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Capsular Repair for Recurrent Dislocation of Shoulders: Pathological Findings and Operative Technic
CAPSULAR REPAIR FOR RECURRENT DISLOCATION OF SHOULDER: PATHOLOGICAL FINDINGS AND OPERATIVE TECHNIC EDWIN
F.
CAVE,
M.D., F.A.C.S.,'"
AND CARTER
R. ROWE, M.D.t
IT is probable that more operations have been suggested to correct recurring dislocation of the shoulder than for any other condition requiring orthopedic surgery. This fact indicates that no one procedure has produced satisfactory results in a high percentage of cases. Hence the continuous striving for some operation that will be uniformly successful. Muscle transplants and tendon substitutes have been received with enthusiasm when first tried, but all have failed in a higher percentage of cases than do most surgical procedures. Prior to Bankart's capsular repair, Nicola's operation, consisting of transplanting the biceps tendon through the head and neck of the humerus, was the best operation. This is easily performed, and seemed to be successful in most cases. As years went by, however, there were more and more recurrences because of rupture and fraying out of the transplanted biceps tendon either at its point of exit from the tunnel in the humeral neck or at its point of entrance into the humeral head. The operation advocated by Bankart1 has appealed to the authors as being the most logical procedure suggested thus far. We also agree with Bankart as to the site of the lesion in the majority of cases. The lesions consistently found have been fracture and fraying of the glenoid labrum and complete separation of the capsule from the glenoid along the anterior and inferior portions. In some cases, only small fragments of the cartilaginous labrum remained. The bony rim of the glenoid was rounded off and eburnated, and in some instances there were small chip fragments along the rim. Since the lesions are consistently in one location, it is. reasonable to carry out the repair at ~ \ this point. Bankart's operation is not as easily performed as most procedures' advocated for recurrent shoulder dislocation, but it is logical and we believe that the time consumed in doing the operation is well spent, for to date our known results have been gratifying. We do not propose to give end results in this short paper. What we do wish to accomplish is to state our belief in the soundness of the "Visiting Orthopedic Surgeon and Chief of Fracture Service, Massachusetts General Hospital, Boston. t Assistant in Orthopedic Surgery, Massachusetts General Hospital.
1289
1290
EDWIN F. CAVE, CARTER R. ROWE
capsular repair of the shoulder, and to describe certain characteristic pathological findings and the technic of the operation as we have done it, pointing out particularly some of its attendant difficulties. PATHOLOGICAL FINDINGS
In our series of twenty-five cases, three related pathological findings were present: (1) trauma to the cartilaginous glenoid labrum; (2) trauma to the bony rim of the glenoid; (:3) separation or shearing off of the capsular attachment. These three findings were confined to one area in anterior dislocations-namely, the anterior inferior aspect of the joint. In only two cases was there a tear through the anterior capsule per se, and these were large rents along the inferior border of the subscapularis muscle. The most consistent finding was trauma to the cartilaginous labrum. This occurred in twenty-one of the twenty-five cases (84 per cent). The labrum was completely destroyed anteriorly in nine cases. In the other twelve cases, moderate damage was present in eight cases, i.e., thinning or shredding of the cartilage or multiple small fractures or tears, the main portion of the labrum remaining intact. In the remaining four cases there was mild trauma consisting of early disintegrative changes. Injury to the bony rim of the glenoid was noted in fifteen cases (60 per cent). The rim was severely eroded and eburnated in eight cases, and in one of these there was an avulsed fracture of the rim at the capsular border. In four cases there was a moderate degree of trauma, and in three cases there were slight or early changes. In fourteen cases (56 per cent) the joint capsule was completely torn from its attachment to the rim of the glenoid. Thirteen of these tears were in the anterior and anterior inferior portion of the glenoid, and one in the superior portion. The separation of the capsule from the glenoid rim may not be recognized easily, and it is well in each case to pass a blunt instrument along the anterior rim of the glenoid to determine the presence or absence of capsular separation. In two joints cartilaginous loose bodies were found, originating from the glenoid labrum in one case and from the head of the humerus in the other. In five cases (20 per cent) there had been previous Nicola repairs performed. In tWo of these the biceps tendon had separated at the suture line; in two others the biceps tendon was thinned and stretched, but intact. The anterior deltoid muscle was atrophied in two cases in which a muscle-splitting incision had been used. In four cases with anterior dislocation then~ was no evidence of trauma in the joint.
