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Bankart Augmentation for Capsulolabral Deficiency Using a Split Subscapularis Tendon Flap
Technical Note With Video Illustrations
Bankart Augmentation for Capsulolabral Deficiency Using a Split Subscapularis Tendon Flap Patrick J. Denard, M.D., Pablo Narbona, M.D., Alexandre Lädermann, M.D., and Stephen S. Burkhart, M.D.
Abstract: Traumatic anterior shoulder instability is a frequent problem and often requires surgical management. In the absence of significant bone deficiency, arthroscopic capsulolabral repair is associated with low recurrence rates and good functional outcome. However, capsulolabral deficiency, particularly after multiple previous attempts at repair, may preclude traditional arthroscopic Bankart techniques. Previous reports have described the use of autograft or allograft augmentation or coracoid transfer in the treatment of this difficult problem. The purpose of this report is to describe a novel technique of arthroscopic Bankart augmentation of capsulolabral deficiency using a split subscapularis tendon flap to reinforce a damaged capsule. In the absence of bone deficiency, this technique can restore anterior shoulder restraint without excessively constraining the glenohumeral joint.
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raumatic anterior shoulder instability is a frequent problem and often requires surgical management. Arthroscopic capsulolabral repair can decrease the risk of recurrence and leads to a good functional outcome in the majority of cases.1 Various factors have been considered to contribute to failure of arthroscopic reconstruction. The importance of identifying bone lesions of the glenoid or
From The San Antonio Orthopaedic Group (P.J.D., S.S.B.), and Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio (S.S.B.), San Antonio, Texas, U.S.A; Department of Shoulder Surgery, Sanatorio Allende (P.N.), Cordoba, Argentina; and Division of Orthopaedics and Trauma Surgery, Geneva University Hospital (A.L.), Geneva, Switzerland. S.S.B. receives royalties from and is a paid consultant for Arthrex, Naples, Florida. Received December 15, 2010; accepted February 23, 2011. Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra Blvd, Ste 300, San Antonio, TX 78259, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/10747/$36.00 doi:10.1016/j.arthro.2011.02.032 Note: To access the videos accompanying this report, visit the August issue of Arthroscopy at www.arthroscopyjournal.org.
humeral head has been recognized, and treatment algorithms for this are well-defined.2,3 Inadequate soft-tissue quality such as a thin ligament-labrum complex or capsular deficiency also predisposes to recurrent instability.4,5 Although soft-tissue quality is usually adequate during first-time dislocations, multiple dislocations can stretch and thin the anterior capsule.6 More commonly, capsulolabral deficiency occurs postoperatively after multiple failed surgical stabilizations or after thermal capsulorrhaphy.7-10 In these cases a traditional arthroscopic Bankart repair is not possible. The primary techniques described for managing this difficult problem include autograft or allograft tendon, as well as autologous coracoid bone transfer.11-13 One case report has described an open technique in which a full-thickness portion of the superior subscapularis is used to augment the anterior capsule.14 We are not aware of any published descriptions of arthroscopic techniques using the subscapularis to manage capsulolabral deficiency. The purpose of this report is to describe a novel technique of ar-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 8 (August), 2011: pp 1135-1141
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FIGURE 1. Left shoulder, anterosuperolateral viewing portal. (A and B) Severe capsulolabral deficiency (arrows) is observed in this patient, who has had multiple previous failed attempts at instability repair. (C) The absence of a significant bone defect is confirmed arthroscopically. (G, glenoid; H, humeral head.)
throscopic Bankart augmentation of capsulolabral deficiency using a split subscapularis tendon flap to reinforce a deficient capsule and labrum.
