Aim
Repair of the anterior capsule & avulsed labrum to anterior glenoid
- anatomic repair
Usually combined with a capsular shift
Contraindications
Bony bankart > 25% glenoid
Technique
Position
- beach chair position
- arm free
- Mayfield head ring / Spyder and Tmax
Incision
Can perform axillary incision
- in axillary fold
- mobilise skin to gain view
- more cosmetic scar
- more difficult visualisation
Superficial dissection
- deltopectoral approach
- cephalic vein lateral with deltoid
- divide clavipectoral fascia
- mobilise lateral aspect conjoint tendon
- insert shoulder retractor deep to conjoint
- expose subscapularis with three sisters inferiorly
Increase exposure
- +/- partially detach conjoint tendon from coracoid
- ± partially release P major tendon (1.5 cm) from humerus
- can take of tip of coracoid (predrill for lateral repair)
Deep Dissection Options
Note:
Always leave inferior 1/4 of SSC
- protects AXN
L shaped incision in SSC / Capsulotomy
Technique
Mark lower 3/4 of SSC
- ER shoulder
- use knife to divide muscle belly transversely
- expose capsule underneach
- use Cobb / dissecting scissors
- pass artery forcep up between capsule and SSC to rotator interval
- open interval further by spreading forceps
- tagging sutures in SSC medially (artery clips)
- divide SSC tendon vertically down onto forcep protecting capsule
- carefully elevate SSC from capsule medially using Cobb
Separate vertical incision in capsule
- right on humeral insertion
- superior and inferior
- stay on articular margin at all times
- can release down past 6 o'clock if wish to perform capsular shift
- usually don't perform horizontal / T shaped capsulotomy if repairing labrum
- T shaped capsulotomy used for MDI
Repair
- insert Fukuda retractor to expose joint
- displaces head posteriorly, exposes labrum
- inspect for pathology: labral detachment / loose bodies / loose capsule
- labrum mobilised
- bony glenoid roughened to bleeding surface
- suture anchors at 3, 4 & 5.30
- sutures passed through labrum and capsule
Capsular plication / shift as required
- always repair with arm ER 30o to prevent loss of ER
- check ER with arm adducted and abducted
- need 50% of normal ER / other side
Tie medial labral / capsular sutures
- recheck ER as above
Subscapularis repaired / close rotator interval if shoulder still loose
Post-op
- shoulder immobiliser for 6/52 with pendulars
- no ER
- elbow & hand exercises
- ROM exercises at 6/52 (passive, active assist, active)
- muscle strengthening at 3/12
- return to sport at 6/12
Results
Rowe et al JBJS Am 1978
- classic quoted paper
- 5 recurrences in 145 patient(3.5%)
Flatow et al Orthopedics 2006
- 41 open stabilisations followed for average 6 years
- one recurrence
- average loss of ER 4o