Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

359. Bankart Repair and Inferior Capsular Shift

Theodore A. Blaine, Andrew Green, and Louis U. Bigliani

DEFINITION

images Shoulder instability is caused by a disruption of the normal stabilizing anatomic structures of the shoulder, leading to recurrent dislocation or subluxation of the glenohumeral joint.

ANATOMY

images Glenohumeral stability depends on the integrity of static and dynamic components.

images Dynamic stabilizers include the rotator cuff muscles, which provide a concavity compression effect, the scapular stabilizers, and the biceps tendon, which contributes to anterior stability when the arm is in an abducted and externally rotated position (FIG 1A,B).

images Static stabilizers consist of the bony and articular anatomy of the glenoid and humeral head, the negative intra-articular pressure supplied by the intact glenohumeral capsule, and the capsule–labral complex, which contains the glenoid labrum and anterior, middle, and superior glenohumeral ligaments (FIG 1C).

images The glenoid labrum plays an important role in deepening the glenoid socket and as an attachment site for the glenohumeral ligaments (FIG 1D).

images The primary restraint to anterior inferior translation of the humeral head in 90 degrees of abduction and external rotation is the inferior glenohumeral ligament (IGHL).

images The middle glenohumeral ligament (MGHL) has a variable attachment site into the glenoid labrum, glenoid neck, and biceps tendon origin. The MGHL is important in resisting anterior subluxation of the humeral head in the middle range of shoulder abduction (45 degrees).

images The superior glenohumeral ligament (SGHL) is located in the rotator interval capsule, and prevents inferior and posterior subluxation of the humeral head with the arm in an adducted and neutral or internally rotated position. The SGHL is important in inferior and posterior translation of the humeral head.

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FIG 1  Dynamic stabilizers of the glenohumeral joint include the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis; A,B). The static stabilizers of the glenohumeral joint include the glenohumeral ligaments of the capsule (C), and the glenoid labrum (D), which deepens the socket and serves as an attachment for the glenohumeral ligaments and biceps tendon.

PATHOGENESIS

images Glenohumeral instability (subluxation or dislocation) occurs when the static or dynamic stabilizers of the glenohumeral joint are disrupted, either from acute rupture or repetitive microtrauma.

images The “essential anatomical defect,” or Bankart lesion, was first described by a British pathologist, A. Blundell Bankart, in 1923, and the operative procedure was first described in 1938 (FIG 2A).3,20

images The Bankart lesion is present in at least 40% of shoulders undergoing anterior instability procedures.

images The “essential” nature of the Bankart lesion has been challenged, since a simulated Bankart lesion without capsular stretching does not lead to significant increases in glenohumeral translation.

images In addition to tearing of the glenoid labrum, the labrum may also be avulsed from the glenoid rim as a sleeve of tissue (anterior labral periosteal sleeve avulsion [ALPSA]) (FIG 2B).17

images Recurrent major trauma and repetitive microtrauma creates substantial deformation to the IGHL, producing subsequent episodes of symptomatic subluxation.

images Biomechanical studies of this ligament have demonstrated that failure typically occurs at the glenoid insertion (40%), followed by the ligament substance (35%) and the humeral attachment (25%). Significant capsular stretching can occur (23% to 34%) before failure.

images Osseous deficiency on the anterior rim (bony Bankart) may contribute to glenohumeral instability (FIG 2C).

images Significant defects accounting for instability occur when 30% of the glenoid is involved, and the glenoid acquires an “inverted pear” appearance (FIG 2D).

NATURAL HISTORY

images The incidence of glenohumeral instability has been estimated at 8.2 to 23.9 per 100,000 person-years.23

images The incidence in at-risk populations is significantly higher (military population, 1.69 per 1000 person-years; NCAA athletes, 0.12 injuries/1000 athletic exposures).19

images Overhead athletes are prone to this repeat injury as their motions in the abducted, externally rotated position put stress on the capsulolabral structures. Contact athletes (football players and wrestlers) have the highest incidence of shoulder dislocations as compared to other sports.

images Depending on the patient's age and activity level, redislocation rates in active patients may be as high as 92% with nonoperative treatment.13,19,24

