Open Anterior Glenohumeral Instability Repair

E. Scott Paxton, MD

Brett D. Owens, MD

Dr. Owens or an immediate family member serves as a paid consultant to CONMED Linvatec, Mitek, Musculoskeletal Transplant Foundation, and Rotation Medical; has received research or institutional support from Hisogenics; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from the American Journal of Sports Medicine, Saunders/Mosby-Elsevier, SLACK Incorporated, and Springer; and serves as a board member, owner, officer, or committee member of American Academy of Orthopaedic Surgeons, the American Journal of Sports Medicine, the American Orthopaedic Association, the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, the journal Orthopedics, and Orthopedics Today. Dr. Paxton or an immediate family member serves as a paid consultant to Tornier; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Arthrex, Smith & Nephew, and Tornier; and serves as a board member, owner, officer, or committee member of the Journal of Bone and Joint Surgery–American.

Introduction

Open anterior shoulder stabilization remains an essential procedure for the orthopaedic surgeon. Historically, a number of procedures, anatomic and nonanatomic, have been described. The open Bankart procedure, which involves anterior capsulolabral repair, was described initially by Sir Blundell Bankart in 1923 and later popularized by Carter Rowe. Variations of this procedure are used to treat traumatic recurrent anterior dislocations with anterior labral injury. The Latarjet procedure, coracoid transfer, was described in 1953 by Michel Latarjet. The mechanism of stability of the Latarjet procedure includes the elongation of the anterior bony glenoid, anterior capsular reconstruction, and the inferior sling effect of the conjoined tendon. In the last two decades, open stabilization surgery was supplanted by arthroscopic stabilization procedures. However, reported failures of arthroscopic instability repairs, as well as a greater understanding of the implications of glenoid and humeral bone loss, have resulted in a renewed appreciation and study of both the open Bankart repair and Latarjet coracoid transfer.

The rehabilitation of all anterior shoulder stabilization procedures share some common aspects. The goal is to allow the capsulolabral tissues to heal without undue tension while allowing return of motion by 12 weeks and the initiation of strengthening with return to sport at approximately 24 weeks. The major differences in the rehabilitation after open Bankart repair stabilization and Latarjet procedures stem from the surgical management of the subscapularis tendon and the goal of osseous healing of the coracoid bone block. These differences direct the alterations in the approaches to rehabilitation; therefore, the chapter will differentiate between the open Bankart and Latarjet procedures.

Surgical Procedure

Open Bankart Procedure

Indications

The indications for open Bankart repair are first-time anterior dislocation in a young athlete or recurrent anterior instability. This procedure is a great option for the surgical treatment of patients who are at high risk for recurrence, including young contact athletes and military personnel. The open Bankart repair is also a great option for shoulder instability with “subcritical” bone loss or for revision anterior stabilization in shoulders without significant glenoid bone loss.

Contraindications

A relative contraindication for open Bankart repair is glenoid bone loss greater than 20%, for which many surgeons would recommend a bone augmentation procedure, such as the Latarjet procedure, autogenous glenoid bone graft (iliac crest), or osteochondral allograft. Another relative contraindication for open Bankart repair is poor-quality capsular tissue, as can be encountered following thermal modification or cases of multiple failed stabilization procedures.

Voluntary shoulder instability is a contraindication to surgical reconstruction in general. Additionally, uncontrolled epilepsy, instability associated with significant permanent
nerve injury, and multidirectional instability are thought to be contraindications.

Procedure

Relevant Anatomy

The open Bankart repair is performed through a true internervous plane, the deltopectoral interval. Deep to this interval is the conjoint tendon. A critical decision in performing this procedure is how to approach the subscapularis tendon. The stabilization can be performed through a horizontal subscapularis split or by a vertical tenotomy and retraction of the subscapularis tendon with subsequent repair. The axillary nerve located along the lower border of the subscapularis and inferior to the capsule is at risk of injury. The musculocutaneous nerve, which enters the deep aspect of the coracobrachialis and short head of the biceps, is at risk for injury as well.

