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Subscapularis tendon disruption after bankart reconstruction for anterior instability
Subscapularis tendon disruption after Bankart reconstruction for anterior instability Patrick E. Greis, MD, Mark Dean, MD, and RichardJ. Hawkins, MD, FRCS(C), Vail, Colo.
After undergoing a Bankart repair with a subscapularis tendon and capsular incising technique, four patients were identified who had failure of their subscapularis tendon repair. All had a traumatic event or injury to their shoulder between 1 day and 4 months after operation. The patients presented with findings including recurrent instability, weakness in internal rotation, an abnormal liftoff test, and increased external rotation of the affected extremity. Surgical exploration demonstrated failure of the Bankart repair in two cases in addition to failure of the subscapularis tendon repair in all four. In one patient magnetic resonance imaging was diagnostic of subscapularis tendon disruption. After reoperation was performed, stability was achieved in three of four patients, return of normal internal rotation strength in two, and a normal liftoff test in two. Prompt reexploration and repair of the subscapularis tendon-capsule complex is recommended. (J SHOULDERELBOWSURG 1996;5:219-22.) Recurrent anterior instability of the shoulder after traumatic dislocation is a common problem. 1" 7, 1~ In the past, the surgical treatment of anterior shoulder instability has involved operations such as the Putti-Platt, Magnusen-Stack, and Bristow procedures.8-1,, 13, 16, 22 These procedures have been successful in preventing recurrent instability; however, they do not address avulsion of the anterior capsulolabral structures from the glenoid, which has been reported to be present in 45% to 100% ofthe casesT' s, ~s,12, 18, 19,21 This injury, described by Perthes17 in 1906 and later elaborated on by Bankart, 1 is believed to be a common cause of recurrent anterior instability. 14' is, 2s Bankart described repair of the anterior capsulolabral structures to the glenoid with sutures through bone. Modifications of the repair have been described by Rowe~9 in 1978 and by Thomas and Matsen 21 in 1989. It has been the practice of the senior author to use a surgical approach similar to that
described by Thomas and Matsen. This approach involves incising the subscapularis tendon and anterior capsule at right angles to their fiber orientation approximately 1 cm medial and parallel to the biceps tendon. The Bankart lesion is identified and repaired to the anterior glenoid with suture anchors. The subscapularis tendon and anterior capsule are repaired anatomically with nonabsorbable sutures. Postoperative rehabilitation includes 2 weeks of passive range-of-motion exercises with external rotation limited to 30 ~. Exercises allowing active range of motion are used during weeks 3 and 4, with strengthening exercises started on week 5. During the course of postoperative rehabilitation four cases of failure of the subscapularis tendon repair have been identified and documented by surgical exploration. This article describes these cases of subscapularis tendon repair failure as a complication of Bankart reconstruction with this surgical approach.
Fromthe Steadman-HawkinsClinic and the Departmentof Orthopaedics, Universityof Colorado. Reprint requests: Patrick E. Greis, MD, AssistantProfessorof OrthopaedicSurgery,Centerfor SportsMedicine,4601 Baum Blvd., Pittsburgh,PA 15213. Copyright 9 1996 by Journalof Shoulderand ElbowSurgery Boardof Trustees. 1058-2746/96/$5.00 + 0 32/!/71201
PATIENTS AND METHODS Between October 1989 and October 1994, 88 patients underwent open Bankart repair with the described technique. Of these, four patients (age range 18 to 37 years) required reoperation (4.5%] for subscapularis tendon repair failure between 7 days and 16 months after operation. All patients
219
220
Greis, Dean, and Hawkins
had surgical exploration of the anterior shoulder with attention to the subscapularis and anterior capsule at its repair site and to the presence or absence of a recurrent Bankart lesion. Repair of the subscapularis tendon was possible in all cases after mobilization. Patients were monitored an average of 21 months after operation (range 8 to 39 months) to determine outcome with respect to recurrent instability and return of subscapularis function as documented by internal rotation strength assessment and the return of a normal lifloff examination. 4 An evaluation of each case history was made to determine causes of subscapularis tendon repair failure, so that recommendations on the prevention of this complication could be made. CASE HISTORIES Case !. A 36-year-old woman underwent a left Bankart procedure for recurrent anterior instability. An interscaline block was placed before operation for postoperative pain control management. In the immediate postoperative period, while still partially anesthetized from the interscaline block, the patient removed her sling and began unsupervised and unadvised active motion of her shoulder with external rotation to 70 ~. The patient subsequently reported a feeling of shoulder looseness, and because of concern that the patient had disrupted her repair, she was taken back to the operating room 7 days after operation and had an examination under anesthesia and diagnostic arthroscopy. The examination