Anteroinferior Glenohumeral Instability - Revision history

Alexandre.laedermann: /* Dynamic Anterior Stabilization (DAS) */

2021-09-26T06:05:46Z

Dynamic Anterior Stabilization (DAS)

Alexandre.laedermann at 06:58, 15 August 2021

2021-08-15T06:58:47Z

Alexandre.laedermann: /* Peripheral Neuromuscular Lesion */

2021-08-08T10:41:04Z

Peripheral Neuromuscular Lesion

Alexandre.laedermann: /* Pathoanatomy and biomechanics */

2021-08-08T10:36:28Z

Pathoanatomy and biomechanics

Alexandre.laedermann: /* Pathoanatomy and biomechanics */

2021-08-08T10:35:35Z

Pathoanatomy and biomechanics

Marko.nabergoj: text

2021-08-05T16:22:36Z

text

Marko.nabergoj: Text

2021-08-05T15:59:38Z

Text

Marko.nabergoj: Text - Latarjet

2021-08-05T15:31:27Z

Text - Latarjet

Alexandre.laedermann: /* Bony procedures */

2021-07-31T17:29:33Z

Bony procedures

Alexandre.laedermann: /* Treatments */

2021-07-31T17:28:35Z

Treatments

Show changes

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 =====Dynamic Anterior Stabilization (DAS)=====
-[[File:1562547970547-lg.mp4|center|thumb|600x600px|Video]]
+[[File:DAS long.mov|thumb|Surgical Technique]]
 Dynamic anterior stabilization transfers the long head of the biceps to the anterior glenoid margin, thereby creating a “sling effect” (Figure).
@@ Line 329: / Line 329: @@
 <br />The dynamic anterior stabilization technique provides decreased anterior glenohumeral translation in cases of Bankart lesions with limited anterior bone loss (<20%)<ref>Mehl J, Otto A, Imhoff FB, Murphy M, Dyrna F, Obopilwe E, Cote M, Lädermann A, Collin P, Beitzel K, Mazzocca AD. Dynamic Anterior Shoulder Stabilization With the Long Head of the Biceps Tendon: A Biomechanical Study. Am J Sports Med. 2019 May;47(6):1441-1450.</ref>
-In comparison with isolated Bankart repair, it is able to stop the anterior translation less anterior and therefore reduces the risk of a conflict between the humeral head and the anterior margin of the glenoid. It is also easier and safer than arthroscopic Latarjet. Moreover, it does not require screws nor traction of the coracoid process, and should consequently reduce the risks of neurologic damage. Furthermore, the procedure can be performed with only 3 small incisions (Video), as it does not require coracoid transfer, which eliminates risks of nerve dissection, graft overhang and cortical resorption, hence reducing the probability for dislocation arthroplasty. Lastly, the pectoralis minor remains intact, which would avoid scapular dyskinesis. The potential drawbacks of the dynamic anterior stabilization are that it relies on the long head of biceps tendon, which has smaller diameter than the conjoint tendon and could therefore have a weaker “sling effect” than that of the standard Latarjet. Also, there are, like in the Latarjet procedure, the risks of biceps pain, and secondary iatrogenic factors. Furthermore, in cases with larger bone defects (≥ 20 %) there is a relevant posterior and inferior shift of the humeral head in relation to the glenoid, when the arm is brought in the ABER position.(reference to be completed) Indications and limitations are yet to be defined. MRI scans showed that the transposed long head of the biceps successfully healed to the glenoid rim and remained intact at the 6- and 12-month follow-ups in patients who underwent dynamic anterior stabilization for the treatment of chronic anteroinferior glenohumeral instability with bipolar and/or SLAP II lesions with limited (<13.5%) to subcritical (13.5%—25%) glenoid bone loss.<ref name=":28">de Campos Azevedo  C, Ângelo  AC. All-Suture Anchor Dynamic Anterior Stabilization Produced Successful Healing of the Biceps Tendon: A Report of 3 Cases.  JBJS Case Connect . 2021:17;11(1)</ref> However, it is recommended that future studies are carried out with a more long-term follow-up.
+In comparison with isolated Bankart repair, it is able to stop the anterior translation less anterior and therefore reduces the risk of a conflict between the humeral head and the anterior margin of the glenoid. It is also easier and safer than arthroscopic Latarjet. Moreover, it does not require screws nor traction of the coracoid process, and should consequently reduce the risks of neurologic damage. Furthermore, the procedure can be performed with only 3 small incisions (Video), as it does not require coracoid transfer, which eliminates risks of nerve dissection, graft overhang and cortical resorption, hence reducing the probability for dislocation arthroplasty. Lastly, the pectoralis minor remains intact, which would avoid scapular dyskinesis. The potential drawbacks of the dynamic anterior stabilization are that it relies on the long head of biceps tendon, which has smaller diameter than the conjoint tendon and could therefore have a weaker “sling effect” than that of the standard Latarjet. Also, there are, like in the Latarjet procedure, the risks of biceps pain, and secondary iatrogenic factors. Furthermore, in cases with larger bone defects (≥ 20 %) there is a relevant posterior and inferior shift of the humeral head in relation to the glenoid, when the arm is brought in the ABER position.(reference to be completed) Indications and limitations are yet to be defined. MRI scans showed that the transposed long head of the biceps successfully healed to the glenoid rim and remained intact at the 6- and 12-month follow-ups in patients who underwent dynamic anterior stabilization for the treatment of chronic anteroinferior glenohumeral instability with bipolar and/or SLAP II lesions with limited (<13.5%) to subcritical (13.5%—25%) glenoid bone loss.<ref name=":28">de Campos Azevedo  C, Ângelo  AC. All-Suture Anchor Dynamic Anterior Stabilization Produced Successful Healing of the Biceps Tendon: A Report of 3 Cases. JBJS Case Connect. 2021:17;11(1)</ref> However, it is recommended that future studies are carried out with a more long-term follow-up.
 Preoperative Patient Positioning

