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The modified staple capsulorrhaphy for the correction of recurrent anterior dislocation of the shoulder
Injury
(1987)
18,51-54
Printedin GreatBn’fain
51
The modified staple capsulorrhaphy for the correction of recurrent anterior dislocation of the shoulder J. P. Hodgkinson
and D. B. Case
Royal Preston Hospital,
Preston, Lancashire
Recurrent anterior dislocation of the shoulder is a fairly common disorder for which numerous surgical procedures have been described. This paper reviews 22 patients treated between 1970 and 1983 by a modified staple capsulorrhaphy. It describes the surgical technique and demonstrates an instrument designed to hold and aid the insertion of the staple. There were no major complications in using this technique. All patients had some restriction of external rotation after operation but no patient suffered a further dislocation during a long-term follow-up of 6.4 years on average.
The Putti-Platt repair as described by OsmondClarke in 1948 has a recurrent dislocation rate which varies from 0 to 13 per cent (Adams, 1948; Watson; Jones, 1948; Brav, 1960; Morrey and Janes, 1976). This paper describes an operation to correct recurrent anterior dislocation of the shoulder by a modified staple capsulorrhaphy. It demonstrates an instrument designed to aid the procedure and reports the results in 22 patients who underwent this operation between 1970 and 1983.
INTRODUCTION THERE have been more than 150 different operations described to correct recurrent anterior dislocation of the shoulder. Until 50 years ago, the results of operation were very poor. In the pre-war years, the Nicola repair (Nicola, 1949) consisted of passing the long head of biceps through a tunnel in the humeral head and attaching it to the anterior edge of the glenoid cavity, but long-term follow-up revealed a failure rate as high as 50 per cent. In 1938, Bankart offered a rational explanation of recurrence and based repair on the ‘Bankart’ lesion. The results of the Bankart repair show a reported recurrent dislocation rate which varies from 0 to 6 per cent (Adams, 1948; Eyre-Brook, 1948; Dickson and Devas, 1957; Rowe, 1963). In 1956, Du Toit and Roux described a procedure similar to the Bankart repair except that staples instead of sutures were used to reattach the labrum to the glenoid. The recurrence rate after staple capsulorrhaphy is about 4 per cent (Du Toit and Roux, 1956; Boyd and Hunt, 1965).
PATIENTS AND METHQDS Patients In the period from November 1970 to October 1983,22 patients (18 men and 4 women) were treated for recurrent anterior dislocation of the shoulder by a modified staple capsulorrhaphy. Their ages ranged from 23 to 68 years with an average of 32.2. Twenty patients were reviewed personally but the other 2 were untraceable and their details were therefore obtained from the hospital records. Sixteen patients were right handed and 6 were left handed. The dominant shoulder was affected in 59 per cent of the series. The interval from first dislocation to operation ranged from 5 months .to 5 years, with an average of 2.3 years. The average number of dislocations before operation was 4.2. All patients had had at least one dislocation reduced under general anaesthesia before repair, and they had all been treated by immobilization in a broad arm sling for 3 weeks on at least one occasion. One patient had had an associated fracture of
Summary
8-
Number of patients
8 _
I
42-
) Fighting
Fig.
Fall darn stain
MIamII-s lindudirq injurin .t WarkMdmai acxidmtsl
time
Type of injury at of first dislocation
1. The type of injury at the time of first anterior shoulder dislocation and the number
of patients in each group.
