Coracoid / Latarjet Approach (Subscapularis Split)

What it exposes. The coracoid / Latarjet approach is an anterior exposure of the shoulder used to transfer the coracoid process — together with its attached conjoint tendon (short head of biceps and coracobrachialis) — onto the anteroinferior glenoid neck. It is the open surgical access for the Latarjet (and the related Bristow) coracoid transfer procedures, which reconstruct anterior glenoid bone loss and restore anteroinferior stability in recurrent anterior shoulder instability. At its core the approach is the deltopectoral approach taken to the level of the coracoid, followed by a horizontal split of the subscapularis to reach the anteroinferior glenoid. Understanding it therefore depends on mastering the deltopectoral interval and the neurovascular relationships of the coracoid, the conjoint tendon and the subscapularis. How the Latarjet works — the triple effect. The transferred coracoid block stabilises the shoulder by three mechanisms, which explain why the conjoint tendon must remain attached to the graft: - Bony augmentation — the coracoid lengthens the glenoid arc, restoring the anteroinferior bony deficiency and creating a larger articulating arc.

• Sling effect — the conjoint tendon, now lying across the front of the lower subscapularis, forms a dynamic hammock that tightens in abduction and external rotation, blocking anteroinferior humeral escape.
• Capsulolabral reinforcement — the stump of the coracoacromial ligament is secured to the capsule, augmenting the soft-tissue restraint. Indications. - Recurrent anterior instability with significant glenoid bone loss (the classic indication — the bony Bankart or inverted-pear glenoid).
• Engaged (off-track) Hill-Sachs lesion where the humeral bone loss interacts with the glenoid deficiency.
• Failed soft-tissue (arthroscopic or open Bankart) repair.
• High-risk recurrence profile — young contact or collision athletes with recurrent traumatic anterior dislocation.
• Glenoid bone loss greater than approximately 20 to 25 percent is the commonly cited threshold at which a soft-tissue-only repair is predicted to fail and bony reconstruction is preferred. Contraindications. - Volitional (habitual) dislocation — the problem is neuromuscular control, not a bony deficiency.
• Multidirectional instability without a significant bony defect.
• Active infection of the shoulder.
• Severe glenohumeral arthritis — instability is then better addressed by arthroplasty strategies.
• Subscapularis deficiency — the procedure depends on an intact, functioning subscapularis for the sling effect.

Position & landmarks. The beach-chair (semi-sitting, roughly 45 to 60 degrees) position is standard for the open Latarjet — it gives excellent access to the front of the shoulder, allows free arm manipulation and is compatible with intra-operative fluoroscopy; a minority of surgeons use a supine position with a bolster behind the scapula, the principles unchanged. Palpate and mark the coracoid process (just inferior to the lateral third of the clavicle, in the deltopectoral groove) and the deltopectoral groove containing the cephalic vein; the acromioclavicular joint and the anterior corner of the acromion define the superior extent.

Work down through the layers along the deltopectoral interval to the coracoid, osteotomise the coracoid at the knee, then split the subscapularis horizontally to reach the anteroinferior glenoid neck and bed the graft flush. Key anatomy you must know before you cut. The coracoid process projects anterolaterally and superiorly from the superior neck of the scapula. It has a horizontal part (lying in the coronal plane, giving attachment to the coracoacromial and coracoclavicular ligaments and to pectoralis minor) and a vertical part (turning downwards to give attachment to the conjoint tendon); the bend between the two is the knee of the coracoid — the site of osteotomy. The graft is bedded onto the anteroinferior glenoid neck, approximately the three to five o'clock position in a right shoulder.

Structures at risk, by layer

Protection principles in brief. - Identify the coracoid and conjoint tendon early and keep the osteotomy on bone.

• Never retract the conjoint tendon forcefully medially — the musculocutaneous nerve is tethered within it.
• Palpate the axillary nerve along the inferior border of subscapularis before deepening the split.
• Place retractors on bone, under direct vision — never blindly around the glenoid neck.
• Keep the arm adducted and internally rotated during deep work to relax the neurovascular bundle.

Extensile options. Because the coracoid / Latarjet approach is the deltopectoral approach at its core, it shares the same extensility. Extend proximally along the deltopectoral interval toward the clavicle and AC joint to access the anterosuperior shoulder (the basis for shoulder arthroplasty, proximal humeral fracture fixation and open rotator cuff work). Extend distally down the humeral shaft to reach the proximal humeral diaphysis (the anterolateral humeral exposure). Closure. Close the subscapularis split side-to-side with non-absorbable sutures — this restores the muscle and preserves the sling mechanism. Repair the coracoacromial ligament if it was divided and not used for capsular augmentation, re-approximate the deltopectoral interval loosely over a drain if required, and close the subcutaneous tissue and skin in layers.

• Latarjet coracoid transfer — bony reconstruction for anterior instability with glenoid bone loss (the index procedure).
• Bristow procedure — coracoid tip transfer, principally a dynamic sling.
• Open Bankart repair and anterior capsulolabral reconstruction (soft-tissue, when there is no bone loss).
• Coracoid pathology — coracoid fracture, excision of coracoid ossicles, lengthening.
• As the deltopectoral approach more broadly — anatomic and reverse shoulder arthroplasty, proximal humeral fracture ORIF, and pectoralis major and long-head-of-biceps tenodesis.

Guidelines, registries & global practice. Management of anterior shoulder instability with bone loss is convergent across examination systems. The threshold concept of significant glenoid bone loss predicting soft-tissue repair failure, and the rationale for bony reconstruction with a coracoid transfer, are near-universal. Side-by-side principles (where guidance converges): | Body | Position on instability with bone loss | |------|----------------------------------------| | ISAKOS / consensus | Significant glenoid bone loss (commonly cited around 20 percent, the bony Bankart bridge concept) predicts arthroscopic Bankart failure and favours bony reconstruction such as the Latarjet | | AO Foundation | Anatomic restoration of the glenoid arc and stable graft fixation are the operative goals; subscapularis-sparing access is preferred | | National society guidance (e.g. BOA, AAOS-aligned) | Individualise by recurrence risk, glenoid and humeral bone loss, activity and prior surgery; the Latarjet is a recognised option for high-risk recurrent instability with bone deficiency | Registry and population evidence. - Anterior dislocation is the commonest shoulder dislocation, with the highest recurrence in young males, especially contact athletes.

• Long-term coracoid-transfer cohorts show a low recurrence rate but a substantial incidence of late glenohumeral arthritis, strongly linked to graft malposition (a graft placed too lateral or proud) and to the original Hill-Sachs lesion. Global practice variation. In well-resourced settings, open and all-arthroscopic Latarjet variants with congruent-arc grafts and screw fixation are standard. In resource-limited settings, the same principles are applied with conventional small-fragment screws and the classic graft orientation; the Bristow (a single-screw dynamic-sling variant) historically had a larger role where hardware was constrained. Consent (globally applicable): discuss recurrence and its alternatives, infection, haematoma, neurovascular injury (musculocutaneous and axillary nerves), subscapularis dysfunction, graft non-union, malposition and hardware problems, stiffness, and the risk of late glenohumeral arthritis.