← Older revision		Revision as of 06:58, 15 August 2021
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	==Treatments==		==Treatments==
		+	===Clinical Practice Guideline===
		+	The goal of this section is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.
		+
	The degree, nature and combination of injuries induced by traumatic glenohumeral instability are highly variable. Damage to the bony and soft tissue stabilizers of the shoulder, as well as neurologic impairment, must be detected and analyzed in order to provide the patient with the most adequate treatment option. This new knowledge should be applied to rehabilitation therapy and surgical stabilization techniques. As the current stabilization techniques do not seem to prevent residual glenohumeral micro-motion, it remains to be determined which factors help to minimize this phenomenon, whether it is, the increase in the anteroposterior diameter of the glenoid with a bone graft, the sling effect provided by the conjoined tendon or the long head of the biceps, the capsulorraphy, the repaired labrum or the remplissage.<ref>Lädermann A, Bohm E, Tay E, Scheibel M. Bone-mediated anteroinferior glenohumeral instability : Current concepts. Der Orthopade 2018.</ref><ref name=":13">Collin P, Lädermann A. Dynamic Anterior Stabilization Using the Long Head of the Biceps for Anteroinferior Glenohumeral Instability. Arthrosc Tech 2018;7:e39-e44.</ref><ref>Young AA, Maia R, Berhouet J, Walch G. Open Latarjet procedure for management of bone loss in anterior instability of the glenohumeral joint. J Shoulder Elbow Surg 2011;20:S61-9.</ref><ref name=":12" />		The degree, nature and combination of injuries induced by traumatic glenohumeral instability are highly variable. Damage to the bony and soft tissue stabilizers of the shoulder, as well as neurologic impairment, must be detected and analyzed in order to provide the patient with the most adequate treatment option. This new knowledge should be applied to rehabilitation therapy and surgical stabilization techniques. As the current stabilization techniques do not seem to prevent residual glenohumeral micro-motion, it remains to be determined which factors help to minimize this phenomenon, whether it is, the increase in the anteroposterior diameter of the glenoid with a bone graft, the sling effect provided by the conjoined tendon or the long head of the biceps, the capsulorraphy, the repaired labrum or the remplissage.<ref>Lädermann A, Bohm E, Tay E, Scheibel M. Bone-mediated anteroinferior glenohumeral instability : Current concepts. Der Orthopade 2018.</ref><ref name=":13">Collin P, Lädermann A. Dynamic Anterior Stabilization Using the Long Head of the Biceps for Anteroinferior Glenohumeral Instability. Arthrosc Tech 2018;7:e39-e44.</ref><ref>Young AA, Maia R, Berhouet J, Walch G. Open Latarjet procedure for management of bone loss in anterior instability of the glenohumeral joint. J Shoulder Elbow Surg 2011;20:S61-9.</ref><ref name=":12" />