52
Injury: the British Journal of Accident Surgery
the greater tuberosity at the time of the first dislocation, and two other patients had damaged the axillary nerve by dislocation. In both patients, the nerve had fully recovered before repair was undertaken. In most patients the first dislocation was associated with moderate to severe injury (Fig. 1). Subsequent dislocations were associated with much less severe injury, and in many of them, reduction was achieved without general anaesthesia and occasionally without attendance at hospital. Operation
The patient is placed supine with a sandbag under the affected shoulder and the arm is towelled to allow its free movement. An incision about 12-15cm long is made from just below the clavicle, over the coracoid process in the line of the deltopectoral groove, as far as the axillary fold. The deltopectoral groove is developed and the cephalic vein is usually ligated. The anterior fibres of the origin of the deltoid muscle are released, the coracoid process is exposed and the conjoint tendon of coracobrachialis and the short head of biceps is identified. The interval between the conjoint tendon and the pectoralis minor is opened, and care is taken to avoid damage to the musculocutaneous nerve, its branches or the main axillary neurovascular bundle. The conjoint tendon is freed and divided about 1 cm from the tip of the coracoid process. The arm is then held in full external rotation by the assistant and the upper and lower margins of subscapularis are identified. The lower margin is conspicuous because three veins which accompany the anterior
(1987)
Vol. 18/No.
1
humerai circumflex artery run below it. Subscapularis is divided vertically at the level of the glenoid, and the shoulder capsule is divided at the same level. It is our experience that it is not always possible to identify the capsule as a separate layer. The shoulder joint and anterior margin of the glenoid are inspected and the lesion identified. Occasionally the glenoid labrum is detached from bone but usually there is simple laxity within the capsule. If the labrum is detached then the neck of the scapula is roughened with an osteotome. The arm is then fully internally rotated and, using the staple and staple holder (Figs. 2 and 3), the lateral part of the capsule and the adherent subscapularis muscle are secured to the neck of the glenoid (Fig. 4). The
Fig. 3. Diagrammatic punch and staple.
-
representation
of the staple holder,
Bankart Lesion
Capwle
Humeral Head
Stap?a
Fig. 2. The staple holder (left), the punch staple (bottom right).
Fig. 4.
(top right) and
Cross-sectional diagram of the shoulder demonstrating the position of the staple and reefing of the medial capsule and subscapularis.
53
Hodgkinson and Case: Staple capsulorrhaphyfor shoulder dislocation
medial edge of the capsule and the medial portion of subscapularis are sutured to the tendinous insertion of subscapularis which overlies the greater tuberosity. The conjoint tendon of coracobrachialis and the short head of biceps is sutured to the coracoid process. The wound is closed in layers after careful haemostasis. Postoperative
management
All patients had their skin sutures removed at 14 days. They wore a broad arm sling for 6 weeks, with an additional body bandage for the first 3 weeks. They began exercising the shoulder at 6 weeks but were advised to restrict activities until 3 months after operation. Complications
One patient developed a minor superficial wound infection. There were no nerve injuries and no deep infections.
performed. She reported no trouble from her shoulder and was managing to do all her housework without any difficulty. There were 10 patients who were regularly involved in sporting activities after their operations. Three of them played squash and badminton, and 2 of these patients used the racket in the hand on the side on which repair had been performed. Two patients went swimming regularly and the other 5 took regular exercise, including football, cricket and weight-training. The other 10 patients did not participate in any sporting activity but did not feel that their shoulders prevented them from doing so. Eight patients complained of intermittent pain in their shoulders. Three of them reported discomfort in the shoulder if they slept on the affected side and the other 5 reported occasional discomfort when lifting heavy objects. Four patients had slight keloid scars and although none of them had discomfort or tenderness in the scar, 2 of them did complain about its appearance.
RESULTS
We have evaluated the results of a modified staple capsulorrhaphy in 20 patients from 2 to 15 years after operation with an average follow-up of 6.4 years. They were assessed in terms of symptoms, activity, radiographic appearance, range of movement and recurrent anterior dislocation after surgery. Symptoms
Radiographic
appearance
Radiographic examination showed that the staple had remained in situ in 19 patients with no evidence of loosening or deep infection (Fig. 6). In one patient the staple had backed out completely (Fig. 7) but this was noted 3 months after operation and had not caused any
and activity
All 20 patients were asked to complete a questionnaire (Fig. 5) before being reviewed, and the results are shown in Table I. The one patient who had not returned to work following the operation had in fact retired before it wa S Name: Since the operation on your shoulder;
a) Have you returned to work ? b) How soon after your operation did you return to work ? c) Do you participate in any sporting activities ? (Please give details)
Fig. 6. Anteroposterior radiograph showing the staple in situ, 7 years after surgery, with no evidence of infection or loosening.
d) Do you have any pain in your shoulder ? (Pleasegive details) e) Are you pleased with the results of your operation ?
that all patients Fig. 5. The questionnaire complete before being examined.
were asked to
Table 1. The answers given by the 20 patients to the questionnaire shown in Fig. 5 Question a) Have you returned to work? b) How soon did you return to work? c) Do you play any sport? d) Do you have any pain? e) Are you pleased with the operation?
