Arthroscopic Latarjet using Endobuttons

By Alexandre Tadeu Nascimento 2 Videos

638 views

May 22, 2017

The surgical technique we used was based on published descriptions with some adjustments. The patient ...
read more ↘ receives general anesthesia and a plexus block and is then placed in the beach chair position. Surgical marks are drawn on the shoulder, including the J portals, placed in an arc half way between the axillary fold and the anterolateral portal. The J portal provides a direct view of the coracoid, whereas the anterolateral portal provides a better lateral view.
The intra-articular approach begins through the posterior portal, where all the intra-articular inspection is performed. A needle is used to create the anterior portal above the upper edge of the subscapularis tendon. Using a probe inserted through the anterior portal, internal structures are examined in search of injuries (to the labrum, glenoid, and tendons). Radio frequency is used to resect the anteroinferior labrum and medial glenohumeral ligament in the anteroinferior region of the glenoid. A capsulectomy is conducted along the line of the medial glenohumeral ligament to facilitate the subsequent insertion of the graft. After the glenoid cavity is exposed, it is debrided and the cartilage scraped using a soft tissue and bone shaver, preferably through the anterolateral portal. After the glenoid cavity is prepared to receive the graft, the coracoacromial ligament is resected from its insertion into the coracoid to make it easier to view from above. The coracoid is then prepared using the J portal for visualization, deinserting the pectoralis minor muscle, scraping the cortical bone on its inferior side, and taking care to avoid damage to the brachial plexus. After that, the tendon joining the soft tissues on the anterior surface of the coracoid is “released,” and the passage of the axillary nerve behind this tendon is identified to avoid damage.
A longitudinal split is made in the tendon and subscapularis muscle to allow the passage of the coracoid graft. We then pass the 4 wires (2 in the glenoid and 2 in the coracoid) to create the tunnel that the Endobuttons will pass through. The guidewires are inserted into the glenoid using a guide for reconstructing the anterior cruciate ligament (ACL) of the knee, placing the tip of the guide through the anterolateral portal and the other end through the posterior portal. The guide used must be 90° to avoid contact with the articular surface of the glenoid. The guide is positioned in the anteroinferior region of the glenoid where the tunnel is to be created, approximately 0.5 cm from the articular surface, passing the guidewire from back to front. This same process is repeated to pass the second guidewire through the glenoid, approximately 2 cm above the first. After the two glenoid guidewires are positioned, a specific portal is made for the tunnels and the coracoid osteotomy (portal H),7 and the two coracoid guidewires are passed “freehand,” with a distance of approximately 2cm between them.
Having positioned the 4 guidewires, the tunnel is made for the passage of the Endobutton. We prefer to begin with the lower glenoid tunnel using a 5 mm cannulated drill. After drilling, the bit is kept in the outgoing position and the guidewire is removed; a Prolene loop is passed through the drill to bring the Endobutton from back to front. After passing through the glenoid, the Endobutton is provisionally retrieved to the anterolateral portal, taking care to pass it through the split in the subscapularis tendon. We then create the coracoid tunnel in the most distal guidewire and retrieve the same Endobutton that was placed in the glenoid using the Prolene loop in the same manner, bringing it through portal H and passing it through the coracoid tunnel. After these steps, this single Endobutton is connected from the posterior glenoid region to the upper cortical coracoid. The same process is then repeated with the other guidewires, connecting another Endobutton from the glenoid to the coracoid. With the two Endobuttons connected, we perform a coracoid osteotomy and then use the Endobuttons connected to a single posterior button to bring the bone graft through the split in the subscapularis tendon to the area where the cartilage was previously scraped away.
We use a type of Endobutton that has a self-locking mechanism in its wires, making a posterior knot unnecessary; we believe that this allows us to create greater contact force between the graft and glenoid cavity.
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Arthroscopic Latarjet using Endobuttons

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