The open Bankart repair is a suitable option for a specific patient selection. In our hands this group includes mainly male collision athletes under the age of 20 years with limited glenoid bone loss (10–20%). Additional criteria for a preferred open procedure are multiple dislocations, greater than ten times, or intraoperatively presentation of unexpected poor capsulolabral tissue quality. We also think of it as a revision procedure of a failed but correct performed arthroscopic stabilization.

Patient is placed supine with a bolster supporting the medial border of the scapula to prevent scapular protraction. The head of the table is elevated modestly. Examination under anesthesia is performed to evaluate the glenohumeral joint regarding range of motion, laxity, and direction of instability. The arm is supported on a well-padded Mayo stand with the surgeon standing between the arm and thorax of the patient. Incision is marked as an anterior axillary incision along Langer’s lines. A traditional deltopectoral approach is made mobilizing the cephalic vein laterally. While continuing the deeper exposure, the deltopectoral dissection should be extended proximally to the clavicle and distally to the level of the falciform ligament to create a better overview and avoid a keyhole field of view. A self-retaining retractor is used to maintain retraction of the deltoid and pectoralis major muscles. Next, the clavipectoral fascia is incised just lateral to the coracobrachialis muscle all the way up to the CA ligament. To retract the conjoins easier, a partial release of the Ca ligament superior and the falciform ligament inferior can be performed. One of the key parts to get access to the joint is now the subscapularis (SSC) tenotomy. We prefer a tenotomy. However, if the patient does not have a significant component of inferior laxity, a subscapularis split may be preferable. We secure the subscapularis with four non-resorbable sutures in a matrass fashion about 1.5 cm medial to its insertion site on the lesser tuberosity. Now incise the subscapularis in an L-shaped manner, from the superior edge vertically down toward the circumflex vessels and continue medial in fiber direction. Slowly and carefully separate the muscle from the underlying capsule, start inferior just above the circumflex vessels, and work superiorly; this way it is much easier to reflect them (Fig. 13.1). This will open up the rotator interval, which we like to close laterally right away to start out with a closed capsular structure prior to incision and shifting. The capsule will first be incised vertically on the lateral side, followed by a horizontal incision on the mid glenoid level creating a T-capsulotomy with superior and inferior leave (Fig. 13.2). This will expose the anterior glenoid rim and the Bankart lesion. The next step consists of mobilization of capsulolabral tissue and preparing the bony footprint on the glenoid neck. After that, suture anchors can be placed similar to arthroscopic techniques, starting inferior and extending along the rim depending on size of the Bankart lesion. Anchors can be placed in a single- or double-row configuration as the great exposure allows it. Sutures will be passed through the capsulolabral complex in a mattress fashion, being careful to avoid piercing the axillary nerve. Afterward, sutures can be tied, staring again inferiorly (Fig. 13.3). The Bankart repair is now completed at this stage, and the focus will be on the closure including the capsular shift and subscapularis reattachment. At this point we will put the arm in 30° of abduction and 30° of external rotation to avoid over-tensioning. We start out with the closure of the horizontal capsular incision by shifting the superior leave on top of the inferior leave medially but not tying this suture. In order to shift now the inferior capsule superiorly an adequate release has to be performed. The inferior capsule is dissected off the neck of the humerus and tagged with suture until superior shifting of the inferior leaf eliminates the inferior pouch. This is necessary to shift the inferior pouch of the capsule superiorly and laterally and reduce capsule volume. Optional suture anchors can be placed on the humeral neck to refix the superior and lateral shifted inferior capsule, which we would recommend. After shifting the inferior leaf superiorly, the superior leaf will be shifted inferiorly and tied on top (Fig. 13.4). We recommend checking range of motion to exclude the possibility of over-tensioning. The final step is the subscapularis reattachment; depending on your approach and takedown technique, this can be done by tendon to tendon suturing, doing a transosseous repair, or using suture anchors. Whichever technique is used ensures a meticulous and careful reattachment to avoid any subscapularis deficiency. Surgery ends with a wound closer and the arm in a shoulder immobilizer.