Yes
No
19 1 4 weeks to 6 months Average time=3.7 months 10 10 8 12 20 0
Fig. 7. Anteroposterior radiograph whom the staple backed out.
of the one patient
in
54
apparent trouble. This patient had discarded his broad arm sling 4 weeks after the operation in order to return to demolition work!
Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 1
been necessary to remove any of the staples, including the one which had migrated, and therefore it has been our policy to have a radiograph taken only immediately after operation, at 3 months and at 1 year.
Range of movement
In all 20 patients, external rotation following operation was less than in the other shoulder. The decrease in external rotation after stapling ranged from 10 to 40” with an average decrease of 22”. None of the patients complained that this had caused any handicap and most were unaware of any restriction in movement. Abduction was slightly reduced in 4 patients and extension in 1.
Acknowledgements
We would like to thank Mrs Elizabeth Newton for typing this manuscript and the Medical Illustration Department, Royal Preston Hospital, for the photoaphs and illustrations. Further details of the staple holder may be obtained from Mr D. B. Case Mchorth, FRCS, Senior Consultant Orthopaedic Surgeon, Royal Preston Hospital, Sharoe Green Lane, Preston, Lancashire PR2 4HT.
Recurrent dislocation None of the patients had had a further anterior disloca-
tion of the shoulder after the operation. DISCUSSION
Anterior dislocation of the shoulder is a common injury and recurrent dislocation occurs more often at the shoulder than at any other joint. According to McLaughlin and Cavallaro (1950), recurrence occurred in 90 per cent of patients under the age of 20 years, in 60 per cent of patients between the ages of 20 and 40 years but in only 10 per cent of patients over the age of 40 years. Clearly, at any age recurrent anterior dislocation of the shoulder will severely interfere with work and sporting activities. The pathogenesis of recurrent anterior dislocation of the shoulder is probably multifactorial (Saha, 1971; Morrey and Janes, 1976), and in our series the common pathological finding was neither the Hill-Sachs nor the Bankart lesion but laxity of the front of the capsule. Because of this laxity it is justifiable to shorten subscapularis (Osmond-Clarke, 1948; Symeonides, 1972). On the other hand, if a Bankart lesion is demonstrable, either suturing or stapling of the labrum to the anterior margin of the glenoid should be satisfactory. The placing of adequate sutures in the anterior margin of the glenoid is technically difficult and often time consuming. The advantage of the modified staple capsulorrhaphy as described here is that it combines repair of the detached anterior part of the labrum with shortening of the subscapularis; it is technically a much easier procedure and therefore reduces operating time and yet produces comparable long-term results without serious complications. The staple holder, which was designed by one of the authors (D.B.C.), allows leverage of the distal portion of the capsule and subscapularis over the anterior rim of the glenoid, ensures stability of the staple during positioning and aids insertion of the staple. Positioning of the staple is not difficult provided that the initial vertical incision into subscapularis and the capsule leaves a distal cuff of at least 3cm. If the distal cuff is less than this, then placing of the staple through subscapularis and the capsule with leverage over the anterior rim of the glenoid may cause the staple to cut out. It is possible to use more than one staple if required, but we have not found it necessary in this series. It has not
REFERENCES Adams J. C. (1948) Recurrent
dislocation
of the shoulder.