ing studies assist in preoperative planning, bone lesions are always verified during arthroscopy. Identifying Pathology and Quantifying Bone Loss
TECHNIQUE Preoperative Planning In addition to standard radiographs and a magnetic resonance imaging scan, bilateral computed tomography scans with 3-dimensional reconstructions are obtained to quantify bone loss in patients with instability.15 The glenoid index is calculated by performing a comparison with the contralateral shoulder; bone loss of more than 25% of the inferior glenoid diameter is considered an indication for an open Latarjet procedure.3,16 The presence and location of a Hill-Sachs defect are also observed, although quantifying these preoperatively is more difficult. Although these imag-
After induction of anesthesia, the patient is placed in the lateral decubitus position with a warming blanket applied. Five to ten pounds of balanced suspension is used with the arm in 20° to 30° of abduction and 20° of forward flexion (Star Sleeve Traction System; Arthrex, Naples, FL). A standard diagnostic arthroscopy is performed with a 30° arthroscope, viewing through a posterior portal with a pump maintaining pressure of 60 mm Hg. The labrum is inspected in its entirety. The posterior humeral head is inspected for the presence of a Hill-Sachs defect. If there is a large Hill-Sachs lesion, it must be verified that this is a non-engaging lesion with the arm in the 90-90 position. Engaging
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until the subscapularis muscle is visible deep to the cleft. A 2- to 3-mm strip of articular cartilage is removed along the glenoid rim with a ring curette, creating an enhanced bone bed for capsulolabral repair. A capsulolabral repair is performed inferiorly with whatever good tissue remains. An anteroinferior anchor (BioComposite SutureTak; Arthrex) is placed. If the angle from the anterior portal is too oblique, the anchor is placed percutaneously through a 5-o’clock trans-subscapularis portal and a 3-mm Spear guide (Arthrex). Sutures are then passed with a Suture Lasso or Bird Beak (Arthrex) and tied with a double-diameter knot pusher (Surgeon’s Sixth Finger; Arthrex). After
FIGURE 2. Left shoulder, anterosuperolateral viewing portal. After placement of a 7-o’clock anteroinferior anchor (black arrow) in a patient with capsulolabral deficiency, there is inadequate capsulolabral tissue superiorly (blue arrow) to continue a traditional arthroscopic Bankart procedure. (G, glenoid; H, humeral head.)
lesions are a contraindication to the current procedure and require a Latarjet reconstruction.3 To assess for engaging lesions, the arm is taken out of traction and brought into a position of 90° of abduction and 90° of external rotation. An engaging lesion is oriented parallel to the glenoid in this position and will capture or lock at the anterior glenoid rim. An anterior portal is established just above the lateral half of the subscapularis and medial to the sling of the biceps, by use of an 18-gauge spinal needle with an outside-in technique. An anterosuperolateral portal is similarly established off the anterolateral border of the acromion. This portal should be placed so that it provides a 45° angle of approach to the superior glenoid. The arthroscope is placed in the anterosuperolateral portal, and the anterior labrum is more thoroughly inspected. The absence of significant glenoid bone loss is confirmed by visualizing the glenoid en face and quantifying bone loss by direct measurement with a calibrated probe introduced through the posterior portal.16 Candidates for the current procedure will have capsulolabral deficiency without bone loss (Fig 1). Bankart Procedure The remaining capsulolabral sleeve is dissected from the glenoid neck with an arthroscopic elevator
FIGURE 3. Bankart augmentation with split subscapularis tendon transfer. (A) A flap of the posterior portion of the superior half of the subscapularis tendon is created. (B) The subscapularis flap is mobilized in a trapdoor fashion such that the capsular surface of the subscapularis tendon is reflected from medial to lateral as a separate lamina while the outer surface is left unaltered. Note, arrows in (A) and (B) point to the free margin of the subscapularis tendon flap. (C) The subscapularis flap undergoes tenodesis to the anterior glenoid suture anchors to augment capsulolabral deficiency.
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P. J. DENARD ET AL. are passed through the subscapularis flap and tied as described previously. This completes the augmentation with a split subscapularis tendon flap (Figs 6 and 7, Table 1, Videos 1 and 2 [available at www .arthroscopyjournal.org]). Postoperative Protocol Postoperatively, the patient’s extremity is placed in a sling for 6 weeks. At the end of 6 weeks, stretching exercises are commenced with full forward flexion allowed and external rotation to half that of the contralateral shoulder. The goal is to achieve half the
FIGURE 4. Left shoulder, anterosuperolateral viewing portal, showing creation of a split subscapularis flap to augment a Bankart repair in the setting of capsulolabral deficiency. The flap is created with arthroscopic scissors introduced through an anterior portal. Suture is also seen from an inferior Bankart repair (arrow). (SSc, subscapularis tendon.)
