Coracoid Graft - Uses, Contraindications, and Surgical Procedures

Introduction

The coracoid process is a hook-like bony projection from the upper margin of the scapula. The coracoid graft is the attachment point for many ligaments and muscles. The coracoid process is located near major neurovascular structures, like the axillary artery, vein, and brachial plexus. The coracoid process acts as a guiding point in various surgical procedures. Hence, it is referred to as the surgeon’s lighthouse or lighthouse of the shoulder.

What Is a Coracoid Graft?

The coracoid graft is a surgical procedure used in orthopedic surgeries mostly to treat shoulder injuries or instability. Coracoid graft surgery is also known as the coracoid process transfer. During the procedure, a section of the coracoid process is removed and used as a bone graft to repair or reconstruct other parts of the shoulder joint. The coracoid graft is held in place with screws, and with time it fuses with the bone.

What Are the Uses of Coracoid Grafts?

The coracoid graft is used in many orthopedic surgeries involving the shoulder. Some of the cases in which coracoid graft is used include:

• Shoulder Instability - The coracoid process is most commonly used in treating shoulder instability caused by damage or tears to the ligaments and tendons that hold the joint in place. The graft creates a new attachment point for these structures, providing stability to the shoulder joint. Shoulder injuries or instability that do not respond to non-surgical treatments are treated using coracoid grafting.

• Shoulder Arthritis - In some cases of shoulder arthritis, the coracoid graft provides additional support to the joint.

• Rotator Cuff Repair - The coracoid graft is used in some cases of rotator cuff repair surgery to help reinforce the repair and provide additional support for the weakened rotator cuff tendon.

• Fracture Repair - The coracoid process can be used as bone graft material for fracture repair in other body areas. This is because it is easily accessible.

• Recurrent Shoulder Dislocations.

• Glenoid Bone Loss - The glenoid fossa is the lateral part of the scapula which forms the socket in which the humeral head is articulated. Bone loss in the glenoid fossa can be treated using coracoid grafting.

• Scapular Fractures - Fracture of the shoulder girdle.

What Are the Types of Coracoid Graft Surgery?

Coracoid grafting can be performed arthroscopically or by open incision methods, depending on the individual case and considering various factors.

• Latarjet and Modified Latarjet Procedures: This procedure is commonly done for recurrent anterior shoulder dislocations. In the latarjet procedure, a part of the coracoid process is removed along with the muscles attached and placed in front of the glenoid. This coracoid graft acts as a block and increases the glenohumeral stability, preventing dislocations.

• Mini-Open Latarjet Procedure: This procedure is arthroscopically assisted to make the surgery minimally invasive.

• Congruent-Arc Latarjet Procedure: A greater percentage of the glenoid bone deficit can be treated using a congruent-arc Latarjet procedure.

• Bristow Procedure and Modified Bristow Procedure: These procedures are used in treating shoulder instabilities caused due to scapular defects. The Bristow procedure involves transferring a segment of the coracoid process to the anterior surface of the scapula.

• The Bristow-Latarjet Procedure: This procedure combines both the Latarjet and the Bristow procedures.

What Are the Contraindications for Coracoid Grafting?

Coracoid graft surgery is contraindicated in the following cases.

• Infection - Active infection at the surgical site should be treated and resolved first before surgery.

• Excessive bone loss in the coracoid process or the glenoid fossa is a contraindication for coracoid grafting.

• Pregnancy.

• Bone quality - Poor bone quality and underlying bone disorders may make coracoid grafting unsuccessful.

• Older age patients.

• Patients with uncontrolled epilepsy.

• Shoulder instability is associated with the weakness of the deltoid muscle and other muscles related to the scapula.

What Are the Common Steps in the Coracoid Transfer Process?

1. Anesthesia: Either general or regional anesthesia is given, depending on the case. The patient is positioned appropriately.

2. Incision: The surgeon makes an incision in the shoulder area to access the coracoid process.

3. Removal of the Coracoid Process (Coracoid Osteotomy): A segment of the coracoid process is removed as a free graft or with a tendon attached.

4. Exposure and Preparation of the Area in Which the Graft Is to Be Placed.

5. Preparation of the Coracoid Graft: The graft is shaped to fit the area in which it is going to be grafted.

6. Positioning and Fixing the Graft (Implantation): The graft is then positioned in the area to be repaired and fixed using screws or other fixing devices.

7. Closure of the Incision: The incision is closed using sutures or staples.

What Are the Postoperative Instructions after Coracoid Graft Surgery?

• Postoperative care includes monitoring and instructing patients on caring for the incision site, managing pain, and performing rehabilitation exercises.

• A sling is used for about three to four weeks after surgery.

• After surgery, gentle, assisted, active, and passive shoulder range motions are permitted for 3 to 4 weeks.

• NSAIDs are not advised during the initial stages of postoperative days because they interfere with bone healing.

• Radiographs are taken in follow-up appointments to check for the healing process.

• Heavy labor and contact sports are not permitted for about four months postoperatively.

What Are the Complications Associated with Coracoid Grafting?

• The recurrence of shoulder instability is due to the failure of the coracoid grafting procedure, which may be due to a fracture of the coracoid process, improper patient selection, improper positioning of the coracoid graft, or other technical errors.

• Hematoma or blood vessel damage may occur but is very uncommon.

• Neurological complications like damage to the nerves in the shoulder joint may cause tingling, numbness, or weakness in the arms and shoulder.

• The risk of infection is a common complication of all surgical procedures.

• Stiffness of the shoulder may occur due to damage to the muscles during the surgery, causing limitations in the joint's mobility and discomfort or pain.

• Non-union of the bone graft may occur due to malpositioning of the graft, poor bone quality, and in older patients.

• Fracture of the transferred graft.

• Resorption of the bone graft.

• Postoperative arthritis.

Conclusion.

Coracoid graft surgery is a procedure to stabilize shoulder joints in patients with certain shoulder conditions. It is an effective treatment option, but the patient should discuss the risks and complications with their doctor before deciding to go through with it. Postoperative instructions should be followed strictly to get a better prognosis. Recovery time may vary and additional therapeutic interventions such as physical therapy may be necessary to enhance recovery and restore optimal shoulder function. While coracoid graft surgery offers promising results, its long-term efficacy in permanently reducing shoulder issues needs continued research and monitoring to ensure sustained benefits.