@@ Line 184: / Line 184: @@
 The latter plays a significant role in stabilization of a normal healthy shoulder and after any shoulder injury by contributing to motor control.<ref name=":18">Fyhr C, Gustavsson L, Wassinger C, Sole G. The effects of shoulder injury on kinaesthesia: a systematic review and meta-analysis. Man Ther 2015;20:28-37.</ref>
-[[File:1562542594443-lg.jpg|center|thumb|600x600px|Arthroscopic view of a left shoulder through a posterior portal. This patient has sustained more than 50 subluxations. The axillary nerve is clearly identifiable (white asterisk). There is no more capsule or inferior glenohumeral ligament, and the subscapularis muscle is hardly recognizable. Reproduced from Lädermann A, Benchouk S, Denard P. Traumatic Anterior Shoulder Instability: General concepts & proper management. In: Park J, ed. Sports Injuries to the Shoulder and Elbow. Berlin Heidelberg: Springer-Verlag; 2015, with permission.]]
+[[File:1562542594443-lg.jpg|center|thumb|600x600px|Arthroscopic view of a left shoulder through a posterior portal. This patient has sustained more than 50 subluxations. The axillary nerve is clearly identifiable (white asterisk). There is no more capsule or inferior glenohumeral ligament, and the subscapularis muscle is hardly recognizable. Reproduced from Lädermann et al., <ref>Lädermann A, Benchouk S, Denard P. Traumatic Anterior Shoulder Instability: General concepts & proper management. In: Park J, ed. Sports Injuries to the Shoulder and Elbow. Berlin Heidelberg: Springer-Verlag; 2015</ref> with permission.]]
 Surgical stabilization has been shown to help proper healing of these structures and thus restoring proprioception of the glenohumeral joint.<ref>Myers JB, Lephart SM. Sensorimotor deficits contributing to glenohumeral instability. Clin Orthop Relat Res 2002:98-104.</ref>
@@ Line 199: / Line 199: @@
 However, anterior translation of the humeral head was not significantly reduced and remained close to preoperative values confirming that shoulder stabilization does not stabilize the shoulder but uniquely prevents further dislocation. These findings have several important implications. First, it may explain residual pain, apprehension, and impossibility to return to sport at the same level as reported in other studies. Second, persistent abnormal motion between the glenoid and the humeral head might be the underlying cause of dislocation arthropathy that is observed with a prevalence of 36%. Repeated sliding of the humeral head against the glenoid associated with degenerative changes of cartilage properties and decreased biological healing potential related to aging, could lead to a vicious circle of extensive cartilage damage.<ref name=":19" />
-[[File:1562542595262-lg.jpg|center|thumb|600x600px|(A) Abduction simulation obtained from shoulder’s CT reconstruction and optical motion capture, (B) and (C) show a zoom in the shoulder (front and top views). In image (C), we clearly observe an anterior translation (arrow) of the humeral head center (pink sphere) with respect to the glenoid center (white sphere). Note that the clavicle is not shown for clarity. Reproduced from Lädermann et al., with permission.]]
+[[File:1562542595262-lg.jpg|center|thumb|600x600px|(A) Abduction simulation obtained from shoulder’s CT reconstruction and optical motion capture, (B) and (C) show a zoom in the shoulder (front and top views). In image (C), we clearly observe an anterior translation (arrow) of the humeral head center (pink sphere) with respect to the glenoid center (white sphere). Note that the clavicle is not shown for clarity. Reproduced from Lädermann et al.,<ref name=":19" /> with permission.]]
 <br />