placement of this anchor, if there is insufficient capsulolabral tissue to create the desired “bumper” along the anterior glenoid rim, the surgeon must consider various reconstructive options, including a split subscapularis tendon flap (Fig 2). Augmentation With Split Subscapularis Flap To augment the capsulolabral deficiency, a flap of the posterior portion of the superior half of the subscapularis tendon is mobilized and undergoes tenodesis to the anterior glenoid. This flap is created in a “trapdoor” fashion such that the capsular surface of the subscapularis tendon is reflected from medial to lateral as a separate lamina while the outer surface in left unaltered (Fig 3). By use of arthroscopic scissors introduced through the anterior portal, a longitudinal incision through one-half the thickness of the subscapularis is created in the superior half of the tendon (Fig 4). Care is taken not to violate the full thickness of the subscapularis. The subscapularis flap dissection progresses from medial to lateral until the leading medial edge of the flap is mobile enough to reach the anterior glenoid (Fig 5). After mobilization of the subscapularis tendon flap, additional suture anchors are placed on the previously prepared glenoid strip at the 3-o’clock and 4-o’clock positions. Sutures from the anchor
FIGURE 5. Left shoulder, anterosuperolateral viewing portal. (A) Mobilization of a subscapularis (SSc) flap is assessed with a tissue grasper. (B) Adequate mobilization is confirmed when the subscapularis flap reaches the anterior glenoid without excessive tension. (G, glenoid; H, humeral head.)
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less predictable, with recurrence rates of up to 27%.18-20 To avoid a poor outcome, it is important for the surgeon to identify factors associated with recurrence. For patients with bone defects of the glenoid or humeral head, treatment algorithms have been welldefined. Burkhart and De Beer2 report a recurrence rate of 67% in the presence of a glenoid defect of at least 25% of the width or an engaging Hill-Sachs lesion. In a subsequent report, Burkhart et al.3 reduced
FIGURE 6. Left shoulder, anterosuperolateral viewing portal. (A) Anchors are placed in the glenoid (G) in preparation for tenodesis of a split subscapularis flap. (B) Sutures are passed through the split subscapularis (SSc) flap to allow advancement to the anterior glenoid. (G, glenoid; H, humeral head.)
external rotation of the normal side at 3 months postoperatively. Strengthening is delayed until 4 months postoperatively because this is usually a last-resort salvage procedure. Return to full activities is delayed until 1 year postoperatively. DISCUSSION Primary arthroscopic stabilization of anterior instability has been associated with good functional outcomes and low rates of recurrence.1,17 In contrast, outcomes for revision arthroscopic management are
FIGURE 7. Left shoulder, anterosuperolateral viewing portal, showing completed arthroscopic Bankart repair augmented with a split subscapularis flap in the setting of capsulolabral deficiency. (A) Completed repair showing restoration of anterior soft tissue by use of the split subscapularis tendon (SSc) flap. (Compare with Fig 1.) (B) The split between the subscapularis (arrow) is visualized anterior to the flap that has undergone tenodesis. (G, glenoid; H, humeral head.)
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P. J. DENARD ET AL. TABLE 1. Bankart Augmentation With Split Subscapularis Tendon Flap
Indication Recurrent instability with severe capsulolabral deficiency without significant bone loss Steps of procedure 1. Verify absence of bone loss 2. Perform arthroscopic Bankart repair as possible 3. Use arthroscopic scissors to create partial-thickness trapdoor in superior half of subscapularis tendon 4. Continue mobilization from medial to lateral until flap reaches anterior glenoid 5. Secure split subscapularis flap to glenoid with standard suture anchors
the rate of recurrence to 4.9% with the use of a Latarjet reconstruction in patients with such bone defects. In addition to bone defects, poor soft-tissue quality is another factor that predisposes to recurrent shoulder instability, particularly after multiple failed revisions. Several open techniques have been proposed for managing this difficult patient population. Levine et al.21 reported a 44% rate of recurrence in 9 patients managed with an open revision capsulolabral reconstruction after 2 or more previous attempts at stabilization. Other authors have sought to reduce recurrence by using an allograft or autograft to augment soft-tissue deficiency. A case report by Warner and Marks14 described a fullthickness transfer of the subscapularis. They cut the superior half of the subscapularis medially and laterally and secured the full-thickness flap inferiorly to augment the anteroinferior capsule. Using a semitendinosus autograft to manage capsulolabral