CAPSULAR REPAIR FOR DISLOCATION OF SHOULDER
1291
Recurrent posterior dislocations occurred in three of the twenty-five cases (12 per cent). Only one of these presented traumatic changes similar to those found in the anterior dislocations. OPERATIVE TECHNIC
This is essentially Bankart's procedure with a few ,modifications which we believe are improvements in technic. 1. Incision begins along the outer third of the clavicle at the level of the coracoid process. It is then carried downward and outward so as to avoid proximity to the axilla (Fig. 395). 2. Dissection is made between the pectoralis major and the deltoid muscles, retracting the cephalic vein toward the midline with the muscle fibers of the pectoralis major.
SKIN INCISION
OSTEOTOMY OF CORACOID PROCESS
Fig. 895
3. The deltoid is reflected from the clavicle laterally for 1 Y2 inches. This does not need to be done subperiosteally. 4. The deltoid is retracted laterally and the coracoid with its muscle attachments, the short head of the biceps, the pectoralis minor and the coracobrachialis are exposed. 5. With a very small gouge (Ys inch diameter) a hole is made through the long axis of the coracoid process for a distance of 1 inch. . This will simplify the securing of this bone in the closure. 6. Using a small, sharp osteotome (% inch), the coracoid is cut across and this bone fragment and its muscle attachments turned slightly downward and mesially. Osteotomizing the coracoid mini-
1292
EDWIN F. CAVE, CARTER R. ROWE
mizes the tension on these muscles which is necessary for retraction and eliminates the possibility of injury to the musculocutaneous nerve from retraction. Injury to the musculocutaneous nerve may also occur if one attempts to separate these muscles individually (Fig. 395). 7. As the above muscles are retracted mesially, the shoulder is rotated externally, and the insertion of the subscapularis to the lesser tuberosity is identified. 8. This is a most difficult and important step in the operation. The lower border of the subscapularis is identified by a plexus of veins which is secured with suture ligatwres. Separation of the inferior border of the muscle is done with a blunt dissector which is passed deep to the muscle and carried laterally to the musculotendinous junction
MUSCLES TO CORACOID REFLECTED MEDIALLY -BLUNT INSTRUMENT IDENTIFIES LOWER BORDER OF <)UBSCAPULARIS MUSCLE
DISSECTION OF SUBSCAPULARIS FROM LESSER TUBEROSITY AND CAPSULE
Fig. 396.
with the capsule. The subscapularis must be dissected carefully from the underlying capsule and divided from its attachment to the lesser tuberosity before incising the capsule. The muscle is identified with two heavy silk sutures and allowed to retract mesially (Fig. 396). 9. The anterior rim of the glenoid can be felt through the capsule and usually there is a defect in the central portion. 10. The capsule is incised vertically about ~ inch lateral to the glenoi.d rim for a distance of about 2 inches. This allows adequate exposure of the joint and sufficient mesial capsule is left to overlap in the capsular repair (Fig. 397). 11. The anterior margin of the glenoid is "freshened" by the use of a sharp osteotome or curette.
CAPSULAR REPAIR FOR DISLOCATION OF SHOULDER
1293
12. A sometimes difficult step is the making of three holes through the bony rim of the anterior glenoid. These are made with a pointecl curved spike (Fig. 397) which has been fmmcl very useful.
1'-P'eet,Dralls MaJar
SUBSCAPULARIS REFLECTED MEDIALLY
HOLES THROUGH RIM OF GLENOID
Fig. 397.
SECURING LATERAL CAPSULAR FLAP WITH HEAVY SILK SUTURE
PLICATION OF PROXIMAL FLAP OVER LATERAL CAPSULAR FLAP
Fig. 398.
13. While holding the humerus in 45 degrees abduction and 10 degrees external rotation, the lateral capsular flap is sewed to the glenoid through the three drill holes with heavy silk (Fig. 398).
1294
EDWIN F • CAVE, CARTER R. ROWE
14. The subscapularis muscle is resutured to its tendon. 15. The detached coracoid process (having previously been drilled) is resutured to its base with one heavy silk stitch. 16. Closure of the wound is completed with fine cotton or silk. After operation the arm is immobilized with a Velpeau bandage or sling and swathe for ten days, and supported with a sling for an additional two weeks. Motion to the horizontal plane is allowed in six weeks and by the end of eight weeks it is expected that there will be only slight restriction in abduction and external rotation which, if permanent, is probably a good thing. REFERENCE 1. Bankart, A. S. B.: The Pathology and Treatment of Recurrent Dislocation of the
Shoulder Joint. Brit.