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 In addition to progressive soft tissue injury, recurrent dislocations can facilitate cartilage and bony injuries. Bony lesions are frequent in recurrent cases and may include defects of the glenoid (bony Bankart or beveling of the anterior glenoid resulting in loss of glenoid concavity), impaction of the posterolateral humeral head (Malgaigne lesion), or even coracoid or proximal humerus fractures (Figures).<ref>Griffith JF, Antonio GE, Yung PS, Wong EM, Yu AB, Ahuja AT, Chan KM. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR American journal of roentgenology 2008;190:1247-54.</ref><ref>Buscayret F, Edwards TB, Szabo I, Adeleine P, Coudane H, Walch G. Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors. Am J Sports Med 2004;32:1165-72.</ref><ref>Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy 2003;19:732-9.</ref>
-[[File:1562527520975-lg.jpg|thumb|600x600px|A) Sagittal view of a CT arthrogram of a left shoulder demonstrates a significant Bankart fracture (white arrow) that produces an “inverted-pear” glenoid. B) Plain anteroposterior radiograph reveals an anteroinferior glenohumeral dislocation with an “engaged” Malgaigne (Hill-Sachs) lesion of the humerus.|alt=]]
 [[File:Media2-53.mov|alt=Arthroscopy of a right shoulder with a humeral cartilage lesion after one traumatic episode of glenohumeral dislocation. Posterior viewing portal.|thumb|Arthroscopy of a right shoulder with a humeral cartilage lesion after one traumatic episode of glenohumeral dislocation. Posterior viewing portal. ]]
 [[File:Media3-56.mov|alt=Arthroscopy of a right shoulder with a glenoid cartilage lesion after one traumatic episode of glenohumeral dislocation. Posterior viewing portal.|thumb|Arthroscopy of a right shoulder with a glenoid cartilage lesion after one traumatic episode of glenohumeral dislocation. Posterior viewing portal.]]
 Given that the average glenoid diameter is about 24 mm, a 6 mm-wide or larger fragment of the glenoid will typically equate to a 25% or more of the articular surface and is considered a large bony fragment.<ref name=":4">Burkhart SS, De Beer JF. 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;16:677-94.</ref><ref>Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18:488-91.</ref>

@@ Line 83: / Line 83: @@
 The middle glenohumeral ligament functions to limit both anterior and posterior translations of the arm at 45 degrees of abduction and 45 degrees of external rotation whereas the inferior glenohumeral ligament resists translation of the arm in greater degrees of abduction.<ref name=":3" />
-In addition to progressive soft tissue injury, recurrent dislocations can facilitate bony injury. Bony lesions are frequent in recurrent cases and may include defects of the glenoid (bony Bankart or beveling of the anterior glenoid resulting in loss of glenoid concavity), impaction of the posterolateral humeral head (Malgaigne lesion), or even coracoid or proximal humerus fractures (Figure).<ref>Griffith JF, Antonio GE, Yung PS, Wong EM, Yu AB, Ahuja AT, Chan KM. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR American journal of roentgenology 2008;190:1247-54.</ref><ref>Buscayret F, Edwards TB, Szabo I, Adeleine P, Coudane H, Walch G. Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors. Am J Sports Med 2004;32:1165-72.</ref><ref>Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy 2003;19:732-9.</ref>
+In addition to progressive soft tissue injury, recurrent dislocations can facilitate cartilage and bony injuries. Bony lesions are frequent in recurrent cases and may include defects of the glenoid (bony Bankart or beveling of the anterior glenoid resulting in loss of glenoid concavity), impaction of the posterolateral humeral head (Malgaigne lesion), or even coracoid or proximal humerus fractures (Figures).<ref>Griffith JF, Antonio GE, Yung PS, Wong EM, Yu AB, Ahuja AT, Chan KM. Prevalence, pattern, and spectrum of glenoid bone loss in anterior shoulder dislocation: CT analysis of 218 patients. AJR American journal of roentgenology 2008;190:1247-54.</ref><ref>Buscayret F, Edwards TB, Szabo I, Adeleine P, Coudane H, Walch G. Glenohumeral arthrosis in anterior instability before and after surgical treatment: incidence and contributing factors. Am J Sports Med 2004;32:1165-72.</ref><ref>Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy 2003;19:732-9.</ref>
 [[File:1562527520975-lg.jpg|thumb|600x600px|A) Sagittal view of a CT arthrogram of a left shoulder demonstrates a significant Bankart fracture (white arrow) that produces an “inverted-pear” glenoid. B) Plain anteroposterior radiograph reveals an anteroinferior glenohumeral dislocation with an “engaged” Malgaigne (Hill-Sachs) lesion of the humerus.|alt=]]
 Given that the average glenoid diameter is about 24 mm, a 6 mm-wide or larger fragment of the glenoid will typically equate to a 25% or more of the articular surface and is considered a large bony fragment.<ref name=":4">Burkhart SS, De Beer JF. 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;16:677-94.</ref><ref>Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18:488-91.</ref>

