Misventure in the Treacherous Terrain of Subscapularis during Latarjet Procedure: A Case Report

Abstract

Latarjet procedure is one of the commonly performed surgeries for recurrent anterior dislocation of the shoulder and has been modified by many surgeons over the past eight decades. This procedure mandates detailed understanding of the anatomy of the shoulder, axillary region, and brachial plexus, as the subscapularis muscle will be split open during the procedure, which forms the bed for axillary artery and cords and branches of the brachial plexus. Any deviation from the procedure could lead to untoward complications. We present an extremely rare case of injury to the lateral cord of brachial plexus, musculocutaneous nerve, and median nerve following the Latarjet procedure.

 

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Keywords

brachial plexus injury - Latarjet procedure - subscapularis splitting method

Introduction

Proposed by Michael Latarjet in the year 1954 and subsequently modified over the past few decades, the Latarjet procedure is commonly performed now for recurrent anterior dislocation of the shoulder,[1] with varying rates of postprocedural complications. Magnetic resonance imaging (MRI) and high-resolution ultrasound imaging play a crucial role in the timely diagnosis of postoperative complications.

 

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Case Summary

A 21-year-old gentleman with a history of recurrent right anterior dislocation had undergone the Latarjet procedure and complained of weakness in his right hand and thumb on the second postoperative day. The patient was kept under close follow-up. However, in 6 months, there was no further improvement. During a neurological assessment, he was found to have median nerve palsy and musculocutaneous nerve palsy.

Imaging Findings

MRI showed a diffusely thickened, stretched, and tethered lateral cord of the right brachial plexus toward the postoperative site ([Fig. 1A]). Also, the distal part of the lateral cord was sutured to the subscapularis muscle ([Fig. 1B]). Musculocutaneous, median, and, to a lesser extent, the ulnar nerves were thickened and showed short tau inversion recovery hyperintense signal with denervation changes in the coracobrachialis and short head of biceps muscle ([Fig. 1C]). Sutures entrapping the lateral cord were well visualized in the high-resolution ultrasound as well ([Fig. 1D]).

Fig. 1 Magnetic resonance (MR) images (A – T1 coronal, B, and C – short tau inversion recovery [STIR] axial) show diffusely thickened, stretched, and tethered lateral cord of right brachial plexus (yellow arrow) toward the postoperative site (A). Also, the distal part of the lateral cord was sutured (yellow arrow) to the subscapularis muscle (B). The rest of the immediate distal terminal branches could not be well delineated. However, further caudally, the musculocutaneous nerve, median nerve, and, to a lesser extent, the ulnar nerve were thickened and showed STIR hyperintense signal with denervation changes (yellow arrow) in the coracobrachialis and short head of biceps muscle (C). Sutures entrapping the lateral cord were well visualized (yellow arrow) in the high-resolution ultrasound as well (D).

 

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Intraoperative Findings

The patient underwent right brachial plexus exploration, and it was found that the subscapularis was cut in the upper two-thirds craniocaudally and sutured ([Fig. 2A]). One of the suture anchors was seen passing through the distal part of the lateral cord, constricting and scarring the lateral cord and medial root of the median nerve. This tether had lateralized the distal median and musculocutaneous nerves, which were caught under the second and third sutures ([Fig. 2B] and [C]). There was complete severance of the median and musculocutaneous nerves. Scarred part of the lateral cord was excised and group fascicular grafting of median and musculocutaneous nerves was done. Due to the duration of the injury, a distal neurotization of the flexor carpi ulnaris fascicle of the ulnar nerve to the biceps branch of the musculocutaneous nerve was also done. The postop period of the patient was eventful and will be reviewed for supervised therapy.

Fig. 2 (A–C) The intraop pictures of sutures entrapping the lateral cord, musculocutaneous nerve, and medial and lateral roots of the median nerve.

 

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Diagnosis

Suture entrapment of lateral cord, musculocutaneous nerve, and medial, and lateral roots of the median nerve of the right brachial plexus. The patient was followed up serially and after 12 months of the surgery, the patient showed complete resolution of the weakness in the right hand and thumb and there were no new complaints.