J. Bone Joint Surg. 30B. 26.
Bankart A. S. B. (1938) The pathology and treatment of recurrent dislocation of the shoulder joint. Br. J. Surg. 26, 23. Boyd H. B. and Hunt H. L. (1965) Recurrent dislocation of the shoulder: the staple capsulorrhapy. J. Bone Joint Surg. 47A, 1514. Brav E. A. (1960) Recurrent dislocation of the shoulder: ten years’ experience with the Putti Platt reconstruction procedure. Am. J. Surg. 100,423. Dickson J. W. and Devas M. B. (1957) Bankart’s operation for recurrent dislocation of the shoulder. J. Bone Joint Surg. 39B, 114. Du Toit G. T. and Roux D. (1956) Recurrent dislocation of the shoulder: a twenty-four year study of the Johannesburg stapling operation. J. Bone Joint Surg. 38A, 1. Eyre-Brook A. L. (1948) Recurrent dislocation of the’ shoulder: lesions discovered in seventeen cases, surgery employed and intermediate report on results. J. Bone Joint Surg. 30B. 39.
McLaughlin H. L. and Cavallaro W. U. (1950) Primary anterior dislocation of the shoulder. Am. J. Surg. 80, 615. Morrey B. F. and Janes J. M. (1976) Recurrent anterior dislocation of the shoulder. Long-term follow up of the Putti-Platt and Bankart procedures. J. Bone Joint Surg.
%A, 252. Nicola T. (1949) Acute anterior dislocation
of the shoulder.
J. Bone Joint Surg. 31A, 153.
Osmond-Clarke H. (1948) Habitual dislocation of the shoulder: the Putti Platt operation. J. Bone Joint Surg. 3OB, 19. Rowe C. R. (1963) The results of operative treatment of recurrent dislocations of the shoulder. Surg. Clin. North Am. 43, 1667.
Saha A. K. (1971) Dynamic stability of the gleno-humeral joint. Acta Orthop. Stand. 42, 491. Symeonides P. P. (1972) The significance of the subscapularis muscle in the pathogenesis of recurrent anterior dislocation of the shoulder. J. Bone Joint Surg. 54B, 476. Watson-Jones R. (1948) Note on recurrent dislocation of the shoulder joint: superior approach causing the only failure in fifty-two operations for repair of the labrum and capsule. J. Bone Joint Surg. 30B, 49.
Paper accepted 6 March 1986.
Requestsfor reprintsshould be nddressed to: Mr D. B. Case, Royal Preston Hospital, Sharoe Green Lane, Preston, Lancashire PR2 4HT.
(1987)
18,51-54
Printedin GreatBn’fain
51
The modified staple capsulorrhaphy for the correction of recurrent anterior dislocation of the shoulder J. P. Hodgkinson
and D. B. Case
Royal Preston Hospital,
Preston, Lancashire
Recurrent anterior dislocation of the shoulder is a fairly common disorder for which numerous surgical procedures have been described. This paper reviews 22 patients treated between 1970 and 1983 by a modified staple capsulorrhaphy. It describes the surgical technique and demonstrates an instrument designed to hold and aid the insertion of the staple. There were no major complications in using this technique. All patients had some restriction of external rotation after operation but no patient suffered a further dislocation during a long-term follow-up of 6.4 years on average.
The Putti-Platt repair as described by OsmondClarke in 1948 has a recurrent dislocation rate which varies from 0 to 13 per cent (Adams, 1948; Watson; Jones, 1948; Brav, 1960; Morrey and Janes, 1976). This paper describes an operation to correct recurrent anterior dislocation of the shoulder by a modified staple capsulorrhaphy. It demonstrates an instrument designed to aid the procedure and reports the results in 22 patients who underwent this operation between 1970 and 1983.
INTRODUCTION THERE have been more than 150 different operations described to correct recurrent anterior dislocation of the shoulder. Until 50 years ago, the results of operation were very poor. In the pre-war years, the Nicola repair (Nicola, 1949) consisted of passing the long head of biceps through a tunnel in the humeral head and attaching it to the anterior edge of the glenoid cavity, but long-term follow-up revealed a failure rate as high as 50 per cent. In 1938, Bankart offered a rational explanation of recurrence and based repair on the ‘Bankart’ lesion. The results of the Bankart repair show a reported recurrent dislocation rate which varies from 0 to 6 per cent (Adams, 1948; Eyre-Brook, 1948; Dickson and Devas, 1957; Rowe, 1963). In 1956, Du Toit and Roux described a procedure similar to the Bankart repair except that staples instead of sutures were used to reattach the labrum to the glenoid. The recurrence rate after staple capsulorrhaphy is about 4 per cent (Du Toit and Roux, 1956; Boyd and Hunt, 1965).