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 Coracoid Positioning and Fixation
-The coracoid process is retrieved and the two sutures that were previously placed through the labrum are inserted through the two predrilled graft holes if the transosseous labral fixation is underway. The coracoid process is placed at the prepared anterior glenoid neck surface. A K-wire is passed through the lower predrilled coracoid and glenoid hole to position the coracoid process on the anterior glenoid neck. The screw length is measured, and the screw is introduced for preliminary fixation (Fig 16 and Video 1). A thin Darrach retractor is used to place the superior part of the coracoid process flush with the glenoid face. Afterward, the superior hole is drilled with a 2.75 mm cannulated drill in the anterior glenoid neck, the length is measured, and the screw is introduced but not fully tightened (Fig 17 and Video 1). The anterior labrum is fixed on the coracoid process by tightening the knots of the sutures passing through the labrum. (Fig 18 and Video 1) Then the coracoid is fully fixed by completely tightening the two partially threaded 4.0 mm cancellous screws. This accomplishes an excellent compression between the coracoid process and the anterior glenoid neck due to the lag-by-design technique. If, however, the surgeon an anchor technique, around two anchors are placed at the medial coracoid-glenoid edge, and fixation of the labrum is performed.
+The coracoid process is retrieved and the two sutures that were previously placed through the labrum are inserted through the two predrilled graft holes if the transosseous labral fixation is underway. The coracoid process is placed at the prepared anterior glenoid neck surface. A K-wire is passed through the lower predrilled coracoid and glenoid hole to position the coracoid process on the anterior glenoid neck. The screw length is measured, and the screw is introduced for preliminary fixation.
+[[File:Figure 16.png|none|thumb|Left shoulder of a patient placed in a semi beach-chair position. The coracoid process (CP) is placed at the prepared AGN surface. First, the inferior screw is introduced for preliminary fixation of the coracoid process so that the graft can still slightly rotate around the screw. CT – conjoined tendon.]]
-The coracoid bone block is now removed from its protective location behind the autostatic retractor. Usually, a 28-30 mm inferior screw is used. The graft is positioned on the prepared anteroinferior glenoid quadrant in such a way that its lateral border is perfectly flush with the glenoid. The superior hole is then drilled and measured with precision to avoid any screw protrusion. Another 4.5 mm self-tapping standard cortical screw is chosen accordingly. The capsule and the labrum are reinserted between the glenoid and the graft according to Luc Favard’s technique in order to decrease the risk of dislocation arthropathy (Video). The sutures are tighten with the arm positioned in full external rotation elbow at the side, elevation, with the assistant pushing the humeral head posteriorly in order to reduce the shoulder. Both screws are finally tightened using a ‘‘2-finger’’ technique.
+A thin Darrach retractor is used to place the superior part of the coracoid process flush with the glenoid face. Afterward, the superior hole is drilled with a 2.75 mm cannulated drill in the anterior glenoid neck, the length is measured, and the screw is introduced but not fully tightened.
+[[File:Figure 17.png|none|thumb|Left shoulder of a patient placed in a semi beach-chair position. A Darrach (D) is used to place the superior part of the coracoid process flush with the glenoid face. The superior hole is drilled with a 2.75 mm cannulated drill in the AGN, the length is measured, and the screw is introduced but not fully tightened. CP – coracoid process, white arrow – coracoacromial ligament.]]
-[[File:1562551689499-lg.mp4|center|thumb|600x600px|Video]]
+The anterior labrum is fixed on the coracoid process by tightening the knots of the sutures passing through the labrum.
-[[File:1562551676712-lg.mp4|center|thumb|600x600px|Video]]
+[[File:Figure 18A.png|none|thumb|Left shoulder of a patient placed in a semi beach-chair position. Reattachment of the labrum (white arrow) on the coracoid process (CP) remains to be done. The labral reattachment (white arrow) has been performed ]]
-[[File:1562551685548-lg.mp4|center|thumb|600x600px|Video]]
+[[File:Figure 18B.png|none|thumb|Left shoulder of a patient placed in a semi beach-chair position. Reattachment of the labrum (white arrow) on the coracoid process (CP) remains to be done. G – glenoid.]]
-[[File:1562551686995-lg.mp4|center|thumb|600x600px|Video]]
+Then the coracoid is fully fixed by completely tightening the two partially threaded 4.0 mm cancellous screws. This accomplishes an excellent compression between the coracoid process and the anterior glenoid neck due to the lag-by-design technique. If, however, the surgeon an anchor technique, around two anchors are placed at the medial coracoid-glenoid edge, and fixation of the labrum is performed.
 Capsulo-labral reconstruction
-Finally, the anterior capsule is reconstructed by the imbrication of the coracoacromial ligament with a resorbable suture. While the operated arm is held in external rotation to avoid the postoperative rotational deficit, the humeral head is reduced posteriorly in the center of the glenoid during adduction, slight anterior forward flexion, and a posterior level push. (Figure and Video). Only then, an adequate capsular tension is expected. The wound is copiously irrigated.
+Finally, the anterior capsule is reconstructed by the imbrication of the coracoacromial ligament with a resorbable suture. While the operated arm is held in external rotation to avoid the postoperative rotational deficit, the humeral head is reduced posteriorly in the center of the glenoid during adduction, slight anterior forward flexion, and a posterior level push.
 Closure
-The Trillat retractor is removed. The tendinous part of the subscapularis muscle lateral to the conjoint tendon is closed side to side with a non-resorbable suture, while making sure not to puncture the anterior ascending branch of the circumflex artery. The wound is closed and a drain is typically not used, unless excessive bleeding is noted.
+The wound is copiously irrigated. The lateral tendinous part of the subscapularis is repaired with a non-resorbable suture. A standard layered closure is performed.
 =====Arthroscopic Latarjet=====

