Surgery for Traumatic Instability of the Shoulder.
Last updated Thursday, February 10, 2005
Figure 1 - Glenohumeral ligaments Figure 2 - Bankart lesion Figure 3 - The knots are tied so that they come to rest over the capsule Details of the surgeryWhat are the details of surgery for traumatic instability of the shoulder? Here are some details regarding surgery for the management of traumatic anterior glenohumeral instability.
This section on surgical treatment concerns the management only of
patients who have traumatic anterior inferior glenohumeral instability
that has been established preoperatively by careful history and
physical examination. The indications for surgical treatment of this
lesion are persistent significant functional deficits (apprehension,
subluxation, dislocation) in abduction, external rotation, and
extension resulting from an initial episode which was sufficiently
traumatic to tear part of the major capsuloligamentous supporting
structures of the glenohumeral joint. For patients not meeting these
strict criteria, we use the methods of treatment for atraumatic instability.
The goals of treating traumatic anterior inferior glenohumeral
instability are to repair the traumatic lesion safely, restoring the
attachment of the glenohumeral ligaments, capsule, and labrum to the
rim of the glenoid. By assuring that reattachment occurs to the rim,
the effective depth of the glenoid is restored. By definition these
patients do not have a functional problem with capsular laxity, thus,
capsular reefing is not a part of this procedure. What is the surgical technique for surgery for traumatic instability of the shoulder? The goal of the surgical treatment for traumatic anterior
glenohumeral instability is the safe and secure reattachment of the
detached glenohumeral ligaments to the lip of the glenoid from which
they were avulsed. No attempt is made to modify the normal laxity of
the anterior capsule. This anatomic reattachment should reestablish not
only the capsuloligamentous check rein but also the fossa-deepening
effect of the glenoid labrum. A repair that is secure from the time of
surgery is highly desirable in that it allows patients to resume many
of their activities of daily living while the repair is healing. A
repair that is secure from the time of surgery also allows controlled
mobilization, thereby minimizing the possibility of unwanted stiffness.
In traumatic anterior instability, the absence of the normal
anterior glenoid lip can often be demonstrated by the lack of
resistance to anterior glenohumeral translation on the sheer test.
The patient is positioned in a 30 degree inclined beach chair
position with the arm free over the edge of the table. No sand bag is
used underneath the shoulder blade. Prepping and draping allow the arm
to be freely moveable and allows generous exposure to the anterior
aspect of the shoulder.
The skin incision is marked in the dominant anterior axillary crease
which is revealed when the arm is adducted. After the incision is
marked, an adhesive drape is applied and the incision is made. The
deltopectoral groove is entered, retracting the cephalic vein laterally
with the deltoid. The clavipectoral fossa is incised just lateral to
the short head of the biceps, up to but not through the coracoacromial
ligament. We routinely palpate the axillary nerve as it crosses the
anteroinferior border of the subscapularis. A Balfour retractor is
useful in the exposure. The anterior humeral circumflex vessels can
usually be protected by bluntly dissecting them off of the
subscapularis muscle at its inferior border. The subscapularis tendon
and the subjacent capsule are incised 5 mm medial to their insertion at
the lesser tuberosity. This incision starts superiorly at the upper
rolled edge of the subscapularis and extends inferiorly to the bottom
of the lesser tuberosity. It is important that the incision through the
subscapularis tendon leaves strong tendinous material on both sides of
the incision to facilitate a secure repair at the conclusion of the
procedure. We examine the joint for loose bodies, for displaced
fragments of glenoid labrum and particularly in older patients for
evidence of rotator cuff tears. We can usually palpate a posterior
lateral humeral head defect. The capsule and subscapularis are then
retracted medially as a unit and a humeral head retractor is placed in
the joint. An angled retractor is used to expose the glenoid lip and to
identify the capsuloligamentous avulsion know as the Bankart defect.
