surg Am. 2012; 94: 495-501
        • Lo I.K.
        • Burkhart S.S.
        • Parten P.M.
        Surgery about the coracoid: Neurovascular structures at risk.
        Arthroscopy. 2004; 20: 591-595
        • Crimmins I.M.
        • Mulcahey M.K.
        • O'Brien M.J.
        Diagnostic shoulder arthroscopy: Surgical technique.
        Arthrosc Tech. 2019; 8: e443-e449
        • Matthews L.S.
        • Zarins B.
        • Michael R.H.
        • Helfet D.L.
        Anterior portal selection for shoulder arthroscopy.
        Arthroscopy. 1985; 1: 33-39
        • Hutton K.S.
        Shoulder arthroscopy.
        in: Brown D.A. Neumann R.D. Orthopaedic Secrets. Ed 3. Elsevier Publishing, Philadelphia2004: 125-138
        • Flatow E.L.
        • LU Bigliani
        • April E.W.
        An anatomic study of the musculocutaneous nerve and its relationship to the coracoid process.
        Clin Orthop Relat Res. 1989; 244: 166-171
        • Moga I.
        • Konstantinidis G.
        • Wong I.H.
        The safety of a far medial arthroscopic portal for anatomic glenoid reconstruction: A cadaveric study.
        Orthop J Sports Med. 2018; 6 (2325967118795404)
        • Valenti P.
        • Maroun C.
        • Wagner E.
        • Werthel J.D.
        Arthroscopic Latarjet procedure combined with Bankart repair: A technique using 2 cortical buttons and specific glenoid and coracoid guides.
        Arthrosc Tech. 2018; 7: e313-e320
        • Boileau P.
        • Gendre P.
        • Baba M.
        • et al.
        A guided surgical approach and novel fixation method for arthroscopic Latarjet.
        J Shoulder Elbow Surg. 2016; 25: 78-89
        • Freehill M.T.
        • Srikumaran U.
        • Archer K.R.
        • McFarland E.G.
        • Petersen S.A.
        The Latarjet coracoid process transfer procedure: Alterations in the neurovascular structures.
        J Shoulder Elbow Surg. 2013; 22: 695-700