PATIENT HISTORY AND PHYSICAL FINDINGS

images Evaluation of the patient with suspected instability begins with a thorough history.

images Arm dominance, sport, position, and level of competition should be noted, as well as associated factors, including other sporting activities, training modalities, and past history of injuries.

images Traumatic causes of instability should be determined, as these are more likely to be associated with Bankart lesions.

images The character of the problem should be elicited.

images Does the athlete complain of pain or instability?

images Does the shoulder subluxate or dislocate?

images What arm positions reproduce symptoms?

images Any prior treatments (physical therapy, training modifications, medication, and surgery) should be noted.

images Physical examination should include assessment of both shoulders.

images Inspection should be performed to identify any skin incisions, evidence of wasting in the deltoid, rotator cuff, or periscapular musculature, and gross evidence of laxity, including sulcus signs or signs of generalized ligamentous laxity.

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FIG 2  A. The Bankart lesion: tear of the anterior inferior glenoid labrum. B. Axial view MRI scan showing the anterior labral periosteal sleeve avulsion (ALPSA). C,D. CT scan with axial view and reconstruction image, respectively, showing a large anterior inferior glenoid “bony Bankart” fracture.

images Palpation is performed to identify point tenderness; anterior joint line tenderness may be present in acute anterior dislocations; subacromial tenderness may be present with impingement secondary to subtle instability.

images Active and passive motion tests are an important part of the instability examination. Significant variations in motion are encountered in throwing athletes, with increased external rotation and decreased internal rotation common in the affected shoulder.

images Provocative testing is perhaps the most important aspect in the clinical evaluation of shoulder instability.

images The sulcus sign is often elicited in patients with inferior instability.

images Anterior translation and posterior translation are similarly graded with the patient supine and with an anterior or posterior load and shift test, although this test is performed only in the anesthetized patient.

images In the awake patient, signs of instability can be more subtle. The apprehension test is routinely performed with the arm abducted, extended, and externally rotated. A sensation of impending subluxation or dislocation in the patient is diagnostic of instability. Pain is less specific and may instead indicate internal impingement of the articular surface of the rotator cuff or functional impingement of the bursal side of the rotator cuff on a prominent coracoacromial ligament.

images A posterior-directed force on the arm by the examiner that relieves the apprehension in this position (Jobe relocation test) suggests an unstable shoulder.

images Subscapularis integrity and strength should be evaluated in patients with glenohumeral instability.

images Inability to press the hand to the belly is a positive result of the belly press test and indicates subscapularis muscle weakness or tear.

images Inability to lift the hand from the back is a positive result in the lift-off test and indicates subscapularis muscle weakness or tear.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Radiographs include anteroposterior (AP), lateral, and axillary views (FIG 3A,B).

images The axillary view is particularly important for assessing anterior glenoid rim defects.

images The Hill-Sachs lesion of the posterosuperior humeral head is best seen on the AP internal rotation or Stryker notch views.

images CT scan is not necessary in all cases but may be helpful in patients with bony defects (see FIG 2C,D).

images MRI scan is not necessary in all cases but can be useful in identifying labral lesions as well as subscapularis tears (FIG 3C).

images MRI arthrogram is more sensitive in identifying labral pathology and may be necessary when superior or posterior labral pathology is suspected.

DIFFERENTIAL DIAGNOSIS

images External impingement, subacromial bursitis, rotator cuff tendinitis

images Internal impingement

images SLAP (superior labral tear)

images Voluntary instability

images Collagen disorder (Ehlers-Danlos syndrome, Marfan syndrome)

images Subscapularis insufficiency, tear

NONOPERATIVE MANAGEMENT

images After reduction of an acute dislocation, a sling is used for immobilization. The duration of immobilization has been controversial, but 3 to 6 weeks is recommended.21

images Some surgeons recommend immobilization in a position of abduction and external rotation to improve healing. However, many patients will not tolerate this position, and a position of adduction and internal rotation therefore is more commonly used.

images For treatment of acute injuries, rotational and scapular strengthening exercises of the affected shoulder are started after the initial immobilization period. The program is progressed toward normalization of strength and motion through increased resistance training.

images Return to sports is allowed when the patient has a full and pain-free range of motion, normal strength, and little or no apprehension.21

images For chronic and recurrent instability, strengthening is focused on the rotator cuff and scapular stabilizers, as well as core strengthening of the abdominal and trunk musculature. Resistive exercises of the rotator cuff are begun with the arm in neutral below 90 degrees and are progressed gradually. Strengthening of scapular stabilizers is particularly important.