deficiency, Lazarus and Harryman22 reported a 30% rate of recurrence in 17 patients. Alcid et al.23 reported augmentation with hamstring tendon allograft or tibialis tendon allograft in 15 patients. Although there were no recurrences in this report, external rotation decreased by a mean of 24° and 2 patients required total shoulder arthroplasty within 3 to 5 years for painful glenohumeral arthritis. Despite the fact that this was a population with multiple failed procedures, it is possible that excessive constraint of the glenohumeral joint contributed to the development of arthritis. Another downside to open techniques for managing capsulolabral deficiency is the difficulty of dissection and disruption of the subscapularis tendon. Open procedures in the anterior glenohumeral joint cross the axillary nerve, which is at higher risk for iatrogenic injury in the setting of scarring associ-
ated with multiple failed procedures. Furthermore, these open techniques divide the subscapularis tendon, which is important in maintaining stability, particularly in conjunction with capsulolabral deficiency. Disruption of the subscapularis tendon has been described as a cause of failure after open revision stabilization.24 Arthroscopic management of capsulolabral deficiency is technically challenging but carries the advantage of avoiding dissection of the axillary nerve and does not disrupt the subscapularis tendon insertion. Boileau et al.11 reported only an 8% recurrence rate when using arthroscopic Bristow coracoid transfer in 36 patients with minimum 1-year follow-up. Although 68% of patients were identified as having “capsular distention,” bone defects were also common, with glenoid defects in 75% of cases and Hill-Sachs lesions in 78% of cases. The role of this procedure in addressing capsulolabral deficiency in the absence of a bone defect is therefore unclear. We have described a novel technique for the arthroscopic augmentation of a Bankart procedure using a split subscapularis tendon flap. The main indication for this procedure is capsulolabral deficiency after multiple failed anterior instability surgeries in the absence of a bone defect of the glenoid or humeral head. This technique provides anterior coverage and containment using a split subscapularis tendon flap. Potential advantages of this procedure include augmenting capsulolabral deficiency while obviating the need for axillary nerve dissection, not violating the subscapularis tendon insertion, and avoiding excessive constraint of the glenohumeral joint. In summary, current arthroscopic techniques for anterior shoulder instability are associated with good clinical outcomes when there is sufficient capsulolabral tissue to obtain a repair and there are not any significant bone defects. Patients with multiple failed revisions, however, may have insufficient capsulolabral tissue to maintain stability with traditional arthroscopic approaches. As techniques continue to advance, increasingly complex problems can be managed arthroscopically. We have presented a novel technique for managing severe capsulolabral deficiency by Bankart augmentation with a split subscapularis tendon flap. The advantages of a less invasive procedure appear attractive compared with open approaches. However, it is technically difficult, and further studies are needed to
CAPSULOLABRAL DEFICIENCY show whether this technique is a consistently successful option for improving functional outcomes. REFERENCES 1. Robinson CM, Jenkins PJ, White TO, Ker A, Will E. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. J Bone Joint Surg Am 2008;90:708-721. 2. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694. 3. Burkhart SS, De Beer JF, Barth JR, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy 2007;23: 1033-1041. 4. Green MR, Christensen KP. Arthroscopic Bankart procedure: Two- to five-year followup with clinical correlation to severity of glenoid labral lesion. Am J Sports Med 1995;23:276-281. 5. Hayashida K, Yoneda M, Nakagawa S, Okamura K, Fukushima S. Arthroscopic Bankart suture repair for traumatic anterior shoulder instability: Analysis of the causes of a recurrence. Arthroscopy 1998;14:295-301. 6. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: A prospective study. J Shoulder Elbow Surg 1999;8:66-74. 7. Meehan RE, Petersen SA. Results and factors affecting outcome of revision surgery for shoulder instability. J Shoulder Elbow Surg 2005;14:31-37. 8. Hattrup SJ, Cofield RH, Weaver AL. Anterior shoulder reconstruction: Prognostic variables. J Shoulder Elbow Surg 2001; 10:508-513. 9. Miniaci A, McBirnie J. Thermal capsular shrinkage for treatment of multidirectional instability of the shoulder. J Bone Joint Surg Am 2003;85:2283-2287. 10. Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am 2001;83:151155 (Suppl 2). 11. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The “belt-
12. 13.
14. 15.
16. 17.
18. 19. 20. 21.
22. 23.
24.