@@ Line 390: / Line 390: @@
 Incision
 The incision is performed under the tip of the coracoid process extending 4 to 5 cm distally.
-The dissection begins at the level of the Mohrenheim fossa, a triangular region just inferior to the clavicle, between the deltoid and pectoralis major muscles which do not contain neurovascular structures. The deltopectoral interval is then opened bluntly with two Richardson retractors, letting the cephalic vein medially (Fig 2 and Video 1). The Gelpi retractor is placed deep in the approach, while the cephalic vein is retracted laterally. The whole coracoid process with the insertion of pectoralis minor, coracoacromial ligament, and the conjoined tendon (CT) is exposed by placing the Hohmann retractor on its tip (Fig 3 and Video 1). The pectoralis minor is released from the coracoid process with electrocautery while the arm is internally rotated and adducted (Fig 4 and Video 1). The upper limb is abducted and fully externally rotated to improve the coracoacromial ligament visualization, which is then released approximately 1.5 cm laterally from its attachment (Fig 5 and Video 1).
+Glenoid exposure and preparation
-Coracoid graft harvest and preparation
+Coracoid Positioning and Fixation
-Glenoid preparation
+The coracoid process is retrieved and the two sutures that were previously placed through the labrum are inserted through the two predrilled graft holes if the transosseous labral fixation is underway. The coracoid process is placed at the prepared anterior glenoid neck surface. A K-wire is passed through the lower predrilled coracoid and glenoid hole to position the coracoid process on the anterior glenoid neck. The screw length is measured, and the screw is introduced for preliminary fixation (Fig 16 and Video 1). A thin Darrach retractor is used to place the superior part of the coracoid process flush with the glenoid face. Afterward, the superior hole is drilled with a 2.75 mm cannulated drill in the anterior glenoid neck, the length is measured, and the screw is introduced but not fully tightened (Fig 17 and Video 1). The anterior labrum is fixed on the coracoid process by tightening the knots of the sutures passing through the labrum. (Fig 18 and Video 1) Then the coracoid is fully fixed by completely tightening the two partially threaded 4.0 mm cancellous screws. This accomplishes an excellent compression between the coracoid process and the anterior glenoid neck due to the lag-by-design technique. If, however, the surgeon an anchor technique, around two anchors are placed at the medial coracoid-glenoid edge, and fixation of the labrum is performed.
 The coracoid bone block is now removed from its protective location behind the autostatic retractor. Usually, a 28-30 mm inferior screw is used. The graft is positioned on the prepared anteroinferior glenoid quadrant in such a way that its lateral border is perfectly flush with the glenoid. The superior hole is then drilled and measured with precision to avoid any screw protrusion. Another 4.5 mm self-tapping standard cortical screw is chosen accordingly. The capsule and the labrum are reinserted between the glenoid and the graft according to Luc Favard’s technique in order to decrease the risk of dislocation arthropathy (Video). The sutures are tighten with the arm positioned in full external rotation elbow at the side, elevation, with the assistant pushing the humeral head posteriorly in order to reduce the shoulder. Both screws are finally tightened using a ‘‘2-finger’’ technique.