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FIG 3  AP radiographs of the left shoulder showing a dislocated shoulder (A) and subsequent reduction (B). There is a Hill-Sachs fracture of the posterolateral humeral head. C. Axial MRI scan in a patient with deficient glenoid labrum and subscapularis tendon tear.

images The rate of redislocation after nonoperative treatment depends on the patient's age and activity level. In young patients participating in high-risk activities (eg, military cadets), the rate of redislocation is as high as 92%.24

images In a meta-analysis comparing operative to nonoperative treatment for first-time dislocators, 50% of the conservatively treated patients eventually opted for surgery.19

SURGICAL MANAGEMENT

images Surgical treatment options are generally categorized into anatomic and nonanatomic procedures.

images Nonanatomic procedures (Putti-Platt, Magnuson-Stack) are aimed at tightening the anterior structures and preventing atrisk arm positions (ie, abduction and external rotation). These procedures have largely been abandoned after it was discovered that overtightening the anterior structures could lead to posterior subluxation and glenohumeral arthritis.11,18

images The Putti-Platt procedure consists of a vertical incision through both the subscapularis tendon and capsule followed by repair of the lateral flap to the soft tissue at the glenoid rim.18

images The Magnuson-Stack procedure is a transfer of the subscapularis tendon lateral to the bicipital groove (FIG 4A).

images Coracoid transfer procedures are other nonanatomic procedures where the coracoid process, with its attached short head of the biceps and coracobrachialis tendons, is transferred to the anterior glenoid rim and secured with screws.1

images The Bristow procedure uses the tip of the coracoid and typically a single bicortical cancellous screw.

images The Laterjet procedure lays the coracoid on its side and is typically secured with two screws (FIG 4B).

images Although several authors have achieved excellent success with these procedures, the concern for hardware migration and late resorption of the bone block have made these procedures less popular than the anatomic procedures. They are used mainly for revision procedures and in cases where there is deficient glenoid bone stock.

images Anatomic reconstruction procedures have been aimed at reconstructing the anterior labrum using sutures, staples, or tacks.2,8,9,12,22 These anatomic procedures have had excellent success, with minimal (less than 5%) recurrence rates, and therefore are the procedure of choice in the surgical treatment of glenohumeral instability.

images The Bankart repair and inferior capsular shift procedures are the most commonly used anatomic reconstruction procedures.

images Although recurrence rates for arthroscopic Bankart repair and capsular shift were initially higher than open procedures, these rates have become comparable to open as the arthroscopic techniques have evolved.

images Open treatment, however, is recommended over arthroscopic treatment in the following situations:

images Significant bony Bankart lesions (over 30%)

images Significant Hill-Sachs defects where the defect “engages” the glenoid rim with external rotation as visualized during diagnostic arthroscopy

images Revision procedures

images Some contact athletes (football) and extreme sports, where a slightly lower recurrence rate can be expected in comparison to the arthroscopic procedure

Preoperative Planning

images A careful assessment of the patient's expectations of the surgery and postoperative care, including thorough discussions with the patient and family, are required as part of the preoperative plan.

images Noncompliance with the postoperative restrictions will increase the risk of redislocation after surgical repair.

images It is important to assess mental status and any secondary gain issues in patients with multidirectional instability. Patients with voluntary dislocations and malingering (Munchausen syndrome) patients have a high rate of failure and should be identified before surgery.

images It is important to identify before surgery any glenoid bony deficiency that may require bony augmentation via coracoid transfer or allograft reconstruction. Special equipment (allograft bone and instrumentation to perform ORIF) may be required and should be arranged before surgery.

Positioning

images Interscalene block anesthesia is preferred because of the excellent muscle relaxation and postoperative pain relief it offers. If an adequate block cannot be performed, however, general anesthesia can also be used.

images The patient is positioned in the beach-chair position with the back elevated. The patient should be moved to the edge of the table or the shoulder cut-out removed to allow access to the anterior and posterior shoulder as required.

images A hydraulic arm positioner (Tenet Spider) is particularly helpful and can obviate the need for an additional assistant to hold the arm (FIG 5).

