Anterior Shoulder Stabilization Procedures: From Arthroscopic to Open to Latarjet

Richard J. McLaughlin, MD

Christopher L. Camp, MD

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. McLaughlin and Dr. Camp.

This chapter is adapted from Bryant B, Bradley JP: Arthroscopic and open Bankart repair, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 7-13.

PATIENT SELECTION

Indications

Patients who present with a history of a traumatic shoulder dislocation should undergo a comprehensive history and a physical examination of both shoulders. Overhead and contact athletes with documented anteroinferior glenohumeral instability should be considered for either arthroscopic or open Bankart repair.¹ Older and recreational athletes without engaging Hill-Sachs lesions or large (>25%) bony Bankart lesions should be initially considered for a supervised physical therapy program.² In patients who have recurrent dislocation events or in those with persistent symptoms despite initial nonsurgical management, we recommend surgical intervention. In the mid 2000s, arthroscopic Bankart repair emerged as an equivalent treatment method for successful stabilization of soft-tissue defects as compared with the previous benchmark of open repair techniques.²^,³ However, in the presence of significant glenoid bone loss (>25%), it is recommended that bony reconstruction via an open approach be performed as opposed to soft-tissue reconstruction alone.¹^,⁴^,⁵^,⁶

Contraindications

The decision whether to pursue an arthroscopic repair or an open repair is often one of surgeon preference, although certain conditions exist under which open techniques are preferred. The presence of significant glenoid bone loss (>25%), an engaging Hill-Sachs lesion, glenohumeral capsulolabral attenuation (congenital or as a result of previous thermal use or failed instability surgery), connective tissue disorders, and concomitant subscapularis tears or humeral avulsions of the glenohumeral ligament (HAGL lesions) are considered contraindications to performing an arthroscopic Bankart repair.⁶^,⁷ Patients with chronic recurrent instability after surgical or nonsurgical treatment represent a relative contraindication; the decision to proceed with arthroscopic repair should be based on imaging and tissue quality during diagnostic arthroscopy.⁷ When considering bony reconstruction of the anterior glenoid, relative contraindications include concomitant irreparable rotator cuff tear, first-time dislocation in the elderly population, voluntary dislocators, patients with epilepsy, shoulder “microinstability,” posttraumatic inferior subluxation, static anterior subluxation, and anterior instability with soft-tissue incarceration.⁴

PREOPERATIVE IMAGING

Preoperative radiographs are needed to assess the position of the humeral head with respect to the glenoid, to assess the presence and size of any associated Hill-Sachs or bony glenoid defects, and to rule out any associated fractures, such as those of the greater tuberosity. We routinely obtain true AP, axillary lateral, and scapular Y views. Additional views, such as the apical oblique, West Point, and Didiee, are not routinely obtained but are useful if there is a clinical need to further define bony glenoid defects; the Stryker notch view can better assess Hill-Sachs defects.⁶^,⁹^,¹⁰

Given the association of anterior instability to intra-articular pathology, MRI with gadolinium arthrography is routinely performed preoperatively to assess the capsule, labrum, rotator cuff, cartilage, and bony anatomy⁶ (Figure 1). When significant bone defects are observed on either plain radiographs or magnetic resonance images, a thin-cut, three-dimensional CT scan can be obtained. This modality allows for the subtraction of the humeral head with direct measurement of the glenoid face, in addition to accurate sizing of humeral head defects.³^,⁹ This information is extremely valuable to the clinician as it helps to determine if bony reconstruction of the anterior glenoid is necessary at the time of surgery.⁵

FIGURE 1 A, Preoperative T2-weighted magnetic resonance arthrograms of the shoulder of a patient with an anteroinferior labral tear, or Bankart lesion (arrow). B, Hills-Sachs lesion (arrowhead).

PROCEDURE

Room Setup/Patient Positioning

We prefer to use the beach chair position for shoulder arthroscopy, although the standard lateral decubitus position can also be effectively used. With the beach chair position, the patient is laid supine with the waist in the crease of the bed. The bed is then adjusted such that the waist flexes to 45° and the knees to 30° while simultaneously raising the torso. It is important to stabilize the head, keeping the cervical spine in neutral flexion and rotation, and use cushioning pads to protect the contralateral ulnar nerve (Figure 2, A and B). This position can be used for either open or arthroscopic shoulder stabilization.

