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Anterior Shoulder Stabilisation

Aims

  • Aim to restore anatomy of anterior glenoid, by reattachment of labrum & gentle imbrication of capsule & hence prevent recurrent dislocation
  • Arthroscopic technique may be useful for relatively simple lesions in well trained hands
  • Inferior capsular shift may be added if inferior laxity is present
  • Bristow procedure may be added for revision cases

Indications

  • Recurrent anterior dislocation or subluxation of shoulder with failure of non operative Treatment, especially in young patients (? X3 dislocations)

Contraindications

  • MDI / AMBRII lesions
  • Relative C/I in older patients
  • Moderately large Hill-Sach’s lesion is not C/I

Consent / Preop Planning

  • Good quality XR
  • CT
    • bony bankart lesions
    • Hillsachs lesions
  • MRI
    • exclude HAGL or intrasubstance tear of MGHL
  • Pre op physio to achieve good ROM
  • Consent including
    • ↓ ER
    • Frozen shoulder
    • Recurrent dislocation

Position

  • GA, Abx, supine with armboard, prep & drape arm free

Landmarks

  • Acromion, Coracoid process

Incision

  • Routine delto-pectoral approach
    • take cephalic vein laterally
    • Avoid excessive retraction of conjoined tendon to avoid damage to musculocutaneous nerve
    • May osteotimise coracoid if any difficulty with exposure
    • ER shoulder -> exposure of whole subscapularis tendon & start of muscle fibres

Dangers

Nerves

  • Musculocutaneous nerve

Vessels

  • Cephalic vein

Procedure

  • Subscapularis options
    • 1. Division of subscapularis 1 cm from insertion after dissection of capsule. Tagging sutures to prevent retraction
    • 2. Subscapularis split
  • Capsule options
    • 5cm long vertical incision 5mm from glenoid rim
    • O’Brien : as above + horizontal limb for inferior capsular shift
    • Neer : reverse of above with vertical limb on humeral side allows more inferior shift
    • Transverse only : (useful if massive periosteal stripping off anterior neck of scapula in patient. for whom preservation of all ER is important e.g. baseball pitcher
  • Place retractors firstly to retract humeral head postero-laterally & second on anterior scapula neck inside capsule to expose glenoid rim
  • Freshen anterior glenoid with burr or rasp. Take care inferiorly for axillary nerve
  • Repair labrum back to bone in anatomical position
  • Options
    • Bone anchors
    • Trans osseous sutures
  • Repair capsule
    • Options
      • If vertical incision used, overlap medial & lateral leaves
      • If T shaped incision, overlap corners of lateral leaves ± incorporate into sutures that reattach labrum & medial leaf
      • Simple repair of transverse only
  • Check ER to 30° possible & joint stable
  • Repair or reattach subscapularis at anatomical length
  • Re attach coracoid if required
  • Approximate delto-pectoral interval & skin

Postop / Rehab

  • Sling for comfort
  • Start pendular exercises immediately
  • No ER greater than zero° or Abduction greater than 90° for 6/52
  • 3/52, start active isometric exercises
  • 3/12, full range resistive exercises are allowed
  • 6/12 contact sport & heavy labor allowed

Results

  • Rowe : 95% good or excellent result with 3% re-dislocation rate
  • Same with bone anchors

Complications / Dangers

Perioperative

General
  • Anaesthetic
Local
  • Axillary & musculocutaneous nerve

Postoperative

Early
  • Reduced ER
  • Frozen shoulder
Late
  • Osteoarthritis with overtightening (rare with anatomical repair)
  • Re-dislocation
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