PATIENTS AND METHQDS Patients In the period from November 1970 to October 1983,22 patients (18 men and 4 women) were treated for recurrent anterior dislocation of the shoulder by a modified staple capsulorrhaphy. Their ages ranged from 23 to 68 years with an average of 32.2. Twenty patients were reviewed personally but the other 2 were untraceable and their details were therefore obtained from the hospital records. Sixteen patients were right handed and 6 were left handed. The dominant shoulder was affected in 59 per cent of the series. The interval from first dislocation to operation ranged from 5 months .to 5 years, with an average of 2.3 years. The average number of dislocations before operation was 4.2. All patients had had at least one dislocation reduced under general anaesthesia before repair, and they had all been treated by immobilization in a broad arm sling for 3 weeks on at least one occasion. One patient had had an associated fracture of
Summary
8-
Number of patients
8 _
I
42-
) Fighting
Fig.
Fall darn stain
MIamII-s lindudirq injurin .t WarkMdmai acxidmtsl
time
Type of injury at of first dislocation
1. The type of injury at the time of first anterior shoulder dislocation and the number
of patients in each group.
52
Injury: the British Journal of Accident Surgery
the greater tuberosity at the time of the first dislocation, and two other patients had damaged the axillary nerve by dislocation. In both patients, the nerve had fully recovered before repair was undertaken. In most patients the first dislocation was associated with moderate to severe injury (Fig. 1). Subsequent dislocations were associated with much less severe injury, and in many of them, reduction was achieved without general anaesthesia and occasionally without attendance at hospital. Operation
The patient is placed supine with a sandbag under the affected shoulder and the arm is towelled to allow its free movement. An incision about 12-15cm long is made from just below the clavicle, over the coracoid process in the line of the deltopectoral groove, as far as the axillary fold. The deltopectoral groove is developed and the cephalic vein is usually ligated. The anterior fibres of the origin of the deltoid muscle are released, the coracoid process is exposed and the conjoint tendon of coracobrachialis and the short head of biceps is identified. The interval between the conjoint tendon and the pectoralis minor is opened, and care is taken to avoid damage to the musculocutaneous nerve, its branches or the main axillary neurovascular bundle. The conjoint tendon is freed and divided about 1 cm from the tip of the coracoid process. The arm is then held in full external rotation by the assistant and the upper and lower margins of subscapularis are identified. The lower margin is conspicuous because three veins which accompany the anterior
(1987)
Vol. 18/No.
1
humerai circumflex artery run below it. Subscapularis is divided vertically at the level of the glenoid, and the shoulder capsule is divided at the same level. It is our experience that it is not always possible to identify the capsule as a separate layer. The shoulder joint and anterior margin of the glenoid are inspected and the lesion identified. Occasionally the glenoid labrum is detached from bone but usually there is simple laxity within the capsule. If the labrum is detached then the neck of the scapula is roughened with an osteotome. The arm is then fully internally rotated and, using the staple and staple holder (Figs. 2 and 3), the lateral part of the capsule and the adherent subscapularis muscle are secured to the neck of the glenoid (Fig. 4). The
Fig. 3. Diagrammatic punch and staple.
-
representation
of the staple holder,
Bankart Lesion
Capwle
Humeral Head
Stap?a
Fig. 2. The staple holder (left), the punch staple (bottom right).
Fig. 4.
(top right) and
Cross-sectional diagram of the shoulder demonstrating the position of the staple and reefing of the medial capsule and subscapularis.