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FIG 4  A. AP radiograph of the right shoulder in a patient with previous Magnuson-Stack procedure (the subscapularis tendon has been stapled laterally to the bicipital groove). B. AP radiograph of the right shoulder in a patient with a Laterjet procedure. There are two screws securing the coracoid bone block to the glenoid.

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FIG 5  Hydraulic arm positioner (Spider, Tenet Medical Engineering, Calgary, Alberta, Canada) used to position the arm during surgery.

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FIG 6  A. The concealed axillary incision is made from below the coracoid process toward the axillary fold. B. The miniincision is made in line with the deltopectoral interval and is centered one-third above and two-thirds below the coracoid process.

Approach

images The bony landmarks of the shoulder are identified, including the acromion, clavicle, and coracoid process.

images Approaches to the shoulder that may be used include the deltopectoral, the concealed axillary incision, and the miniincision approach. All of these are variations of the standard deltopectoral approach.

images Standard deltopectoral approac.

images This is the utility approach to the shoulder.

images A 7- to 15-cm incision is made lateral to the coracoid process beginning below the clavicle and extending toward the anterior humeral shaft at the deltoid insertion. Skin flaps are elevated and the deltopectoral interval is identified.

images The remainder of this approach is described in detail below.

images Concealed axillary incisio.

images Whereas the traditional deltopectoral approach is about 15 cm in length, the concealed axillary incision begins 3 cm inferior to the coracoid and extends only 7 cm into the axillary crease (FIG 6A). Skin flaps are widely elevated and the deltopectoral interval is identified.

images This incision is cosmetically appealing and is useful in patients where cosmesis is important.

images Mini-incision approac.

images A 5-cm incision just lateral to the coracoid process can be used in shoulder stabilization procedures (FIG 6B). Wide subcutaneous flaps are created and the deltopectoral interval is identified. The remainder of the exposure is similar to the standard deltopectoral approach.

images The location of this incision is important to achieve direct access to the glenoid without extending the incision: one third of the incision should be above and two thirds below the coracoid process.

TECHNIQUES

BANKART PROCEDURE

images The skin incision is based on surgeon preference as described above. The concealed axillary incision is the most commonly used.

images Skin flaps are elevated and the deltopectoral interval is identified (TECH FIG 1A).

images The cephalic vein is taken laterally with the deltoid muscle, and the clavipectoral fascia overlying the subscapularis tendon and strap muscles is exposed.

images When additional exposure is needed, it is helpful to incise and tag with a suture the upper third of the pectoralis major insertion into the humerus. Great care should be taken not to injure the biceps tendon, which lies just underneath the pectoralis major insertion.

images The clavipectoral fascia is incised lateral to the strap muscles, and a retractor is placed between them to expose the subscapularis muscle and tendon.

images A small wedge of the coracoacromial ligament can be removed to increase superior exposure (TECH FIG 1B).

images The branches of the anterior circumflex humeral vessels at the inferior margin of the subscapularis muscle should be cauterized at this time to control bleeding.

images The subscapularis tendon is exposed and incised vertically just medial to its insertion. The tendon can be peeled off the underlying capsule with a combination of the periosteal elevator for blunt dissection and the needle-tip Bovie cautery for sharp dissection (TECH FIG 1C,D).

images The anterior capsule is then incised vertically at the level of the glenoid rim (TECH FIG 1E,F).

images With a curette or osteotome, the anterior glenoid rim is roughened and any soft tissue removed to allow for healing of the repair (TECH FIG 1G).

images Transosseous sutures are passed through holes made with pointed forceps or a drill.

images Alternatively, suture anchors may be placed at the margin of remaining articular cartilage. Often, two and sometimes three anchors are used between the 2:30 and 6:00 positions (TECH FIG 1H).

images The capsule is shifted or repaired anatomically as required. Typically, an inferior capsular shift procedure is performed in combination with the Bankart procedure as described below.

images The subscapularis tendon is repaired anatomically at its insertion.