revealed an unstable shoulder, and arthroscopy demonstrated disruption of both the Bankart repair and the subscapularis tendon repair. Exploration confirmed these findings, and both the Bankart lesion and subscapularis tendon were repaired. At 39 months after operation she had 180 ~ of forward flexion. Active internal rotation was L4 compared with T4 on the uninvolved side, with passive internal rotation to T4 bilaterally. External rotation was 90 ~ compared with 80 ~ on the uninvolved side. Strength testing demonstrated residual internal rotation weakness graded as 4/5, and she had an abnormal result on lifloff examination. Case 2. A 37-year-old man with a diagnosis of left anterior shoulder instability after a motor vehicle accident underwent Bankart reconstruction. Four months after operation the patient had a fall with his arm forced into abduction and external rotation. He had immediate pain and weakness and at 6 months after operation was noted on
J. Shoulder Elbow Surg. May/June 1996 examination to have weakness of internal rotation and an abnormal result on lifloff examination. He was reluctant to undergo revision surgery and continued rehabilitation. At 16 months after operation he continued to be weak in internal rotation and continued to have pain. He also had impingement signs and was weak with forward flexion. Subacromial decompression was carried out with exploration of the rotator cuff. At surgery there was a subscapularis tendon rupture with only thin scar tissue attached at the lesser tuberosity. Through a deltopectoral approach the subscapularis was identified and mobilized. This was difficult because of the scar present and medial retraction of the tendon. The Bankart repair was intact; the subscapularis was repaired to a bony trough on the lesser humeral tuberosity. Twelve months after his second surgery the patient lacked 10 ~ of forward flexion, had external rotation equal to the opposite shoulder, and lacked two spinal interspaces on internal rotation compared with his contralateral side. He had residual internal rotation weakness graded as 4/5. He had a normal liftoff test result. Case 3. An 18-year-old goalie for a junior hockey league team underwent right Bankart repair for recurrent right anterior instability. At approximately 4 weeks after operation the patient slipped while going down steps and reached up over his head grabbing a pipe with his right arm. His body weight was supported by his right arm, and during this incident he felt pain and a pop in his shoulder. He had subsequent redevelopment of recurrent instability with a dislocation after a minor event. His examination showed 4+/5 internal rotation strength, significant apprehension in abduction and external rotation, and an abnormal liftoff test result. He had 20 ~ of excessive external rotation on the affected side compared with the uninvolved shoulder. A magnetic resonance image was obtained confirming the diagnosis of subscapularis tendon rupture. The examination with the patient under anesthesia demonstrated his shoulder was easily dislocatable. Arthroscopic findings demonstrated a recurrent Bankart lesion; the subscapularis was not seen. At repair the patient had a rupture of his subscapularis tendon at the previous incision site and a recurrent Bankart lesion. The subscapularis was retracted medially. The patient underwent revision of the Bankart repair. The subscapularis tendon was mobilized and repaired to its anatomic insertion. At 25 months
J. Shoulder Elbow Surg. Volume 5, Number 3
after operation he had normal internal rotation strength. Range of motion compared with that of his contralateral side demonstrated equal forward flexion, 15 ~ of excess external rotation, a 5-level loss of internal rotation, and an abnormal lifloff test result. He has had recurrent anterior instability after further injury playing hockey; additional surgery is planned. Case 4. A 19-year-old man with recurrent anterior instability of the right shoulder after a traumatic anterior dislocation underwent Bankart repair. One month from surgery the patient had pain in his shoulder and felt a pop in the anterior part of the shoulder while throwing a frisbee. He continued with his therapy program, but he had difficulty returning to full activity, and at his 6-month checkup he reported that his shoulder was weak and felt loose. Examination at that time demonstrated apprehension with abduction and external rotation of the shoulder and anterior translation over the rim of the glenoid. He had normal forward flexion and internal rotation and had 5 ~ more of external rotation of his affected arm. He had an abnormal liftoff test result. Internal rotation was weak on manual testing and was graded as 4/5. The diagnosis of recurrent instability with a possible subscapularis rupture was made. He was taken to the operating room 8 months after operation. At the time of surgery the Bankart lesion had healed, but a subscapularis tendon tear was found. Scar tissue was over the anterior humerus, and the subscapularis tendon was retracted medially. The subscapularis was mobilized and then repaired to a trough in bone. Follow-up examination at 8 months demonstrated normal internal rotation strength and a normal lifloff test result. He regained 85 ~ of external rotation compared with 90 ~ on the contralateral side; he has normal forward flexion and internal rotation. DISCUSSION These four cases of subscapularis tendon repair failure after Bankart reconstruction for anterior instability of the shoulder demonstrate the need for a well-supervised postoperative protocol with patient compliance. They also suggest the need for a strong repair of the subscapularis tendon-capsular complex. We now use 1 mm cottony II Dacron suture (Deknatel, Inc., Fall River, Mass.) for this repair. In three of four of the cases an inciting event occurred within 5 weeks of the surgical procedure. Inadvertent or unsupervised activity resulted in a