@@ Line 389: / Line 389: @@
 Incision
-The skin incision is vertical from the tip of the coracoid extending 4 to 5 cm toward the axillary fold. The trajectory should be slightly curved in order to avoid the axillary fold and thus the formation of postoperative adhesions.
+The incision is performed under the tip of the coracoid process extending 4 to 5 cm distally.
-Deltopectoral approach
+The dissection begins at the level of the Mohrenheim fossa, a triangular region just inferior to the clavicle, between the deltoid and pectoralis major muscles which do not contain neurovascular structures. The deltopectoral interval is then opened bluntly with two Richardson retractors, letting the cephalic vein medially (Fig 2 and Video 1). The Gelpi retractor is placed deep in the approach, while the cephalic vein is retracted laterally. The whole coracoid process with the insertion of pectoralis minor, coracoacromial ligament, and the conjoined tendon (CT) is exposed by placing the Hohmann retractor on its tip (Fig 3 and Video 1). The pectoralis minor is released from the coracoid process with electrocautery while the arm is internally rotated and adducted (Fig 4 and Video 1). The upper limb is abducted and fully externally rotated to improve the coracoacromial ligament visualization, which is then released approximately 1.5 cm laterally from its attachment (Fig 5 and Video 1).
-Coracoid preparation
+Coracoid graft harvest and preparation
-While the arm is still abducted on the armrest, external rotation is applied in order to expose the coracoacromial ligament. Before taking any further step, preventive hemostasis of the acromial branch of the acromiothoracic artery that runs along the posterior part of the coracoacromial ligament must be realized. Only then can the ligament be safely removed, one centimeter from its coracoidal insertion. The patient’s arm is now placed in adduction and internal rotation and a pointed Hohmann is placed behind the coracoid elbow. The pectoralis minor tendon is visualized and totally detached from its bony insertion by electrocautery. The space between the coracobrachial tendon and pectoralis minor muscle is cautiously dissected with scissors, as the musculocutaneous nerve may emerge surprisingly high in this area. It is, therefore, wiser to first identify the nerve by palpation or direct visualization. Another danger is the presence of the underlying brachial plexus and axillary vessels, whose arising branches coursing in the surrounding adipose tissue may be a source of bleeding, and should thus be cauterized preventively. A 90 degrees oscillating saw is used to create a medial to lateral osteotomy. This typically allows for the harvesting of a 2.5 to 3 cm coracoid graft. The coracoid fragment is grasped with toothed (Museux) forceps. The oscillating saw is then used to decorticate the inferior coracoid surface. Two drills one cm apart holes are made using a 3.2 mm drill bit. The coracoid is then pushed beneath the pectoralis major until required later in the procedure.
+A 90° angled saw blade is used to perform a coracoid process osteotomy at its base as far back as possible but still just anterior to the coracoclavicular ligament, starting superomedialy and proceeding inferolateraly (Fig 6 and Video 1). When the coracoid process gets loose, a chisel is meticulously used to complete the osteotomy (Fig 7 and Video 1). The coracoid process is rotated for 180° while being held with a grasper. It is attentively released until the muscle belly is uncovered in order to be easily and safely manipulated. The coracoid process should not be placed outside the surgical field to avoid tension in musculocutaneous nerve neuropraxia. Its undersurface is flattened and slightly decorticated with a saw blade to create a healthy bleeding surface that will precisely conform to the later prepared anterior glenoid (Fig 8 and Video 1). The two 4 mm holes for screw fixation are drilled equally distant from the base and the tip, 1 cm apart and 8-9 mm laterally from the insertion of the coracoacromial (Fig 9 and Video 1). It is essential that the holes are drilled perpendicularly to the surface and centrally to the graft. There are two options for labral fixation, either by transosseous coracoid fixation or by fixation with anchors at the later medial coracoid-glenoid edge. If the surgeon chooses the transosseous coracoid fixation, two holes for later labral fixation are predrilled with a K-wire on the lateral coracoid process bony rim where the coracoacromial inserts, but so that they are placed bellow it and do not pass it. A non-resorbable suture is shuttled through each of them. The coracoid process is retracted medially with the pectoralis major muscle.
 Glenoid preparation
 At this stage, the anteroinferior quadrant of the glenoid should be perfectly exposed for preparation. The anterior glenoid surface is prepared with an osteotome to obtain a spongious bed for the graft.
 A 3.2 mm drill is used to first drill the inferior hole in the glenoid. The hole should be at the 5 o’clock position, 7 mm medially to the joint. When drilling, it is important to stay as parallel as possible to the glenoid surface, as an angle exceeding ten degrees in the axial plane puts the suprascapular nerve at high risk of lesion at its course on the posterior glenoid rim (Figure).<ref name=":23">Lädermann A, Denard PJ, Burkhart SS. Injury of the suprascapular nerve during Latarjet procedure: an anatomic study. Arthroscopy 2012;28:316-21.</ref>[[File:1562551669419-lg.jpg|center|thumb|591x591px|A) The suprascapular nerve passes through the scapular notch beneath the transverse scapular ligament to enter the supraspinatus fossa and provide motor innervation to the supraspinatus muscle. The nerve then courses distally around the base of the scapular spine (spinoglenoid notch) to enter the infraspinatus fossa and provide motor innervation to the infraspinatus muscle. B) The infraspinatus branches of the suprascapular nerve are at risk during screw placement for Latarjet reconstruction. Reproduced from Lädermann et al., with permission.]]