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and-suspenders” operative technique and preliminary results. Arthroscopy 2007;23:593-601. Warner JJ, Venegas AA, Lehtinen JT, Macy JJ. Management of capsular deficiency of the shoulder. A report of three cases. J Bone Joint Surg Am 2002;84:1668-1671. Iannotti JP, Antoniou J, Williams GR, Ramsey ML. Iliotibial band reconstruction for treatment of glenohumeral instability associated with irreparable capsular deficiency. J Shoulder Elbow Surg 2002;11:618-623. Warner JJ, Marks PH. Reconstruction of the antero-superior shoulder capsule with the subscapularis tendon: A case report. J Shoulder Elbow Surg 1993;2:260-263. Chuang TY, Adams CR, Burkhart SS. Use of preoperative three-dimensional computed tomography to quantify glenoid bone loss in shoulder instability. Arthroscopy 2008;24:376382. Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18:488-491. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am 2006;88:2326-2336. Kim SH, Ha KI, Kim YM. Arthroscopic revision Bankart repair: A prospective outcome study. Arthroscopy 2002;18: 469-482. Creighton RA, Romeo AA, Brown FM Jr, Hayden JK, Verma NN. Revision arthroscopic shoulder instability repair. Arthroscopy 2007;23:703-709. Neri BR, Tuckman DV, Bravman JT, et al. Arthroscopic revision of Bankart repair. J Shoulder Elbow Surg 2007;16: 419-424. Levine WN, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Open revision stabilization surgery for recurrent anterior glenohumeral instability. Am J Sports Med 2000;28: 156-160. Lazarus MD, Harryman DT II. Complications of open anterior stabilization of the shoulder. J Am Acad Orthop Surg 2000;8: 122-132. Alcid JG, Powell SE, Tibone JE. Revision anterior capsular shoulder stabilization using hamstring tendon autograft and tibialis tendon allograft reinforcement: Minimum two-year follow-up. J Shoulder Elbow Surg 2007;16:268-272. Greis PE, Dean M, Hawkins RJ. Subscapularis tendon disruption after Bankart reconstruction for anterior instability. J Shoulder Elbow Surg 1996;5:219-222.
Bankart Augmentation for Capsulolabral Deficiency Using a Split Subscapularis Tendon Flap Patrick J. Denard, M.D., Pablo Narbona, M.D., Alexandre Lädermann, M.D., and Stephen S. Burkhart, M.D.
Abstract: Traumatic anterior shoulder instability is a frequent problem and often requires surgical management. In the absence of significant bone deficiency, arthroscopic capsulolabral repair is associated with low recurrence rates and good functional outcome. However, capsulolabral deficiency, particularly after multiple previous attempts at repair, may preclude traditional arthroscopic Bankart techniques. Previous reports have described the use of autograft or allograft augmentation or coracoid transfer in the treatment of this difficult problem. The purpose of this report is to describe a novel technique of arthroscopic Bankart augmentation of capsulolabral deficiency using a split subscapularis tendon flap to reinforce a damaged capsule. In the absence of bone deficiency, this technique can restore anterior shoulder restraint without excessively constraining the glenohumeral joint.
T
raumatic anterior shoulder instability is a frequent problem and often requires surgical management. Arthroscopic capsulolabral repair can decrease the risk of recurrence and leads to a good functional outcome in the majority of cases.1 Various factors have been considered to contribute to failure of arthroscopic reconstruction. The importance of identifying bone lesions of the glenoid or
From The San Antonio Orthopaedic Group (P.J.D., S.S.B.), and Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio (S.S.B.), San Antonio, Texas, U.S.A; Department of Shoulder Surgery, Sanatorio Allende (P.N.), Cordoba, Argentina; and Division of Orthopaedics and Trauma Surgery, Geneva University Hospital (A.L.), Geneva, Switzerland. S.S.B. receives royalties from and is a paid consultant for Arthrex, Naples, Florida. Received December 15, 2010; accepted February 23, 2011. Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra Blvd, Ste 300, San Antonio, TX 78259, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/10747/$36.00 doi:10.1016/j.arthro.2011.02.032 Note: To access the videos accompanying this report, visit the August issue of Arthroscopy at www.arthroscopyjournal.org.
humeral head has been recognized, and treatment algorithms for this are well-defined.2,3 Inadequate soft-tissue quality such as a thin ligament-labrum complex or capsular deficiency also predisposes to recurrent instability.4,5 Although soft-tissue quality is usually adequate during first-time dislocations, multiple dislocations can stretch and thin the anterior capsule.6 More commonly, capsulolabral deficiency occurs postoperatively after multiple failed surgical stabilizations or after thermal capsulorrhaphy.7-10 In these cases a traditional arthroscopic Bankart repair is not possible. The primary techniques described for managing this difficult problem include autograft or allograft tendon, as well as autologous coracoid bone transfer.11-13 One case report has described an open technique in which a full-thickness portion of the superior subscapularis is used to augment the anterior capsule.14 We are not aware of any published descriptions of arthroscopic techniques using the subscapularis to manage capsulolabral deficiency. The purpose of this report is to describe a novel technique of ar-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 8 (August), 2011: pp 1135-1141
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FIGURE 1. Left shoulder, anterosuperolateral viewing portal. (A and B) Severe capsulolabral deficiency (arrows) is observed in this patient, who has had multiple previous failed attempts at instability repair. (C) The absence of a significant bone defect is confirmed arthroscopically. (G, glenoid; H, humeral head.)