Technique

A several-centimeter anterior skin incision is made following Langer’s lines and extending superiorly from the anterior axillary fold. The cephalic vein is identified deep to the subcutaneous tissue and dissected to be retracted laterally with the deltoid muscle while the pectoralis muscle is retracted medially. Once the deltoid and pectoralis major muscles are retracted, the clavipectoral fascia is incised and the conjoint tendon retracted medially, exposing the subscapularis tendon and muscle. We describe a subscapularis tenotomy in this chapter with relevant rehabilitation protocols. However, a subscapularis split may also be performed, thus avoiding the risk of failed healing of the subscapularis tendon.

We prefer to enter the glenohumeral joint through a vertical tenotomy of the upper two-thirds of the subscapularis tendon approximately 1 cm medial to the insertion on the lesser tuberosity. This leaves good tendon tissue laterally for repair at the end of the procedure. The subscapularis tendon and anterior capsule can either be left together as a single layer or separated in order to perform a capsular shift. The subscapularis tendon and capsular tissues are controlled with traction sutures.

A humeral head retractor (Fukuda) is placed into the glenohumeral joint and behind the posterior glenoid to expose the anterior glenoid and the Bankart lesion. The labrum is mobilized from the anterior glenoid neck with an elevator so that it can be repaired. The anteroinferior glenoid rim and neck are abraded with a burr or rasp in preparation for the repair. The capsule and labrum can be repaired with sutures placed through bone tunnels on the glenoid rim or with suture anchors. Sutures are passed around the avulsed labrum and medial capsule in a mattress fashion, and knots are tied in succession from inferior to superior on the anterior capsule (Figure 6.1).

Figure 6.1 Radiographs of Bankart lesion with anterior inferior labral detachment: sagittal view (A) and axial view (B). Bankart anterior inferior capsulolabral repair: sagittal view (C).

The humeral head retractor is removed if needed and a laterally based capsular shift can be performed. We prefer to use suture anchors in the anatomic neck of the humeral head to facilitate the capsular shift repair and perform a pants-over-vest
closure. Last, the subscapularis tendon is securely repaired with nonabsorbable sutures, and the wound is closed.

Complications

The most serious complication is injury to the axillary nerve, which can be palpated as it traverses posteriorly deep to the subscapularis and capsule. It is critical to gently place retractors superior to the nerve to protect it and to avoid injury while passing sutures during Bankart repair. Failure of the subscapularis repair is also a substantial concern and can result from inadequate repair, early postoperative injury, patient noncompliance, or overly aggressive rehabilitation.

Postoperative Rehabilitation

In general, the rehabilitation protocol for an open Bankart repair follows a course of initial immobilization and protection of the subscapularis repair, early protected range of motion (ROM) exercises, progressive strengthening after early soft-tissue healing, and eventual return to premorbid activities. A more conservative approach may be warranted for high-risk patients or revision cases. Our rehabilitation protocol is guided by the need to protect the healing of the subscapularis tendon repair along with healing of the capsulolabral repair. One area of debate is the length of sling immobilization. While there is no consensus, most surgeons recommend a sling for at least 4 weeks and at most 6 weeks. Protection of the subscapularis repair is critically important, as failure can lead to disastrous results.

As the restrictions are released, the ROM is advanced and early strengthening is begun. The focus shifts to progressive strengthening and work on proprioception. The final phase involves sport-specific training and preparation for return to play. Another point of debate is the return-to-play timing. There are few reports on return-to-play criteria, in contrast to return following anterior cruciate ligament (ACL) reconstruction.

Authors’ Preferred Protocol

Week 1

Sling for 6 weeks, even while sleeping
Hand-squeezing exercises
Elbow and wrist active range of motion (AROM) with shoulder in neutral position at side
Supported pendulum exercises
Shoulder shrugs/scapular retraction without resistance
Cryotherapy