images

TECH FIG 1  Bankart procedure. A. The deltopectoral interval is identified and incised using a needle-tip Bovie. The cephalic vein is retracted laterally with the deltoid. B. The anterolateral leading edge of the coracoacromial ligament (indicated by the clamp) is resected for improved superior exposure. C. The subscapularis is incised about 1 cm medial to its insertion, leaving a stout cuff of tissue laterally (arrow) for subsequent repair. D. Blunt dissection inferiorly, where the subscapularis muscle is not adherent to the capsule, facilitates finding the plane of separation between the subscapularis and anterior capsule. E. The capsule is sharply incised, taking care not to damage the humeral head cartilage below. F. An adequate cuff of tissue is left behind for subsequent repair. G. The glenoid rim is prepared using an osteotome or curette. H. Suture anchors are placed at the apex of the glenoid rim.

T-PLASTY MODIFICATION OF THE BANKART PROCEDURE

images To address capsular laxity in addition to the Bankart lesion, Altchek and Warren2 described a modification of the Bankart procedure by performing a T incision in the capsule.

images The approach is the same as in the Bankart procedure described and involves dissection of the subscapularis from the anterior glenohumeral capsule.

images Unlike the inferior capsular shift procedure, the T-plasty involves a medially based capsular incision at the glenoid margin.

images The T capsulotomy is made two thirds from the top of the capsule, with the vertical component adjacent to the glenoid rim (TECH FIG 2).

images The Bankart lesion is repaired using suture anchors or transosseous sutures.

images The laterally based inferior flap of capsule is advanced superiorly and medially and secured to the glenoid rim.

images The superior flap is then advanced medially and oversewn to the inferior flap.

images The subscapularis tendon is repaired anatomically at its insertion.

images

TECH FIG 2  T-plasty modification of the Bankart procedure. The T capsulotomy is made two thirds from the top of the capsule, with the vertical component adjacent to the glenoid rim.

ANTERIOR CAPSULOLABRAL RECONSTRUCTION

images Because of the loss of strength and velocity in throwing athletes undergoing anterior stabilization procedures, Jobe12 in 1991 proposed a subscapularis-sparing procedure in which the tendon is split in line with its fibers and its humeral attachment left intact.

images A deltopectoral approach to the shoulder is used and the strap muscles are retracted medially to expose the subscapularis tendon.

images The subscapularis is then divided horizontally in line with its fibers at the junction of the upper two thirds and lower one third (TECH FIG 3A,B).

images A horizontal capsulotomy is now made in the middle of the capsule extending medial to the glenoid rim. The capsule is elevated off the glenoid subperiosteally to allow for superior and inferior capsular advancement (TECH FIG 3C).

images

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TECH FIG 3  The anterior capsulolabral reconstruction procedure. A. The subscapularis is divided horizontally in line with its fibers at the junction of the upper two thirds and lower one third. B. A horizontal capsulotomy is now made in the middle of the capsule extending medial to the glenoid rim. C. The capsule is elevated off the glenoid subperiosteally to allow for superior and inferior capsular advancement. D. The laterally based inferior flap is shifted superiorly and secured to the intra-articular portion of the glenoid rim using transosseous sutures to attempt to recreate the labral “bumper.” E. The superior flap is then shifted medially and oversewn to the inferior flap.

images The laterally based inferior flap is then shifted superiorly and secured to the intra-articular portion of the glenoid rim using transosseous sutures to attempt to recreate the labral “bumper” (TECH FIG 3D,E).

images The superior flap is then shifted medially and oversewn to the inferior flap.

images Because the subscapularis tendon is not detached, active assistive rehabilitation exercises are begun immediately on postoperative day 1, and rehabilitation is progressed more rapidly.