 

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Discussion

Typical steps of Latarjet procedure ([Fig. 3A]–[F]) include access through deltopectoral groove, shaving off the pectoralis minor from medial aspect of the coracoid process, osteotomy at the knee of coracoid with preservation of conjoint tendon, splitting of the subscapularis at the junction between the upper two-thirds and lower one-third along the muscle fibers, capsulotomy of the glenohumeral joint, fixation of the harvested coracoid, closure of capsule, and no suturing of subscapularis.[1] [2] [3] [4] [5] In our case, suturing of the subscapularis led to inadvertent sutural entrapment of the lateral cord, musculocutaneous nerve, and medial, and lateral roots of the median nerve ([Fig. 3G]–[I]) and resultant denervation changes in coracobrachialis and short head of biceps muscle ([Fig. 1C]).

Fig. 3 Steps in Latarjet procedure (A – approach through anterior deltopectoral groove and shave off the pectoralis minor from the medial aspect of the coracoid process, B – osteotomy at the knee of coracoid with preservation of conjoint tendon, C – splitting of subscapularis at the junction between the upper two-thirds and lower one-third along the muscle fibers, D – capsulotomy of the glenohumeral joint, E – fixation of the harvested coracoid, F – closure of capsule and no suturing of subscapularis). However, schematic images (G–I) show the longitudinal incision of the subscapularis (G), fixation of the coracoid graft to the glenoid (H), and (I) inadvertent entrapment of the lateral cord of the brachial plexus, musculocutaneous nerve, and medial and lateral roots of the median nerve while suturing the defect in the subscapularis muscle.

The incidence rate of neurovascular injury could vary anywhere between 1% and as high as 20%.[1] Musculocutaneous nerve and axillary nerve are the most commonly injured nerves during the Latarjet procedure.[1] [2] [3] [4] [5] [6] [7]

While dissecting around the coracoid, surgeon must stay lateral to the conjoint tendon and avoid exposing the medial border of the conjoint tendon to prevent nerve injury.[1] Self-retaining retractor sizes and positions must be selected appropriately according to the patient's habitus to avoid nerve stretching.[2] Avoiding tenotomy and suturing of the subscapularis by using the subscapularis split method for the glenohumeral joint prevents nerve injury.[3] [4] [5]

 

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Conclusion

Careful dissection of the coracoid by limiting the exploration medial to the conjoint tendon, selective usage of self-retaining retractors, and subscapularis split method to access the glenohumeral joint could prevent nerve injury during the Latarjet procedure. MRI and high-resolution ultrasound play a vital role in the early identification of this complication.

 

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Conflict of Interest

None declared.

• References

• 1 Gupta A, Delaney R, Petkin K, Lafosse L. Complications of the Latarjet procedure. Curr Rev Musculoskelet Med 2015; 8 (01) 59-66
• 2 Domos P, Lunini E, Walch G. Contraindications and complications of the Latarjet procedure. Shoulder Elbow 2018; 10 (01) 15-24
• 3 Hurley ET, Schwartz LB, Mojica ES. et al. Short-term complications of the Latarjet procedure: a systematic review. J Shoulder Elbow Surg 2021; 30 (07) 1693-1699
• 4 Boylan MR, Strauss EJ, Jazrawi LM, Virk MS. The Latarjet-Patte procedure past, present, and future. Bull Hosp Jt Dis 2022; 80 (01) 80-87
• 5 McHale KJ, Sanchez G, Lavery KP. et al. Latarjet technique for treatment of anterior shoulder instability with glenoid bone loss. Arthrosc Tech 2017; 6 (03) e791-e799
• 6 Southam JD, Greis PE. Delayed, transient musculocutaneous nerve palsy after the Latarjet procedure. J Shoulder Elbow Surg 2012; 21 (05) e8-e11
• 7 Frank RM, Gregory B, O'Brien M. et al. Ninety-day complications following the Latarjet procedure. J Shoulder Elbow Surg 2019; 28 (01) 88-94

Publication History

Article published online:
08 September 2025