Greis, Dean, and Hawkins
221
compromise of the subscapularis repair. Recognition of this problem was heralded by a feeling of recurrent instability in three of these patients, with weakness of internal rotation and an abnormal lifloff test result documented in the patients who were not in the immediate postoperative period. Increased external rotation was present in two of the patients. These findings are strongly suggestive of subscapularis injury. Failure of these symptoms to resolve promptly after an injury or event in the postoperative period should prompt the surgeon to plan reexploration of the shoulder in a timely fashion. Evaluation of this problem may include a magnetic resonance image of the shoulder. 3 Gerber and Kurshell,4 studying isolated ruptures of the subscapularis, showed that a normal lifloff test result virtually rules out a subscapularis rupture. Conversely, patients with an abnormal lifloff test result (in the setting of normal passive internal rotation and a painfree examination} were all found to have either a complete or partial rupture of the subscapularis at the time of surgical exploration. In the four cases presented here, surgical exploration was undertaken 7 days to 12 months from injury. Scarring of the subscapularis tendon was present in varying degrees with medial retraction of the tendon. Although mobilization of the tendon was possible in each case, the one patient who had a prolonged delay to revision surgery required the most intraoperative dissection, and at 12 months after revision he had regained only four of five internal rotation strength on manual testing. Prolonged delay before the repair of these injuries does not seem to be warranted in the face of clinical evidence of subscapularis rupture. Failure of the subscapularis repair after repair of the glenohumeral ligaments back to the glenoid was not reported in the series by Thomas and Matsen71 Their described operative technique is similar to the one used at this institution. In their series of 39 shoulders with long-term follow-up, the postoperative rehabilitation was slightly less aggressive. Patients younger than 30 years of age were not started on immediate passive range of motion in all cases, and active internal rotation against resistance was not started until 6 weeks. Although none of the cases of subscapularis failure in this series appears to be related to the prescribed rehabilitation exercises, the early mobilization may have given the patients a false sense of security in the early postoperative period, resulting in ill-advised activity in two of the cases. With the
222
Greis, Dean, and Hawkins
new information gleaned from this study, we have slowed our rehabilitation protocol in select cases, limiting external rotation in the first 2 weeks to 0 ~ and then to 30 ~ for weeks 3 and 4. Subscapularis failure after a shoulder stabilization procedure has been described in patients reoperated for recurrent anterior instability of the shoulder. In the work by Rowe et a17 ~ the subscapularis tendon was found to be ruptured in two and attenuated in five of the 32 patients who were reoperated on for recurrent instability after a previous attempt at surgical stabilization. Of these seven cases full documentation was available on five. Three patients had an unsuccessful Magnusen-Stack, one an unsuccessful Putti-Platt, and one an unsuccessful Bankart operation. The failure of the subscapularis repair was believed to be partially responsible for the recurrent instability, although a Bankart lesion was noted in four of the five. In this series instability was present in three of four cases, with a recurrent Bankart in two cases; both of these cases had an acute event in the early postoperative period. Although this surgical technique is quite predictable in its outcome with good functional results reported, 2r it does involve incising through the subscapularis tendon and anterior capsule. In selected patients in whom very early return to activity is desired, a subscapularis-splitting approach is now considered. This procedure eliminates the possibility of repair failure at the humeral insertion site but still requires protection of the Bankart repair. REFERENCES
1. Bankart ASB. Recurrent or habitual dislocation of the shoulder joint. BMJ 1923;2:1132-3. 2. Coughlin L, Rubinovich M, Johansson J, et aJ. Arthroscopic stapJe capsulorraphy for anterior shoulder instability. Am J Sports Med 1992;20:253-6. 3. Deutsch A, Altchek DW, Vehrri DM, Potter HG, Laurencin CT. Isolated injuries of the subscapularis tendon: clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Presented at 11 th Open Meeting of the American Shoulder and Elbow Surgeons , Orlando, Florida, February 2, 1995. 4. Gerber C, Krushel) RJ. Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br 1991;73B:389-94.