ANTERIOR INFERIOR CAPSULAR SHIFT

images The anterior inferior capsular shift operation was first described by Charles Neer16 in 1980.

images The procedure was designed to treat involuntary inferior and multidirectional instability of the shoulder that could not be addressed by repair of the anterior glenoid labrum alone (the Bankart procedure).

images The skin incision may be chosen based on the desired approach.

images The subscapularis tendon is incised about 1 to 2 cm medial to its insertion at the lesser tuberosity, leaving an adequate cuff of tissue for repair.

images The subscapularis consists of both a superior tendinous portion (two thirds) and inferior muscular (one third) portion.14

images To expose the inferior portion of the glenohumeral joint capsule, it is important to carefully separate the muscle fibers' insertion from the underlying anterior capsule using a combination of sharp and blunt dissection. The arm should be in a position of adduction and external rotation during this inferior dissection, and great care is taken to protect the axillary nerve.

images A laterally based capsular shift is then performed by incising the capsule vertically about 5 to 10 mm medial to its insertion on the humeral neck (see Tech Fig 1E,F).

images The medial leaf of the capsule is tagged sequentially with nonabsorbable sutures as the capsular incision is continued inferiorly to at least the 6 o'clock position (TECH FIG 4A).

images By placing traction on the capsular tag sutures in a superior and lateral direction, the axillary pouch should be obliterated when an adequate amount of capsular dissection has been performed.

images It is important to release the inferior capsular attachments to the humerus, which have a broad insertion inferior to the articular surface. This is typically done with blunt subperiosteal dissection with the periosteal elevator and needle-tip Bovie cautery (TECH FIG 4B,C).

images The medial insertion of the glenohumeral ligaments and glenoid labrum should then be assessed for avulsion or tear. Bankart lesion and ALPSA both describe a disruption of the medial capsulolabral complex that must be repaired.

images This technique is described in the Bankart repair technique section.

images Once secure fixation to bone is achieved, the capsule is shifted superiorly and laterally and the nonabsorbable sutures are passed through the capsule from an intraarticular to extra-articular location.

images It is important to place the sutures as close to the glenoid rim as possible so that the capsule is not shortened by medial plication.

images A bimanual technique can be used in which one needle driver is used to pass the suture and a second to “catch” the needle on the extra-articular side.

images The sutures are then tied on the extra-articular side to secure the capsule to the glenoid rim.

images If excess anteromedial capsular redundancy (AMCR) exists after the Bankart repair, a “barrel stitch” technique has been described in which a nonabsorbable pursestring suture is placed to imbricate the anterior capsule.7

images The barrel stitch is placed vertically at the level of the glenoid rim and tied on the extra-articular side. Its size is titrated to the amount of AMCR encountered (TECH FIG 4D,E).

images

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TECH FIG 4  A. In the inferior capsule shift procedure, the laterally based capsular incision is continued inferiorly using tag stitches on the released anterior capsule to apply traction. B. There is a dual attachment of the inferior capsule on the humeral neck. C. Release of the dual inferior capsular attachment, allowing a complete shift of the capsule. D. An anterior crimping (barrel) stitch is used to decrease the redundancy of the anteroinferior capsule. This is a mattress stitch started on the superficial side of the capsule. E. Once tied, the barrel stitch reduces anterior medial capsular redundancy and an anterior inferior bolster is created. F. The anteroinferior capsule is advanced superiorly and reattached to the capsular sleeve preserved on the humeral neck. G. The superior flap is sewn to the inferior flap to reduce volume and increase strength. H. The rotator interval capsule is palpated between the subscapularis and supraspinatus tendons.

images Once the medial instability repair is complete, attention is directed to lateral repair of the capsule to the remaining cuff of tissue at the humeral neck.

images The capsule is shifted superiorly and laterally (TECH FIG 4F).

images The amount of external rotation should be titrated to the patient and should be based on the patient's age, quality of tissue, the presence of the generalized or local ligamentous laxity, sport, level of competition, arm dominance, and expected level of compliance with the prescribed rehabilitation program.

images A good general guideline is to repair the shifted anterior capsule with the arm in 20 degrees of abduction and 30 degrees of external rotation.

images Throwers require an increased amount of external rotation in abduction and may require more laxity than a patient who is noncompliant or not involved in throwing sports.

images Excess tightening of the anterior capsule should be avoided to prevent the development of postcapsulorrhaphy arthropathy.11

images As the capsule is shifted superiorly and laterally, a lax capsule will have an abundance of capsular tissue remaining superiorly. In these shoulders, the capsular incision can be converted to a laterally based T capsulorrhaphy by incising the capsule between the inferior and middle glenohumeral ligaments down to the glenoid rim.

