- See:
-
Arthroscopic Reconstruction
-
Historic Operations:
-
Revision Bankart Procedure
- Bankart
Repair:
- reattachment of the
capsule and glenoid labrum to the glenoid lip;
-
subscapularis is carefully divided to expose the capsule, and is
reapproximated without any overlap or shortening;
- PreOp Eval:
-
rotatory stress test for anterior instability;
- indentify any
multidirectional instability, or bony defects of
the glenoid or the humeral head; (
Hill Sachs Lesion);
-
Axillary Approach:
-
identification of the musculocutaneous nerve
-
identification of the axillary nerve
-
transection of the subscapularis:
-
caspsular transection:
- external rotation of the humerus affords better capsular exposure
and relaxes the nerve;
- insert a blunt retractor inferiorly to protect the
axillary nerve,
insert two single pronged
skin hooks to elevate the capsule superiorly and place it under
tension;
- vertically transect the capsule at a point midway between the
lesser trochanter and the
edgle of
the glenoid;
- carry this vertical capsular incision superiorly into the rotator
interval, which converts the
capsular incision into a T (since the rotator interval lies in a
horizontal direction);
- at the end of the case, the superior and inferior capsular capsular
flaps are closed (and shortened)
inorder to shift the inferior capsule in a superior direction;
- the vertical portion of the incision is closed anatomically (so
that there will be no loss of external rotation);
- Management of Bankhart Lesion:
-
articular exposure:
- in a minority of patients, loose bodies will be present;
-
bankhart lesion assessment:
- a joker or similar instrument may be placed into the defect, which
places the labrum under tension and
allows assessment of its length;
- it is controversial as to whether labral tears less than 0.5 mm to
1 cm need to be repaired;
- if the Bankhart lesion is large enough for repair, freshen the
underlying sclerotic bony surface with a
rasp
or burr;
- if a Bankhart lesion is not present, then consider whether the
patient has a Hagel lesion
(capsular avulsion from the proximal humerus);
-
bankart lesion fixation techniques:
- note that in patients undergoing anterior shoulder reconstruction
for anterior instability, the finding
of a
normal labrum should alert the surgeon to the possibility of a HAGL lesion
(humeral avulsion of the glenohumeral ligament);
- in patients that present with anteiror instability due to trauma,
the prevelence of a HAGL lesion
may
be as high as 39%;
- the HAGL lesion is typically found below the level of the
subscapularis in the inferior pouch
of the shoulder;
- ref: Anterior instability of the glenohumeral joint with
humeral avusion of the glenohumeral
ligament. A review of 41 cases. DJ Bokor et al JBJS. Vol 81-B. No 1. Jan
1999. p 93.
- Capsular Repair:
- based on the preoperative exam and operative findings, the surgeon will
determine the relative need
for a superior shift of the inferior capsule and/or a medial-lateral
capsular imbrication;
- the arm is positioned in 20-25 deg of external rotation and abduction;
- horizontal matress sutures are inserted into the medial half of the
capsular edge but are not yet passed into
the lateral capsular leaf;
- a vertical shift of the capsule is effected by inserting a purse string
stitch thru the superior leaves of the
transected capsule and the superior
coraco-humeral ligamentos (or the
CA ligament
if the coraco-humeral
ligaments are deficient);
- a more superior shift is effected by incorporating a deeper purse
string stitch into each half of the capsule;
- imbricate the medial half of the capsule underneath the lateral half of
the capsule using horizontal matress
sutures;
-
avoid over tightening of the rotator interval:
- in the report by LU Bigliani et al (AOA annual meeting 1999), 16
patients required revision
shoulder reconstruction following overtightening of the rotator interval;
- all patients noted stiffness and antero-inferior
instability following tight closure of the rotator interval;
- references:
- Loss of external rotation following anterior capsulorrhaphy of the
shoulder.
- Isolated closure of the rotator interval defects for shoulder
instability.
LD Field et al. Am J. Sports Medicine. Vol 23. p 557-563.
1995.
- Repair of Subscapularis:
- it is essential that the subscapularis be securely repaired, since
postoperative ruptures do occur and
result in disastrous consequences;
- if necessary an addition suture anchor can be placed in the
proximal humeral to augment the repair;
- it is also essential that sutures are not pass thru the biceps tendon,
since this will produce a painful
biceps tendinitis;
- ref:
Open
Bankart Repair. Correlation of Results With Postoperative Subscapularis
Function.
- Post Op Care:
- range of motion restrictions:
- ER to 0 deg at 0 deg abduction;
- elevation to 90 deg in the scapular plane;
- internal rotation to L1;
- aquatic therapy: range of motion is encouraged as long as the shoulder is
submerged;
- Complications:
- Loss of External Rotation:
-
possible etiologies:
- over-tightening of the capsule;
- obliteration of the sub-deltoid and sub-acromial space
- contracture of the coraco-acromial ligament
- contracture of the rotator interval
- scarring of the subscapularis on the shoulder capsule
- contracture of the subscapularis;
-
preoperative considerations:
- patients may be encouraged to undergo physical therapy, however,
many surgeon's are pessimistic
about the ability of nonoperative therapy to improve ROM (in
this particular situation);
- amount of external rotation:
- less than 0 deg of external rotation: proceed with surgery;
- between 0 deg and 30 deg: consider surgical release based
on symptoms;
- more than 30 deg of external rotation: surgery can be
avoided in most cases;
-
treatment:
- arthroscopic release:
- prior to performing capsular release, ensure that the
subscapular tendon is well demarcated
(inorder to avoid transecting the tendon) and to demarcate the 5 o'clock
position of the
capsule (below which lies the axillary nerve);
- scarring may distort the usual features of these
structures;
- damage to the axillary nerve is minized by keeping
the arm in adduction during the release;
- the
anterior capsule is released at a point just inferior to the biceps tendon
and is continued to
the inferior edge of the glenoid;
- release of the rotator interval and coracohumeral
ligament is especially important for patients
who have loss of external rotation in adduction;
- following capsular release, attempt a gentle closed
manipulation;
- open release:
- indicated for failure of arthroscopic release to improve
motion;
- z plasty lengthening of the subscapularis and anterior
capsule;
- alternatively the subscapularis can be reattached to the
anatomic neck of the humerus which
places it medial to its anatomic insertion;
- references:
Loss of external rotation following anterior capsulorrhaphy of the
shoulder. Release of the subscapularis
Release of the subscapularis for internal rotation contracture and
pain after anterior repair for recurrent
anterior dislocation of
the shoulder. Arthroscopic release of postoperative capsular contracture of the
shoulder. JP Warner MD
et al. JBJS Vol 79-A. No 8. Aug 1997. p 1151.