J. Shoulder Elbow Surg. May/June 1996 5. Grana W, Buckby P, Yates C. Arthroscopic Bankart repain Am J Sports Med 1993;21:348-53. 6. Hawkins RH, Hawkins RJ. Failed anterior reconstruction for shoulder instability. J Bone Joint Surg Br 1985;67B:709-14. 7. Hawkins RJ. Arthroscopic stapling repair for shoulder instability: a retrospective study of 50 cases. Arthroscopy 1989;5:122-8. 8. Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br 1958;40B:198-202. 9. Hovelius L, Akermark C, Atbrektsson B, et ah Bristo-Lataret procedure for recurrent anterior dislocation of the shou der. Acta Orthop Scand 1983;54:284-90. 10. Hovelius L, ThorlingJ, Fredin H. Recurrent anterior dislocation of the shoulder: results after the Bankart and Putti-Platt operations. J Bone Joinl Surg Am 1979;61A:566-9. 11. Leach RE, Corbett M, Schepsis A, Storkel J. Results of a modified Putti-Platt operation for recurrent shoulder dislocations and subluxations. Clin Orthop 1982;164:20-5. 12. Levine WN, Richmond JC, Donaldson WR. Use of the suture anchor in open Bankart reconstruction: a follow-up report. Am J Sports Med 1994;22:723-26. 13. Magnuson PB, Stack JR. Recurrent dislocation of the shoulden JAMA 1943;123:889-92. t4. O'Brien SJ, Neves MC, Arnoczky SP, et ah The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;18:449-56. 15. O'Connell PW, Nuber GW, Mileski RA, et ah The contribution of the glenohumeral ligaments to anterior stability of the shoulder. Am J Sports Me d 1990;18:579-84. 16. Osmond-Clarke H. Habitual dislocation of the shoulder. The Putii-Platt operation. J Bone Joint Surg Br 1948;30B:19-25. 17. Perthes G. Uber operationen bei habitueller schulterluxation. Deutsch Z Clin 1906;85:199-227. 18. Richmond JC, Donaldson WR, Fu FH. Modification of the Bankart reconstruction with a suture anchor: report of a new technique. Am J Sports Med 1991 ;19:343-6. 19. Rowe CR, Patel D, Slouthmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am 1978;60A: 1-16. 20. Rowe CR, Zarinns B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. J Bone Joint Surg Am 1984;66A: 159-68. 21. Thomas SC, Matsen FA. An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am 1989;71A:506-13. 22. Torg JS, Balduini FC, Bonci C, et ah A modified BristowHelfet-May procedure for recurrent dislocations and subluxations of the shoulder: report of 212 cases. J Bone Joint Surg Am 1987;69A:904-13. 23. Turkel MA, Panio MW, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981 ;63A: 1208-17.
