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2023 AOSSM Annual Meeting Recordings with CME
The Latarjet: Transition from Open to Arthroscopic
The Latarjet: Transition from Open to Arthroscopic
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Video Transcription
I appreciate the opportunity to present in such a nice meeting, and I will tell you how we did the transition from open to arthroscopic. These are my disclosures. So why should we bother to switch from open to arthroscopic? The open latache has been the gold standard for certain patients for many, many years, but we know that orthopedic practicing in sport medicine, we tend to prefer the arthroscopic procedures, and if you think of it historical, we know that for bunk guard, cuff repair, AC joint stabilization, we would never go back to open procedures, at least most of us. So there's also another benefit, obvious, that it's more easy to treat concomitant injuries, but there's a but, because especially for the arthroscopic latache, that's a technically demanding procedure. So when we decided to start doing it arthroscopically in my department, the first thing we did was to travel and visit an experienced surgeon. We visited Laura Lofos and planned to do the technique with screws. After seeing the procedure several times, we went to the wet lab and practiced on cadavers several times before we scheduled our two first patients. For this operation, we invited a friend and experienced colleague, Dr. Kushner from Sweden, and he was in the OR with us for the two first cases. We were also lucky because we were two experienced surgeons that wanted to start this, so we did all the first cases together. We also wanted to follow the patients closely because we knew that we had good results with the open procedure, so we wanted to follow them to know that we did no harm to our patients. So in the theater, for the first cases, we tried to copy the master. So even though I do most of the shoulder surgeries in lateral decubitus, we did these first cases in beach chair to try to do it exactly the same way that we had seen. It's also very important to monitor the cerebral blood flow because the patients are sitting and we need low blood pressure anesthesia because if the patient starts bleeding, you're lost and the procedure will take a very long time. For the same reason, we also use tranexamic acid for all patients and do meticulous hemostasis during the operation. Right before we are passing the graft through the subscapularis, we give the patient muscular relaxation to do this step of the procedure more easily. So after doing more than 100 cases, I thought, well, I do all my shoulder surgeries in lateral decubitus instead of this. So actually now I have switched. I have switched to the endobutton technique and do it now in lateral decubitus. And also for most of the cases, I use the 70-degree scope now. So for the endobutton technique, these are the portals. I always use the north and the south and the west and the northwest. I don't always need the east portal and you need two portals from posterior. So this is looking from posterior. The first step is to follow the upper border of the subscapularis and this will lead you to the coracoid and you need to release all the soft tissue around the coracoid. So starting from the inferior surface and then moving around to the upper surface and releasing the coracoachromal ligament. And after that, you need to release some tissue around the conjoined tendon and with the 70-degree scope, you can very easily see this room under the deltoid in front of the subscapularis and release the upper part. Then I switched the electrocorticoid device to the north portal to get better access to the pectoralis minor muscle and you have to release this from the medial side of the coracoid and we are still in the posterior portal with the scope. So with the 70-degree scope, you can see all this from posterior. This is just to show you how it looks from anterior and if you're not comfortable using the 70-degree scope because everything looks a little bit different, you can do the whole procedure with a 30-degree scope, but you will then have to use more anterior portals. So here is back to the posterior portal and the 70-degree scope. For the endobutton technique, you depend very much on the surface of the coracoid and the anterior glenoid. So we use this rasp to make the undersurface very flat. And the next step is to use this sugar clamp that has to come perpendicular to the flat surface underneath the coracoid and we drill with a burr that has a sleeve around it. So you have to drill all the way until you see the sleeve and then remove the inner part, the burr, and the sleeve will make it easy for you to thread the suture. So here comes the blue PDS suture and you use this as a traction suture for the endobutton. And the endobutton comes down from the north portal and after seeing the button in its place is a little bit of suture management because the next step is the osteotomy with a saw and you don't want to damage the sutures. So you pull the top suture, the blue one, to the south portal and then all the white sutures to the north portal to get them out of the way. This is a half pipe I use when I go in with the saw so I won't damage anything on my way and you use the saw to do the osteotomy, you could also use a chisel and try to do the osteotomy 15 to 20 millimeters from the tip. Then we're done with the coracoids so far so we go back into the joint and while we have the scope in the posterior portal we mark the height of the glenoid because you are more familiar working from posterior so it's more easily to get the right height. And you have to prepare the anterior glenoid as I said and the position of the graft is very dependent of the flat surfaces so we use the same rasp to make a flat surface anterior of the glenoid. And I also make a weak point in the subscapularis from the articular side so it's more easy to get through with the instrument later on and more easy to make the split from anterior. So this is the guide we use to drill the tunnels in the glenoid, it comes from posterior and it gives you the distance from the articular surface to the tunnel with this hook and it's the same burr as we used in the coracoid with the sleeve around it so you can thread your sutures and you have to watch the tip so it doesn't go too far but you have to go far enough so you see the sleeve. And then you take an instrument either this spreader or a switching stick from posterior in the same height as you had your sleeve and go through the subscapularis and before you go too far you then move your camera anterior to the subscapularis and find the nerve, this is the axillary nerve posterior to the conjoined tendon. And to be safe not to have any injury you would like to see this nerve when you push your spreader or your switching stick through the subscapularis. So here you can see the switching stick coming through and the axillary nerve is very close but when you then proceed with your split you know that the nerve is medial to your switching stick and you can safely make the split lateral to the switching stick. Coming into the split you will then again find your sleeve with the suture and I like to use this blue PDS suture so it's easy to see which suture that is and you can pull your coracoid in through the split, here it comes, and then you have to like lift the subscapularis so it gets into the joint and you might have to do some rotation, some adjustment of the graft and you then put the posterior endobutton and do a NIS knot to secure this endobutton fixation. And after you have done the knot we use a tensioner to know that this is tight. So in the beginning I was surprised that sometimes it didn't feel totally solid so now I always use this tensioner at least three times to 100 Newton. You can do it to 50 first and then take your time to adjust the graft and then at least three times to 100 before you secure it with three more knots. So what we have learned from this process turning to arthroscopically is that we always do a CT scan postoperatively because we really want to know that the graft is not too lateral because that would be a disaster for the patients. And we have published the results from our learning curve after doing 100 cases and happily the complication rate went down and also the time to do the procedure. So you can read this paper if you want to learn more. So my advice would be to talk to people who are familiar with the procedure and practice several times in a cadaver lab before you do this on your patients. And I really recommend to do a postoperative CT scan because these are young patients with instability. We don't want to turn them into young patients with osteoarthritis. Thank you.
Video Summary
In this video, the speaker discusses the transition from open to arthroscopic procedures for certain orthopedic surgeries, specifically focusing on shoulder surgeries. They highlight the benefits of arthroscopic procedures, such as easier treatment of concomitant injuries. The speaker shares their journey of learning and adopting the arthroscopic latissimus dorsi (latache) technique, including visiting an experienced surgeon and practicing on cadavers before performing the procedure on their first patients. They also mention the importance of closely monitoring patients to ensure good outcomes. The speaker then explains the endobutton technique for arthroscopic procedures and provides a step-by-step description of the surgical process. They conclude by emphasizing the importance of talking to experienced practitioners, practicing in a cadaver lab, and conducting postoperative CT scans for optimal results and patient safety. (No credits are provided in the transcript.)
Asset Caption
Berte Boe, MD
Keywords
open to arthroscopic procedures
shoulder surgeries
arthroscopic latissimus dorsi technique
endobutton technique
patient monitoring
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