throscopic Bankart augmentation of capsulolabral deficiency using a split subscapularis tendon flap to reinforce a deficient capsule and labrum.
ing studies assist in preoperative planning, bone lesions are always verified during arthroscopy. Identifying Pathology and Quantifying Bone Loss
TECHNIQUE Preoperative Planning In addition to standard radiographs and a magnetic resonance imaging scan, bilateral computed tomography scans with 3-dimensional reconstructions are obtained to quantify bone loss in patients with instability.15 The glenoid index is calculated by performing a comparison with the contralateral shoulder; bone loss of more than 25% of the inferior glenoid diameter is considered an indication for an open Latarjet procedure.3,16 The presence and location of a Hill-Sachs defect are also observed, although quantifying these preoperatively is more difficult. Although these imag-
After induction of anesthesia, the patient is placed in the lateral decubitus position with a warming blanket applied. Five to ten pounds of balanced suspension is used with the arm in 20° to 30° of abduction and 20° of forward flexion (Star Sleeve Traction System; Arthrex, Naples, FL). A standard diagnostic arthroscopy is performed with a 30° arthroscope, viewing through a posterior portal with a pump maintaining pressure of 60 mm Hg. The labrum is inspected in its entirety. The posterior humeral head is inspected for the presence of a Hill-Sachs defect. If there is a large Hill-Sachs lesion, it must be verified that this is a non-engaging lesion with the arm in the 90-90 position. Engaging
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until the subscapularis muscle is visible deep to the cleft. A 2- to 3-mm strip of articular cartilage is removed along the glenoid rim with a ring curette, creating an enhanced bone bed for capsulolabral repair. A capsulolabral repair is performed inferiorly with whatever good tissue remains. An anteroinferior anchor (BioComposite SutureTak; Arthrex) is placed. If the angle from the anterior portal is too oblique, the anchor is placed percutaneously through a 5-o’clock trans-subscapularis portal and a 3-mm Spear guide (Arthrex). Sutures are then passed with a Suture Lasso or Bird Beak (Arthrex) and tied with a double-diameter knot pusher (Surgeon’s Sixth Finger; Arthrex). After
FIGURE 2. Left shoulder, anterosuperolateral viewing portal. After placement of a 7-o’clock anteroinferior anchor (black arrow) in a patient with capsulolabral deficiency, there is inadequate capsulolabral tissue superiorly (blue arrow) to continue a traditional arthroscopic Bankart procedure. (G, glenoid; H, humeral head.)
lesions are a contraindication to the current procedure and require a Latarjet reconstruction.3 To assess for engaging lesions, the arm is taken out of traction and brought into a position of 90° of abduction and 90° of external rotation. An engaging lesion is oriented parallel to the glenoid in this position and will capture or lock at the anterior glenoid rim. An anterior portal is established just above the lateral half of the subscapularis and medial to the sling of the biceps, by use of an 18-gauge spinal needle with an outside-in technique. An anterosuperolateral portal is similarly established off the anterolateral border of the acromion. This portal should be placed so that it provides a 45° angle of approach to the superior glenoid. The arthroscope is placed in the anterosuperolateral portal, and the anterior labrum is more thoroughly inspected. The absence of significant glenoid bone loss is confirmed by visualizing the glenoid en face and quantifying bone loss by direct measurement with a calibrated probe introduced through the posterior portal.16 Candidates for the current procedure will have capsulolabral deficiency without bone loss (Fig 1). Bankart Procedure The remaining capsulolabral sleeve is dissected from the glenoid neck with an arthroscopic elevator
FIGURE 3. Bankart augmentation with split subscapularis tendon transfer. (A) A flap of the posterior portion of the superior half of the subscapularis tendon is created. (B) The subscapularis flap is mobilized in a trapdoor fashion such that the capsular surface of the subscapularis tendon is reflected from medial to lateral as a separate lamina while the outer surface is left unaltered. Note, arrows in (A) and (B) point to the free margin of the subscapularis tendon flap. (C) The subscapularis flap undergoes tenodesis to the anterior glenoid suture anchors to augment capsulolabral deficiency.