After undergoing a Bankart repair with a subscapularis tendon and capsular incising technique, four patients were identified who had failure of their subscapularis tendon repair. All had a traumatic event or injury to their shoulder between 1 day and 4 months after operation. The patients presented with findings including recurrent instability, weakness in internal rotation, an abnormal liftoff test, and increased external rotation of the affected extremity. Surgical exploration demonstrated failure of the Bankart repair in two cases in addition to failure of the subscapularis tendon repair in all four. In one patient magnetic resonance imaging was diagnostic of subscapularis tendon disruption. After reoperation was performed, stability was achieved in three of four patients, return of normal internal rotation strength in two, and a normal liftoff test in two. Prompt reexploration and repair of the subscapularis tendon-capsule complex is recommended. (J SHOULDERELBOWSURG 1996;5:219-22.) Recurrent anterior instability of the shoulder after traumatic dislocation is a common problem. 1" 7, 1~ In the past, the surgical treatment of anterior shoulder instability has involved operations such as the Putti-Platt, Magnusen-Stack, and Bristow procedures.8-1,, 13, 16, 22 These procedures have been successful in preventing recurrent instability; however, they do not address avulsion of the anterior capsulolabral structures from the glenoid, which has been reported to be present in 45% to 100% ofthe casesT' s, ~s,12, 18, 19,21 This injury, described by Perthes17 in 1906 and later elaborated on by Bankart, 1 is believed to be a common cause of recurrent anterior instability. 14' is, 2s Bankart described repair of the anterior capsulolabral structures to the glenoid with sutures through bone. Modifications of the repair have been described by Rowe~9 in 1978 and by Thomas and Matsen 21 in 1989. It has been the practice of the senior author to use a surgical approach similar to that
described by Thomas and Matsen. This approach involves incising the subscapularis tendon and anterior capsule at right angles to their fiber orientation approximately 1 cm medial and parallel to the biceps tendon. The Bankart lesion is identified and repaired to the anterior glenoid with suture anchors. The subscapularis tendon and anterior capsule are repaired anatomically with nonabsorbable sutures. Postoperative rehabilitation includes 2 weeks of passive range-of-motion exercises with external rotation limited to 30 ~. Exercises allowing active range of motion are used during weeks 3 and 4, with strengthening exercises started on week 5. During the course of postoperative rehabilitation four cases of failure of the subscapularis tendon repair have been identified and documented by surgical exploration. This article describes these cases of subscapularis tendon repair failure as a complication of Bankart reconstruction with this surgical approach.
Fromthe Steadman-HawkinsClinic and the Departmentof Orthopaedics, Universityof Colorado. Reprint requests: Patrick E. Greis, MD, AssistantProfessorof OrthopaedicSurgery,Centerfor SportsMedicine,4601 Baum Blvd., Pittsburgh,PA 15213. Copyright 9 1996 by Journalof Shoulderand ElbowSurgery Boardof Trustees. 1058-2746/96/$5.00 + 0 32/!/71201
PATIENTS AND METHODS Between October 1989 and October 1994, 88 patients underwent open Bankart repair with the described technique. Of these, four patients (age range 18 to 37 years) required reoperation (4.5%] for subscapularis tendon repair failure between 7 days and 16 months after operation. All patients
219
220
Greis, Dean, and Hawkins
had surgical exploration of the anterior shoulder with attention to the subscapularis and anterior capsule at its repair site and to the presence or absence of a recurrent Bankart lesion. Repair of the subscapularis tendon was possible in all cases after mobilization. Patients were monitored an average of 21 months after operation (range 8 to 39 months) to determine outcome with respect to recurrent instability and return of subscapularis function as documented by internal rotation strength assessment and the return of a normal lifloff examination. 4 An evaluation of each case history was made to determine causes of subscapularis tendon repair failure, so that recommendations on the prevention of this complication could be made. CASE HISTORIES Case !. A 36-year-old woman underwent a left Bankart procedure for recurrent anterior instability. An interscaline block was placed before operation for postoperative pain control management. In the immediate postoperative period, while still partially anesthetized from the interscaline block, the patient removed her sling and began unsupervised and unadvised active motion of her shoulder with external rotation to 70 ~. The patient subsequently reported a feeling of shoulder looseness, and because of concern that the patient had disrupted her repair, she was taken back to the operating room 7 days after operation and had an examination under anesthesia and diagnostic arthroscopy. The examination revealed an unstable shoulder, and arthroscopy demonstrated disruption of both the Bankart repair and the subscapularis tendon repair. Exploration confirmed these findings, and both the Bankart lesion and subscapularis tendon were repaired. At 39 months after operation she had 180 ~ of forward flexion. Active internal rotation was L4 compared with T4 on the uninvolved side, with passive internal rotation to T4 bilaterally. External rotation was 90 ~ compared with 80 ~ on the uninvolved side. Strength testing demonstrated residual internal rotation weakness graded as 4/5, and she had an abnormal result on lifloff examination. Case 2. A 37-year-old man with a diagnosis of left anterior shoulder instability after a motor vehicle accident underwent Bankart reconstruction. Four months after operation the patient had a fall with his arm forced into abduction and external rotation. He had immediate pain and weakness and at 6 months after operation was noted on