images The inferior limb of the capsule is first repaired to its lateral insertion on the humerus.

images The superior limb is folded down in a pants-overvest fashion and repaired laterally to the insertion point (TECH FIG 4G). This will both reduce capsular volume and reinforce the anterior capsuloligamentous tissues.

images In addition to assessing residual capsular laxity, the rotator interval should also be assessed (TECH FIG 4H).

images If the rotator interval is widened or attenuated, it should be imbricated and closed using interrupted nonabsorbable sutures.

images The amount of interval closure should also be titrated to the patient as mentioned previously, because excess tightening of the rotator interval can lead to restriction of external rotation.10

images It may be preferable to close only the lateral portion of the rotator interval to preserve glenohumeral motion in competitive athletes.

images The subscapularis tendon is repaired anatomically at its insertion.

PEARLS AND PITFALLS

images

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POSTOPERATIVE CARE

images The rehabilitation protocol must be planned individually.

images The patient remains in a sling for 4 weeks postoperatively.

images Passive forward elevation to 110 degrees and external rotation to 15 degrees is begun at 10 days to 2 weeks, and is gradually increased to 140 degrees forward elevation and 30 degrees external rotation by 4 weeks. During this period, isometric strengthening exercises are begun.

images From 4 to 6 weeks, elevation is increased to about 160 degrees and external rotation to 40 degrees.

images After 6 weeks, motion is increased to achieve a normal range.

images Exercises should be progressed slowly to avoid apprehension and resubluxation.

images Resistive exercises are begun with the arm in neutral below 90 degrees and progressed gradually.

images Strengthening of scapular stabilizers is particularly important.

images Full motion and strength should be regained before contact sports are resumed, usually between 6 and 9 months, depending on the sport and the patient.

OUTCOMES

images The first long-term follow-up study of the Bankart procedure was reported by Carter Rowe22 in 1978, with only a 3.5% rate of redislocation.

images Neer16 reported on 40 unstable shoulders that were repaired with the anterior inferior capsular shift between 1974 and 1979, 11 of which had undergone prior procedures for glenohumeral instability. Satisfactory results were achieved in all except one patient, who had postoperative subluxation of the shoulder.

images Since Neer's initial report, multiple series have been published that have used the anterior inferior capsular shift procedure for anteroinferior instability. Although the surgical technique and the extent of capsular shift may vary with different surgeons, recurrence rates have ranged from 1.5% to 9%.5,6,9,16,25

images T-plasty results: In 42 shoulders with an average of 3 years of follow-up in this initial series, 95% of the patients were satisfied and there were four recurrences (10%).2

images A report on the results of anterior capsulolabral reconstruction at an average of 39 months of follow-up in 25 throwing athletes found excellent or good results in 92% of patients, and 17 (68%) returned to their prior level of competition.

images A subsequent series of 22 subluxators and 9 dislocators found 97% good to excellent results and 94% return to sport.15

images Return-to-sport rates of 32% to 94% have been reported for open surgical treatment of anteroinferior instability in various series.2,5,12

COMPLICATIONS

images Injury to the axillary nerve can occur as it travels an average of only 2.5 mm deep to the IGHL and lies only 12 mm from the glenoid at the 6 o'clock position.

images Nerve injury typically involves sensory function only, and function usually recovers spontaneously.

images Recurrent dislocations may occur in up to 5% of patients. However, this rate may be higher when appropriate indications for surgery are not strictly followed.

images Hardware-related complications may occur owing to loosening, bending or breakage of screws, anchors, or tacks (FIG 7).26

images Synovitis in response to PLLA absorbable implants has also been described.

images Misplacement of labral tacks or suture anchors, both metallic and absorbable, may lead to early arthrosis or arthritis.

images Complications due to positioning have been described including deep venous thrombosis and compression neurapraxia. Bony prominences should be well padded and constrictive bandaging avoided during and after surgery.

images

FIG 7  AP radiograph of a left shoulder showing loose hardware after a prior coracoid transfer procedure.

images Infection in shoulder surgery is uncommon. When it occurs, however, Propionibacterium acnes is a common organism, and specific cultures should be requested.

REFERENCES

1.     Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;80A:841–852.

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