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P. J. DENARD ET AL. are passed through the subscapularis flap and tied as described previously. This completes the augmentation with a split subscapularis tendon flap (Figs 6 and 7, Table 1, Videos 1 and 2 [available at www .arthroscopyjournal.org]). Postoperative Protocol Postoperatively, the patient’s extremity is placed in a sling for 6 weeks. At the end of 6 weeks, stretching exercises are commenced with full forward flexion allowed and external rotation to half that of the contralateral shoulder. The goal is to achieve half the
FIGURE 4. Left shoulder, anterosuperolateral viewing portal, showing creation of a split subscapularis flap to augment a Bankart repair in the setting of capsulolabral deficiency. The flap is created with arthroscopic scissors introduced through an anterior portal. Suture is also seen from an inferior Bankart repair (arrow). (SSc, subscapularis tendon.)
placement of this anchor, if there is insufficient capsulolabral tissue to create the desired “bumper” along the anterior glenoid rim, the surgeon must consider various reconstructive options, including a split subscapularis tendon flap (Fig 2). Augmentation With Split Subscapularis Flap To augment the capsulolabral deficiency, a flap of the posterior portion of the superior half of the subscapularis tendon is mobilized and undergoes tenodesis to the anterior glenoid. This flap is created in a “trapdoor” fashion such that the capsular surface of the subscapularis tendon is reflected from medial to lateral as a separate lamina while the outer surface in left unaltered (Fig 3). By use of arthroscopic scissors introduced through the anterior portal, a longitudinal incision through one-half the thickness of the subscapularis is created in the superior half of the tendon (Fig 4). Care is taken not to violate the full thickness of the subscapularis. The subscapularis flap dissection progresses from medial to lateral until the leading medial edge of the flap is mobile enough to reach the anterior glenoid (Fig 5). After mobilization of the subscapularis tendon flap, additional suture anchors are placed on the previously prepared glenoid strip at the 3-o’clock and 4-o’clock positions. Sutures from the anchor
FIGURE 5. Left shoulder, anterosuperolateral viewing portal. (A) Mobilization of a subscapularis (SSc) flap is assessed with a tissue grasper. (B) Adequate mobilization is confirmed when the subscapularis flap reaches the anterior glenoid without excessive tension. (G, glenoid; H, humeral head.)
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less predictable, with recurrence rates of up to 27%.18-20 To avoid a poor outcome, it is important for the surgeon to identify factors associated with recurrence. For patients with bone defects of the glenoid or humeral head, treatment algorithms have been welldefined. Burkhart and De Beer2 report a recurrence rate of 67% in the presence of a glenoid defect of at least 25% of the width or an engaging Hill-Sachs lesion. In a subsequent report, Burkhart et al.3 reduced
FIGURE 6. Left shoulder, anterosuperolateral viewing portal. (A) Anchors are placed in the glenoid (G) in preparation for tenodesis of a split subscapularis flap. (B) Sutures are passed through the split subscapularis (SSc) flap to allow advancement to the anterior glenoid. (G, glenoid; H, humeral head.)
external rotation of the normal side at 3 months postoperatively. Strengthening is delayed until 4 months postoperatively because this is usually a last-resort salvage procedure. Return to full activities is delayed until 1 year postoperatively. DISCUSSION Primary arthroscopic stabilization of anterior instability has been associated with good functional outcomes and low rates of recurrence.1,17 In contrast, outcomes for revision arthroscopic management are
FIGURE 7. Left shoulder, anterosuperolateral viewing portal, showing completed arthroscopic Bankart repair augmented with a split subscapularis flap in the setting of capsulolabral deficiency. (A) Completed repair showing restoration of anterior soft tissue by use of the split subscapularis tendon (SSc) flap. (Compare with Fig 1.) (B) The split between the subscapularis (arrow) is visualized anterior to the flap that has undergone tenodesis. (G, glenoid; H, humeral head.)
