title: 2014 Neer Award Paper: neuromonitoring the Latarjet procedure.
abstract: BACKGROUND
  We used intraoperative neuromonitoring to define the stages of the Latarjet procedure during which the nerves are at greatest risk.
  
  
  METHODS
  Thirty-four patients with a mean age of 28.4 years were included. The Latarjet procedure was divided into 9 defined stages. Bilateral median and ulnar somatosensory evoked responses and transcranial motor evoked potentials from all arm myotomes were continuously monitored. A "nerve alert" was defined as averaged 50% amplitude attenuation or 10% latency prolongation of ipsilateral somatosensory evoked responses and transcranial motor evoked potentials. For each nerve alert, the surgeon altered retractor placement, and if there was no response to this, the position of the operative extremity was then changed.
  
  
  RESULTS
  Of 34 patients, 26 (76.5%) had 45 separate nerve alert episodes. The most common stages of the procedure for a nerve alert to occur were glenoid exposure and graft insertion. The axillary nerve was involved in 35 alerts; the musculocutaneous nerve, in 22. Of the 34 patients, 7 (20.6%) had a clinically detectable nerve deficit postoperatively, all correlated with an intraoperative nerve alert. All cases involved the axillary nerve, and all resolved completely from 28 to 165 days postoperatively. Prior surgery and body mass index were not predictive of a neurologic deficit postoperatively. However, total operative time (P = .042) and duration of the stage of the procedure in which the concordant nerve alert occurred (P = .010) were statistically significant predictors of a postoperative nerve deficit.
  
  
  CONCLUSIONS
  The nerves, in particular the axillary and musculocutaneous nerves, are at risk during the Latarjet procedure, especially during glenoid exposure and graft insertion.
authors.affiliation: Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Delaney
authors.affiliation: Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Freehill
authors.affiliation: Department of Anesthesiology, Brigham & Women's Hospital, Boston, MA, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Janfaza
authors.affiliation: Department of Anesthesiology, Brigham & Women's Hospital, Boston, MA, USA.
authors.forename: Kamen V
authors.initials: KV
authors.lastname: Vlassakov
authors.affiliation: Boston Shoulder Institute, Brigham & Women's Hospital, Boston, MA, USA.
authors.forename: Laurence D
authors.initials: LD
authors.lastname: Higgins
authors.affiliation: Boston Shoulder Institute, Massachusetts General Hospital, Boston, MA, USA. Electronic address: jwarner@partners.org.
authors.forename: Jon J P
authors.initials: JJ
authors.lastname: Warner
mesh_terms: D000328:Adult; D001132:Arm / Q000294:innervation; D001363:Awards and Prizes; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D008297:Male; D016343:Monitoring, Intraoperative; D009985:Orthopedics; D059348:Peripheral Nerve Injuries / Q000209:etiology / Q000517:prevention & control*; D012785:Shoulder Joint / Q000601:surgery*
keywords: Instability; Latarjet procedure; axillary nerve; musculocutaneous nerve; neurologic complications