J.
Surg., 26:23, 1938.
F.
CAVE,
M.D., F.A.C.S.,'"
AND CARTER
R. ROWE, M.D.t
IT is probable that more operations have been suggested to correct recurring dislocation of the shoulder than for any other condition requiring orthopedic surgery. This fact indicates that no one procedure has produced satisfactory results in a high percentage of cases. Hence the continuous striving for some operation that will be uniformly successful. Muscle transplants and tendon substitutes have been received with enthusiasm when first tried, but all have failed in a higher percentage of cases than do most surgical procedures. Prior to Bankart's capsular repair, Nicola's operation, consisting of transplanting the biceps tendon through the head and neck of the humerus, was the best operation. This is easily performed, and seemed to be successful in most cases. As years went by, however, there were more and more recurrences because of rupture and fraying out of the transplanted biceps tendon either at its point of exit from the tunnel in the humeral neck or at its point of entrance into the humeral head. The operation advocated by Bankart1 has appealed to the authors as being the most logical procedure suggested thus far. We also agree with Bankart as to the site of the lesion in the majority of cases. The lesions consistently found have been fracture and fraying of the glenoid labrum and complete separation of the capsule from the glenoid along the anterior and inferior portions. In some cases, only small fragments of the cartilaginous labrum remained. The bony rim of the glenoid was rounded off and eburnated, and in some instances there were small chip fragments along the rim. Since the lesions are consistently in one location, it is. reasonable to carry out the repair at ~ \ this point. Bankart's operation is not as easily performed as most procedures' advocated for recurrent shoulder dislocation, but it is logical and we believe that the time consumed in doing the operation is well spent, for to date our known results have been gratifying. We do not propose to give end results in this short paper. What we do wish to accomplish is to state our belief in the soundness of the "Visiting Orthopedic Surgeon and Chief of Fracture Service, Massachusetts General Hospital, Boston. t Assistant in Orthopedic Surgery, Massachusetts General Hospital.
1289
1290
EDWIN F. CAVE, CARTER R. ROWE
capsular repair of the shoulder, and to describe certain characteristic pathological findings and the technic of the operation as we have done it, pointing out particularly some of its attendant difficulties. PATHOLOGICAL FINDINGS
In our series of twenty-five cases, three related pathological findings were present: (1) trauma to the cartilaginous glenoid labrum; (2) trauma to the bony rim of the glenoid; (:3) separation or shearing off of the capsular attachment. These three findings were confined to one area in anterior dislocations-namely, the anterior inferior aspect of the joint. In only two cases was there a tear through the anterior capsule per se, and these were large rents along the inferior border of the subscapularis muscle. The most consistent finding was trauma to the cartilaginous labrum. This occurred in twenty-one of the twenty-five cases (84 per cent). The labrum was completely destroyed anteriorly in nine cases. In the other twelve cases, moderate damage was present in eight cases, i.e., thinning or shredding of the cartilage or multiple small fractures or tears, the main portion of the labrum remaining intact. In the remaining four cases there was mild trauma consisting of early disintegrative changes. Injury to the bony rim of the glenoid was noted in fifteen cases (60 per cent). The rim was severely eroded and eburnated in eight cases, and in one of these there was an avulsed fracture of the rim at the capsular border. In four cases there was a moderate degree of trauma, and in three cases there were slight or early changes. In fourteen cases (56 per cent) the joint capsule was completely torn from its attachment to the rim of the glenoid. Thirteen of these tears were in the anterior and anterior inferior portion of the glenoid, and one in the superior portion. The separation of the capsule from the glenoid rim may not be recognized easily, and it is well in each case to pass a blunt instrument along the anterior rim of the glenoid to determine the presence or absence of capsular separation. In two joints cartilaginous loose bodies were found, originating from the glenoid labrum in one case and from the head of the humerus in the other. In five cases (20 per cent) there had been previous Nicola repairs performed. In tWo of these the biceps tendon had separated at the suture line; in two others the biceps tendon was thinned and stretched, but intact. The anterior deltoid muscle was atrophied in two cases in which a muscle-splitting incision had been used. In four cases with anterior dislocation then~ was no evidence of trauma in the joint.