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P. J. DENARD ET AL. TABLE 1. Bankart Augmentation With Split Subscapularis Tendon Flap
Indication Recurrent instability with severe capsulolabral deficiency without significant bone loss Steps of procedure 1. Verify absence of bone loss 2. Perform arthroscopic Bankart repair as possible 3. Use arthroscopic scissors to create partial-thickness trapdoor in superior half of subscapularis tendon 4. Continue mobilization from medial to lateral until flap reaches anterior glenoid 5. Secure split subscapularis flap to glenoid with standard suture anchors
the rate of recurrence to 4.9% with the use of a Latarjet reconstruction in patients with such bone defects. In addition to bone defects, poor soft-tissue quality is another factor that predisposes to recurrent shoulder instability, particularly after multiple failed revisions. Several open techniques have been proposed for managing this difficult patient population. Levine et al.21 reported a 44% rate of recurrence in 9 patients managed with an open revision capsulolabral reconstruction after 2 or more previous attempts at stabilization. Other authors have sought to reduce recurrence by using an allograft or autograft to augment soft-tissue deficiency. A case report by Warner and Marks14 described a fullthickness transfer of the subscapularis. They cut the superior half of the subscapularis medially and laterally and secured the full-thickness flap inferiorly to augment the anteroinferior capsule. Using a semitendinosus autograft to manage capsulolabral deficiency, Lazarus and Harryman22 reported a 30% rate of recurrence in 17 patients. Alcid et al.23 reported augmentation with hamstring tendon allograft or tibialis tendon allograft in 15 patients. Although there were no recurrences in this report, external rotation decreased by a mean of 24° and 2 patients required total shoulder arthroplasty within 3 to 5 years for painful glenohumeral arthritis. Despite the fact that this was a population with multiple failed procedures, it is possible that excessive constraint of the glenohumeral joint contributed to the development of arthritis. Another downside to open techniques for managing capsulolabral deficiency is the difficulty of dissection and disruption of the subscapularis tendon. Open procedures in the anterior glenohumeral joint cross the axillary nerve, which is at higher risk for iatrogenic injury in the setting of scarring associ-
ated with multiple failed procedures. Furthermore, these open techniques divide the subscapularis tendon, which is important in maintaining stability, particularly in conjunction with capsulolabral deficiency. Disruption of the subscapularis tendon has been described as a cause of failure after open revision stabilization.24 Arthroscopic management of capsulolabral deficiency is technically challenging but carries the advantage of avoiding dissection of the axillary nerve and does not disrupt the subscapularis tendon insertion. Boileau et al.11 reported only an 8% recurrence rate when using arthroscopic Bristow coracoid transfer in 36 patients with minimum 1-year follow-up. Although 68% of patients were identified as having “capsular distention,” bone defects were also common, with glenoid defects in 75% of cases and Hill-Sachs lesions in 78% of cases. The role of this procedure in addressing capsulolabral deficiency in the absence of a bone defect is therefore unclear. We have described a novel technique for the arthroscopic augmentation of a Bankart procedure using a split subscapularis tendon flap. The main indication for this procedure is capsulolabral deficiency after multiple failed anterior instability surgeries in the absence of a bone defect of the glenoid or humeral head. This technique provides anterior coverage and containment using a split subscapularis tendon flap. Potential advantages of this procedure include augmenting capsulolabral deficiency while obviating the need for axillary nerve dissection, not violating the subscapularis tendon insertion, and avoiding excessive constraint of the glenohumeral joint. In summary, current arthroscopic techniques for anterior shoulder instability are associated with good clinical outcomes when there is sufficient capsulolabral tissue to obtain a repair and there are not any significant bone defects. Patients with multiple failed revisions, however, may have insufficient capsulolabral tissue to maintain stability with traditional arthroscopic approaches. As techniques continue to advance, increasingly complex problems can be managed arthroscopically. We have presented a novel technique for managing severe capsulolabral deficiency by Bankart augmentation with a split subscapularis tendon flap. The advantages of a less invasive procedure appear attractive compared with open approaches. However, it is technically difficult, and further studies are needed to
CAPSULOLABRAL DEFICIENCY show whether this technique is a consistently successful option for improving functional outcomes. REFERENCES 1. Robinson CM, Jenkins PJ, White TO, Ker A, Will E. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. J Bone Joint Surg Am 2008;90:708-721. 2. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-694. 3. Burkhart SS, De Beer JF, Barth JR, et al. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy 2007;23: 1033-1041. 4. Green MR, Christensen KP. Arthroscopic Bankart procedure: Two- to five-year followup with clinical correlation to severity of glenoid labral lesion. Am J Sports Med 1995;23:276-281. 5. Hayashida K, Yoneda M, Nakagawa S, Okamura K, Fukushima S. Arthroscopic Bankart suture repair for traumatic anterior shoulder instability: Analysis of the causes of a recurrence. Arthroscopy 1998;14:295-301. 6. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: A prospective study. J Shoulder Elbow Surg 1999;8:66-74. 7. Meehan RE, Petersen SA. Results and factors affecting outcome of revision surgery for shoulder instability. J Shoulder Elbow Surg 2005;14:31-37. 8. Hattrup SJ, Cofield RH, Weaver AL. Anterior shoulder reconstruction: Prognostic variables. J Shoulder Elbow Surg 2001; 10:508-513. 9. Miniaci A, McBirnie J. Thermal capsular shrinkage for treatment of multidirectional instability of the shoulder. J Bone Joint Surg Am 2003;85:2283-2287. 10. Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am 2001;83:151155 (Suppl 2). 11. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C. Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The “belt-
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