J. Shoulder Elbow Surg. May/June 1996 examination to have weakness of internal rotation and an abnormal result on lifloff examination. He was reluctant to undergo revision surgery and continued rehabilitation. At 16 months after operation he continued to be weak in internal rotation and continued to have pain. He also had impingement signs and was weak with forward flexion. Subacromial decompression was carried out with exploration of the rotator cuff. At surgery there was a subscapularis tendon rupture with only thin scar tissue attached at the lesser tuberosity. Through a deltopectoral approach the subscapularis was identified and mobilized. This was difficult because of the scar present and medial retraction of the tendon. The Bankart repair was intact; the subscapularis was repaired to a bony trough on the lesser humeral tuberosity. Twelve months after his second surgery the patient lacked 10 ~ of forward flexion, had external rotation equal to the opposite shoulder, and lacked two spinal interspaces on internal rotation compared with his contralateral side. He had residual internal rotation weakness graded as 4/5. He had a normal liftoff test result. Case 3. An 18-year-old goalie for a junior hockey league team underwent right Bankart repair for recurrent right anterior instability. At approximately 4 weeks after operation the patient slipped while going down steps and reached up over his head grabbing a pipe with his right arm. His body weight was supported by his right arm, and during this incident he felt pain and a pop in his shoulder. He had subsequent redevelopment of recurrent instability with a dislocation after a minor event. His examination showed 4+/5 internal rotation strength, significant apprehension in abduction and external rotation, and an abnormal liftoff test result. He had 20 ~ of excessive external rotation on the affected side compared with the uninvolved shoulder. A magnetic resonance image was obtained confirming the diagnosis of subscapularis tendon rupture. The examination with the patient under anesthesia demonstrated his shoulder was easily dislocatable. Arthroscopic findings demonstrated a recurrent Bankart lesion; the subscapularis was not seen. At repair the patient had a rupture of his subscapularis tendon at the previous incision site and a recurrent Bankart lesion. The subscapularis was retracted medially. The patient underwent revision of the Bankart repair. The subscapularis tendon was mobilized and repaired to its anatomic insertion. At 25 months
J. Shoulder Elbow Surg. Volume 5, Number 3
after operation he had normal internal rotation strength. Range of motion compared with that of his contralateral side demonstrated equal forward flexion, 15 ~ of excess external rotation, a 5-level loss of internal rotation, and an abnormal lifloff test result. He has had recurrent anterior instability after further injury playing hockey; additional surgery is planned. Case 4. A 19-year-old man with recurrent anterior instability of the right shoulder after a traumatic anterior dislocation underwent Bankart repair. One month from surgery the patient had pain in his shoulder and felt a pop in the anterior part of the shoulder while throwing a frisbee. He continued with his therapy program, but he had difficulty returning to full activity, and at his 6-month checkup he reported that his shoulder was weak and felt loose. Examination at that time demonstrated apprehension with abduction and external rotation of the shoulder and anterior translation over the rim of the glenoid. He had normal forward flexion and internal rotation and had 5 ~ more of external rotation of his affected arm. He had an abnormal liftoff test result. Internal rotation was weak on manual testing and was graded as 4/5. The diagnosis of recurrent instability with a possible subscapularis rupture was made. He was taken to the operating room 8 months after operation. At the time of surgery the Bankart lesion had healed, but a subscapularis tendon tear was found. Scar tissue was over the anterior humerus, and the subscapularis tendon was retracted medially. The subscapularis was mobilized and then repaired to a trough in bone. Follow-up examination at 8 months demonstrated normal internal rotation strength and a normal lifloff test result. He regained 85 ~ of external rotation compared with 90 ~ on the contralateral side; he has normal forward flexion and internal rotation. DISCUSSION These four cases of subscapularis tendon repair failure after Bankart reconstruction for anterior instability of the shoulder demonstrate the need for a well-supervised postoperative protocol with patient compliance. They also suggest the need for a strong repair of the subscapularis tendon-capsular complex. We now use 1 mm cottony II Dacron suture (Deknatel, Inc., Fall River, Mass.) for this repair. In three of four of the cases an inciting event occurred within 5 weeks of the surgical procedure. Inadvertent or unsupervised activity resulted in a