CAPSULAR REPAIR FOR DISLOCATION OF SHOULDER
1291
Recurrent posterior dislocations occurred in three of the twenty-five cases (12 per cent). Only one of these presented traumatic changes similar to those found in the anterior dislocations. OPERATIVE TECHNIC
This is essentially Bankart's procedure with a few ,modifications which we believe are improvements in technic. 1. Incision begins along the outer third of the clavicle at the level of the coracoid process. It is then carried downward and outward so as to avoid proximity to the axilla (Fig. 395). 2. Dissection is made between the pectoralis major and the deltoid muscles, retracting the cephalic vein toward the midline with the muscle fibers of the pectoralis major.
SKIN INCISION
OSTEOTOMY OF CORACOID PROCESS
Fig. 895
3. The deltoid is reflected from the clavicle laterally for 1 Y2 inches. This does not need to be done subperiosteally. 4. The deltoid is retracted laterally and the coracoid with its muscle attachments, the short head of the biceps, the pectoralis minor and the coracobrachialis are exposed. 5. With a very small gouge (Ys inch diameter) a hole is made through the long axis of the coracoid process for a distance of 1 inch. . This will simplify the securing of this bone in the closure. 6. Using a small, sharp osteotome (% inch), the coracoid is cut across and this bone fragment and its muscle attachments turned slightly downward and mesially. Osteotomizing the coracoid mini-
1292
EDWIN F. CAVE, CARTER R. ROWE
mizes the tension on these muscles which is necessary for retraction and eliminates the possibility of injury to the musculocutaneous nerve from retraction. Injury to the musculocutaneous nerve may also occur if one attempts to separate these muscles individually (Fig. 395). 7. As the above muscles are retracted mesially, the shoulder is rotated externally, and the insertion of the subscapularis to the lesser tuberosity is identified. 8. This is a most difficult and important step in the operation. The lower border of the subscapularis is identified by a plexus of veins which is secured with suture ligatwres. Separation of the inferior border of the muscle is done with a blunt dissector which is passed deep to the muscle and carried laterally to the musculotendinous junction
MUSCLES TO CORACOID REFLECTED MEDIALLY -BLUNT INSTRUMENT IDENTIFIES LOWER BORDER OF <)UBSCAPULARIS MUSCLE
DISSECTION OF SUBSCAPULARIS FROM LESSER TUBEROSITY AND CAPSULE
Fig. 396.
with the capsule. The subscapularis must be dissected carefully from the underlying capsule and divided from its attachment to the lesser tuberosity before incising the capsule. The muscle is identified with two heavy silk sutures and allowed to retract mesially (Fig. 396). 9. The anterior rim of the glenoid can be felt through the capsule and usually there is a defect in the central portion. 10. The capsule is incised vertically about ~ inch lateral to the glenoi.d rim for a distance of about 2 inches. This allows adequate exposure of the joint and sufficient mesial capsule is left to overlap in the capsular repair (Fig. 397). 11. The anterior margin of the glenoid is "freshened" by the use of a sharp osteotome or curette.
CAPSULAR REPAIR FOR DISLOCATION OF SHOULDER
1293
12. A sometimes difficult step is the making of three holes through the bony rim of the anterior glenoid. These are made with a pointecl curved spike (Fig. 397) which has been fmmcl very useful.
1'-P'eet,Dralls MaJar
SUBSCAPULARIS REFLECTED MEDIALLY
HOLES THROUGH RIM OF GLENOID
Fig. 397.
SECURING LATERAL CAPSULAR FLAP WITH HEAVY SILK SUTURE
PLICATION OF PROXIMAL FLAP OVER LATERAL CAPSULAR FLAP
Fig. 398.
13. While holding the humerus in 45 degrees abduction and 10 degrees external rotation, the lateral capsular flap is sewed to the glenoid through the three drill holes with heavy silk (Fig. 398).
1294
EDWIN F • CAVE, CARTER R. ROWE
14. The subscapularis muscle is resutured to its tendon. 15. The detached coracoid process (having previously been drilled) is resutured to its base with one heavy silk stitch. 16. Closure of the wound is completed with fine cotton or silk. After operation the arm is immobilized with a Velpeau bandage or sling and swathe for ten days, and supported with a sling for an additional two weeks. Motion to the horizontal plane is allowed in six weeks and by the end of eight weeks it is expected that there will be only slight restriction in abduction and external rotation which, if permanent, is probably a good thing. REFERENCE 1. Bankart, A. S. B.: The Pathology and Treatment of Recurrent Dislocation of the
Shoulder Joint. Brit.
J.
Surg., 26:23, 1938.