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 In consideration of the current literature, the following indications for osseous reconstruction procedures of the glenoid concavity can be recommended: - Substantial erosion-type defects (type IIIb), which constitute the instability-associated main pathology. - Chronic fragment-type defects (type II), where the glenoid area and concavity cannot be reconstructed by mobilization and refixation of the fragment. - In the rare patient with an acute, non-reconstructible, multifragmented glenoid fracture (type Ic). - In cases of revision surgery, e.g. after failed soft-tissue stabilization, a glenoid augmentation procedure is recommended also for smaller bony defects (type IIIa).
-=====Open Latarjet======
+=====Open Latarjet=====
 In 1954, Latarjet reported a coracoid transfer procedure in which the inferior aspect of the coracoid was secured to the anterior glenoid. The excellent stability of this procedure is obtained by a triple effect first proposed by Patte:<ref>Patte D, Debeyre J. Luxations récidivantes de l’épaule. Tech Chir Orthop Paris: Encycl Med Chir 1980:44–52.</ref>
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 [[File:1562552292659-lg.jpg|center|thumb|600x600px|A) arthroscopic view and B) postoperative anteroposterior x-ray of a left Latarjet procedure. * indicates the graft fixed on the anterior glenoid. Reproduced from Lädermann et al., with permission.]]
-======Open Bristow======
+=====Open Bristow=====
 Independently of Latarjet, Helfet reported in 1958 a slightly different procedure named after his master, Bristow, where the coracoid with conjoined tendon attached was pressed against the anterior glenoid by suturing it to a slit in the subscapularis tendon instead of a screw.<ref name=":2" />
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-======Trillat======
+=====Trillat=====
 [[File:Capture d’écran 2020-01-28 à 22.02.11.png|thumb|Native situation]]