Alternatively, the lateral decubitus position can be used for arthroscopic shoulder stabilization surgery. In this case, a vacuum beanbag holds the patient in this position. It is important to protect the axillary nerve with a gel pad and to place pillows between the legs and beneath the contralateral leg to protect the peroneal nerve (Figure 3).

FIGURE 2 A, Photograph showing the beach chair positioning for shoulder arthroscopy. A pneumatic arm holder is used to control shoulder positioning. Cervical spine is kept in neutral positioning. This position is also used for the open Latarjet procedure. B, Photograph showing the operative extremity in increased internal rotation and adduction.

Special Instruments/Equipment/Implants

Successful arthroscopic Bankart repair can be performed using standard shoulder arthroscopy equipment. The particular equipment used is dependent on surgeon preference. Many different cannulas, anchors, and soft-tissue suture-passing devices have been developed, any of which can be used to perform successful repair. Success is related more to surgical technique than to the specific devices used. We prefer to use curved suture-shuttling devices for exchange suture passing and placement of knotless anchors. To accomplish this, we routinely use a 1.5-mm flat, nonabsorbable, high-strength suture paired with small biocomposite bone anchors. During open shoulder stabilization,
adequate visualization is paramount. A pronged glenoid retractor; a long, narrow right-angle retractor; and Richardson retractors are used to maintain critical visualization. In this case, the same sutures and anchors are used to perform the labral repair, and additional anchors are used in the humeral head to allow for robust fixation of the capsular shift and subscapularis muscle. Additional equipment needed for the Latarjet procedure includes a periosteal elevator, small burr, right-angle saw, and a standard drill/screw set. Alternatively, there are specialized Latarjet instrument sets and guides that can be used.

FIGURE 3 Photograph shows lateral decubitus positioning for shoulder arthroscopy. A beanbag and an axillary roll are used, and pillows are placed underneath and between the legs, padding all prominences.

Surgical Technique

Arthroscopic Bankart Repair

Following the induction of general anesthesia and positioning of the patient into the beach chair position, a physical examination of both the affected and the unaffected shoulder is performed. After prepping and draping, the forearm is placed into a mechanical arm holder. If using the lateral decubitus position, a foam arm traction sleeve is placed on the surgical arm and secured with self-adherent wrap. Lateral traction is then applied using 5 to 10 pounds, depending on patient size, in approximately 20° of forward flexion and 20° to 30° of abduction.

FIGURE 4 A, Arthroscopic view of a Bankart lesion in a right shoulder in the posterior portal with a visible “drive-through sign.” B, The same pathology as seen from the anterosuperolateral portal.

The posterior portal is established, the arthroscope is introduced, and a comprehensive diagnostic arthroscopy is performed (Figure 4). A standard anterior portal is established, and a clear 8.25-mm cannula is placed low in the interval at the superior margin of the subscapularis, which allows for proper placement of the anteroinferior glenoid anchors. A third (anterosuperior) portal is then established, high in the rotator interval, and a smaller, 5-mm cannula is placed here.

If an engaging Hill-Sachs lesion is seen on diagnostic arthroscopy, an arthroscopic remplissage procedure should be performed. An accessory posterolateral portal is created under initial needle localization and a 5.75-mm cannula is inserted. A shaver is then used to débride the lesion, and a 4.5-mm double-loaded corkscrew anchor is placed in the center of the defect (Figure 5, A). After this, the cannula
is gently retracted to just outside the capsule in the infraspinatus, and a penetrating bird beak suture retriever is used to independently pass all four suture limbs through the capsule (Figure 5, B). These sutures are left inside the cannula and tagged to prevent retraction of the cannula, and the labral repair is performed. Following completion of the labral repair, the sutures are tied in a standard fashion, allowing the capsule to reduce down into the defect.

FIGURE 5 Intraoperative arthroscopic views of the remplissage procedure demonstrating (A) anchor placement in the posterior humeral head and (B) suture passage through the capsule and tendinous portion of the infraspinatus. C, Image following tying of the sutures, closing the Hills-Sachs defect.

Only gold members can continue reading. Log In or Register to continue