Greis, Dean, and Hawkins
221
compromise of the subscapularis repair. Recognition of this problem was heralded by a feeling of recurrent instability in three of these patients, with weakness of internal rotation and an abnormal lifloff test result documented in the patients who were not in the immediate postoperative period. Increased external rotation was present in two of the patients. These findings are strongly suggestive of subscapularis injury. Failure of these symptoms to resolve promptly after an injury or event in the postoperative period should prompt the surgeon to plan reexploration of the shoulder in a timely fashion. Evaluation of this problem may include a magnetic resonance image of the shoulder. 3 Gerber and Kurshell,4 studying isolated ruptures of the subscapularis, showed that a normal lifloff test result virtually rules out a subscapularis rupture. Conversely, patients with an abnormal lifloff test result (in the setting of normal passive internal rotation and a painfree examination} were all found to have either a complete or partial rupture of the subscapularis at the time of surgical exploration. In the four cases presented here, surgical exploration was undertaken 7 days to 12 months from injury. Scarring of the subscapularis tendon was present in varying degrees with medial retraction of the tendon. Although mobilization of the tendon was possible in each case, the one patient who had a prolonged delay to revision surgery required the most intraoperative dissection, and at 12 months after revision he had regained only four of five internal rotation strength on manual testing. Prolonged delay before the repair of these injuries does not seem to be warranted in the face of clinical evidence of subscapularis rupture. Failure of the subscapularis repair after repair of the glenohumeral ligaments back to the glenoid was not reported in the series by Thomas and Matsen71 Their described operative technique is similar to the one used at this institution. In their series of 39 shoulders with long-term follow-up, the postoperative rehabilitation was slightly less aggressive. Patients younger than 30 years of age were not started on immediate passive range of motion in all cases, and active internal rotation against resistance was not started until 6 weeks. Although none of the cases of subscapularis failure in this series appears to be related to the prescribed rehabilitation exercises, the early mobilization may have given the patients a false sense of security in the early postoperative period, resulting in ill-advised activity in two of the cases. With the
222
Greis, Dean, and Hawkins
new information gleaned from this study, we have slowed our rehabilitation protocol in select cases, limiting external rotation in the first 2 weeks to 0 ~ and then to 30 ~ for weeks 3 and 4. Subscapularis failure after a shoulder stabilization procedure has been described in patients reoperated for recurrent anterior instability of the shoulder. In the work by Rowe et a17 ~ the subscapularis tendon was found to be ruptured in two and attenuated in five of the 32 patients who were reoperated on for recurrent instability after a previous attempt at surgical stabilization. Of these seven cases full documentation was available on five. Three patients had an unsuccessful Magnusen-Stack, one an unsuccessful Putti-Platt, and one an unsuccessful Bankart operation. The failure of the subscapularis repair was believed to be partially responsible for the recurrent instability, although a Bankart lesion was noted in four of the five. In this series instability was present in three of four cases, with a recurrent Bankart in two cases; both of these cases had an acute event in the early postoperative period. Although this surgical technique is quite predictable in its outcome with good functional results reported, 2r it does involve incising through the subscapularis tendon and anterior capsule. In selected patients in whom very early return to activity is desired, a subscapularis-splitting approach is now considered. This procedure eliminates the possibility of repair failure at the humeral insertion site but still requires protection of the Bankart repair. REFERENCES
1. Bankart ASB. Recurrent or habitual dislocation of the shoulder joint. BMJ 1923;2:1132-3. 2. Coughlin L, Rubinovich M, Johansson J, et aJ. Arthroscopic stapJe capsulorraphy for anterior shoulder instability. Am J Sports Med 1992;20:253-6. 3. Deutsch A, Altchek DW, Vehrri DM, Potter HG, Laurencin CT. Isolated injuries of the subscapularis tendon: clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Presented at 11 th Open Meeting of the American Shoulder and Elbow Surgeons , Orlando, Florida, February 2, 1995. 4. Gerber C, Krushel) RJ. Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br 1991;73B:389-94.
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