21 Open Anterior Stabilization (Bankart/Capsular Shift)
Abstract
The open Bankart procedure remains the gold standard for treating anterior shoulder instability. Though the rise of arthroscopic shoulder stabilization procedures have decreased its utilization, there remain certain clinical scenarios where traditional open techniques offer a clinical advantage over arthroscopic approaches. This chapter reviews the indications and pearls for visualization and obtaining a mechanically secure repair.
21.1 Goals of Procedure
Goals of management for shoulder instability includes achieving stable shoulder for occupational and/or sporting activities, while at the same time minimizing iatrogenic motion loss. Surgically, this includes repairing any labral tear to its native position with an associated capsular plication to reduce capsular volume.
21.2 Advantages
The open Bankart procedure remains the gold standard for treating anterior shoulder instability, with durable results at long-term follow-up. Advances in technology and techniques have led to the rise in arthroscopic management of shoulder instability. 1 , 2 In meta-analyses, arthroscopic methods have been shown to have similar results to open techniques for anterior instability, particularly when suture anchors are used. 3 – 7 Advantages of the open procedure include the ability to precisely set capsular tension for a more comprehensive shift.
However, more recent studies have found open techniques may provide longer time to recurrent instability after surgery. 8 , 9 These findings may be particularly relevant in the higher risk patient, such as in contact athletes, patulous capsule, or those with glenoid bone loss. 10 – 13 Even bone loss above 13.5% may result in unacceptably inferior clinical outcomes with isolated arthroscopic labral repair. 14 Recurrent dislocation rates for revision arthroscopic Bankart repair has been reported around 14%, 15 , 16 compared to 5.5 to 11.5% after open Bankart repair. 17 A recent randomized trial found lower rates of recurrent instability following open Bankart repair compared to arthroscopic Bankart repair, particularly in males younger than 25 years with a preoperative Hill–Sachs lesion. 18
21.3 Indications
Indications for open Bankart stabilization for anterior instability include (1) revision procedure after failed arthroscopic Bankart or (2) anterior instability in a patient at high risk for recurrent instability following arthroscopic stabilization (such as moderate glenoid bone loss, 13.5–20%), presence of an engaging, “off-track” Hill–Sachs lesion, or high-risk patient (male, age less than 20 years, multiple prior dislocations, contact athlete, and excessive ligamentous laxity).
Indications for open capsular plication for multidirectional instability include revision procedure after failed arthroscopic capsular plication, or primary treatment in high-risk patients (such as excessive soft-tissue laxity in Marfan’s syndrome and Ehlers–Danlos syndrome).
21.4 Contraindications
Risks of the procedure include loss of forward flexion and external rotation (ER), which are estimated at approximately 10 degrees. 17 Patients with significant glenoid bone loss (> 20 degrees) should undergo consideration for coracoid transfer procedure or glenoid reconstruction using autograft/allograft. Caution should be utilized when performing open shoulder stabilization in overhead throwing athletes, given the risk of overtensioning and possibly limiting ER.
21.5 Preoperative Preparation/Positioning
We prefer the patient to receive a general anesthetic to allow muscular paralysis for ease of exposure, particularly in young, muscular patients.
The patient is placed in the beach-chair position, with the thorax elevated approximately 45 degrees. The operating room table is rotated 90 degrees to create extra working room around the shoulder. A rolled towel is placed posteriorly along the inferior angle to stabilize the scapula. We use a pneumatic arm holder to assist in positioning of the arm. Prior to prepping and draping, maximal ER should be tested to make sure the edge of the table does not limit exposure. Examination under anesthesia is performed to assess range of motion, as well as load and shift testing.
21.6 Operative Technique
21.6.1 Superficial Dissection
Prior to making the incision, the arm should be placed in slight forward flexion and abduction to take tension off the pectoralis major and deltoid, respectively. The coracoid and axillary fold should first be identified and marked out. The skin incision is planned vertically from the center of the coracoid toward the axillary fold, approximately 6 cm ( Fig. 21.1 ). Preinjection of the incision with local anesthetic with diluted epinephrine can be used to aid in both pain control and hemostasis.
The skin and dermis is incised until subcutaneous fat is identified, and the dissection is carried deep using electrocautery until the deltopectoral fascia is identified. The next step is to identify the cephalic vein, which is usually found proximally and medially in the wound. A sharp rake retractor can be used to elevate the medial skin flap, and dissection along the muscular fascia using Metzenbaum scissors will help find the vein. The plane on the medial side of the vein will be developed to allow the vein to be retracted laterally with the deltoid muscle belly. Proximally, there is often a branch from the cephalic vein diving deep in the deltopectoral interval that will require ligation to allow the vein to be fully retracted laterally. Once the vein is freed, the remainder of the deltopectoral interval can be released either bluntly or with the aid of electrocautery.
21.6.2 Deep Dissection
A Kolbel self-retaining retractor can be used to retract the deltoid laterally and pectoralis medially. The arm is then adducted and externally rotated to bring the lesser tuberosity into view. The clavipectoral fascia is incised lateral to the muscular portion of the conjoint tendon. The deep aspect of the conjoint tendon is bluntly freed with a finger, and the medial blade of the Kolbel retractor is placed deep to the conjoint tendon. Excessive retraction on the conjoint tendon should be avoided to prevent injury to the musculocutaneous nerve, which passes through the conjoint tendon 5 to 8 cm distal to the coracoid. The lesser tuberosity and subscapularis tendon should now be brought into view through arm rotation ( Fig. 21.2 ). Ligation of the “three sisters” (anterior humeral circumflex artery and two accompanying veins) using electrocautery is performed at this time.
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