Occasionally flimsy attempts to heal the lesion will temporarily
obliterate the defect. However, in these cases a blunt elevator will
easily reveal the typical lesion in the anterior-inferior quadrant of
the glenoid. A spiked retractor is then placed through the ligamentous
avulsion to expose the defect at the glenoid lip.
We roughen the anterior, non-articular aspect of the glenoid lip
with a curette or a motorized burr, taking care not to compromise the
bony strength of the glenoid lip. We mark the intended sites for holes
in the glenoid lip with cautery. A i.7 mm drill is then used to make
holes on the articular aspect of the glenoid 3 to 4 mm back from the
edge of the lip to ensure a sufficiently strong bony bridge. We place
these holes 5 to 6 mm apart; thus the size of the defect dictates the
number of holes used for reattachment of the avulsed capsule.
Corresponding slots are placed on the anterior non-articular aspect of
the glenoid. Using a 000 angled curette, we establish continuity
between the corresponding slots and holes.
We then pass a strong number 2 absorbable braided suture through the
holes in the glenoid lip using a trocar needle and an angled needle
holder. After each suture is placed through the glenoid lip, the
integrity of the bony bridge is checked by a firm pull on the suture.
At this point in the procedure it is again useful to verify the
location of the axillary nerve.
The spiked retractor is then removed from the lesion and an angled
retractor is used to expose the trailing medial edge of the avulsed
capsule. Next, using the trocar needle, we pass the end of the suture,
exiting the anterior non-articular aspect of the glenoid lip through
the trailing medial edge of the capsule, taking care to include the
glenoid labrum, if present. We avoid including any more capsule than
necessary to obtain a firm purchase; this prevents unwanted tightening
of the anteroinferior capsule. In larger glenohumeral ligament
avulsions, the detached medial edge of the capsule tends to sag
inferiorly; thus, in these larger lesions an effort needs to be made to
pass the needle through the capsule slightly inferior to the bony holes
in the glenoid. At the time of closure the inferiorly sagging medial
capsule will be repositioned anatomically.
Once the sutures have been passed through the capsule, they are tied
so that the labrum and medial edge of the capsule are positioned on the
glenoid lip. The knots are tied so that they come to rest over the
capsule, rather than on the articular surface of the glenoid.
Once these sutures are tied, the smooth continuity between the
articular surface of the glenoid fossa and the capsule should be
reestablished. No stepoff or discontinuity in the capsule should be
present. If such a discontinuity is noted, the sutures are replaced so
that they obliterate the defect.
At the conclusion of the surgical repair the capsule and
subscapularis tendon are repaired anatomically to their mates at the
lesser tuberosity. The integrity of the axillary nerve, which has been
monitored through the case, is again verified on closure.
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What happens after surgery for traumatic instability of the shoulder? The sheer test is checked again after the repair.
The shoulder should have at least 30 degrees of external rotation at
the side after the subscapularis/capsular repair. A standard wound
closure is carried out, using a subcuticular suture, which is removed
at three days.
Within the first few days after surgery, reliable patients are
encouraged to use the arm up to 90 degrees of elevation in the anterior
plane and out to zero degrees of external rotation. This allows
sufficient range of motion to perform most activities of daily living,
such as eating and personal hygiene, as well as certain vocational
activities, such as writing and typing. Gripping, isometric external
rotation, and isometric abduction exercises are started immediately
after surgery to minimize effects of disuse. If a patient does not
appear able to comply with this restricted use program, we require that
the arm be kept in a sling for three weeks.
At three weeks the patient should return for an examination and
should have at least 90 degrees of elevation and external rotation to
zero degrees. From three weeks to six weeks postoperatively, the
patient is instructed to increase the range of motion to 140 degrees of
elevation and 40 degrees of external rotation. At six weeks after
surgery, if there is good evidence of active control of the shoulder,
gentle repetitive activities such as swimming and using a rowing
machine may be instituted to help with coordination, strength, and
endurance of the shoulder. More vigorous activities such as basketball,
volleyball, throwing, and serving in tennis should not be started until
three months and only then if there is excellent strength, endurance,
range of motion, and coordination of the shoulder.
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