53
Hodgkinson and Case: Staple capsulorrhaphyfor shoulder dislocation
medial edge of the capsule and the medial portion of subscapularis are sutured to the tendinous insertion of subscapularis which overlies the greater tuberosity. The conjoint tendon of coracobrachialis and the short head of biceps is sutured to the coracoid process. The wound is closed in layers after careful haemostasis. Postoperative
management
All patients had their skin sutures removed at 14 days. They wore a broad arm sling for 6 weeks, with an additional body bandage for the first 3 weeks. They began exercising the shoulder at 6 weeks but were advised to restrict activities until 3 months after operation. Complications
One patient developed a minor superficial wound infection. There were no nerve injuries and no deep infections.
performed. She reported no trouble from her shoulder and was managing to do all her housework without any difficulty. There were 10 patients who were regularly involved in sporting activities after their operations. Three of them played squash and badminton, and 2 of these patients used the racket in the hand on the side on which repair had been performed. Two patients went swimming regularly and the other 5 took regular exercise, including football, cricket and weight-training. The other 10 patients did not participate in any sporting activity but did not feel that their shoulders prevented them from doing so. Eight patients complained of intermittent pain in their shoulders. Three of them reported discomfort in the shoulder if they slept on the affected side and the other 5 reported occasional discomfort when lifting heavy objects. Four patients had slight keloid scars and although none of them had discomfort or tenderness in the scar, 2 of them did complain about its appearance.
RESULTS
We have evaluated the results of a modified staple capsulorrhaphy in 20 patients from 2 to 15 years after operation with an average follow-up of 6.4 years. They were assessed in terms of symptoms, activity, radiographic appearance, range of movement and recurrent anterior dislocation after surgery. Symptoms
Radiographic
appearance
Radiographic examination showed that the staple had remained in situ in 19 patients with no evidence of loosening or deep infection (Fig. 6). In one patient the staple had backed out completely (Fig. 7) but this was noted 3 months after operation and had not caused any
and activity
All 20 patients were asked to complete a questionnaire (Fig. 5) before being reviewed, and the results are shown in Table I. The one patient who had not returned to work following the operation had in fact retired before it wa S Name: Since the operation on your shoulder;
a) Have you returned to work ? b) How soon after your operation did you return to work ? c) Do you participate in any sporting activities ? (Please give details)
Fig. 6. Anteroposterior radiograph showing the staple in situ, 7 years after surgery, with no evidence of infection or loosening.
d) Do you have any pain in your shoulder ? (Pleasegive details) e) Are you pleased with the results of your operation ?
that all patients Fig. 5. The questionnaire complete before being examined.
were asked to
Table 1. The answers given by the 20 patients to the questionnaire shown in Fig. 5 Question a) Have you returned to work? b) How soon did you return to work? c) Do you play any sport? d) Do you have any pain? e) Are you pleased with the operation?
Yes
No
19 1 4 weeks to 6 months Average time=3.7 months 10 10 8 12 20 0
Fig. 7. Anteroposterior radiograph whom the staple backed out.
of the one patient
in
54
apparent trouble. This patient had discarded his broad arm sling 4 weeks after the operation in order to return to demolition work!
Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 1
been necessary to remove any of the staples, including the one which had migrated, and therefore it has been our policy to have a radiograph taken only immediately after operation, at 3 months and at 1 year.
Range of movement
In all 20 patients, external rotation following operation was less than in the other shoulder. The decrease in external rotation after stapling ranged from 10 to 40” with an average decrease of 22”. None of the patients complained that this had caused any handicap and most were unaware of any restriction in movement. Abduction was slightly reduced in 4 patients and extension in 1.
Acknowledgements
We would like to thank Mrs Elizabeth Newton for typing this manuscript and the Medical Illustration Department, Royal Preston Hospital, for the photoaphs and illustrations. Further details of the staple holder may be obtained from Mr D. B. Case Mchorth, FRCS, Senior Consultant Orthopaedic Surgeon, Royal Preston Hospital, Sharoe Green Lane, Preston, Lancashire PR2 4HT.
Recurrent dislocation None of the patients had had a further anterior disloca-
tion of the shoulder after the operation. DISCUSSION
Anterior dislocation of the shoulder is a common injury and recurrent dislocation occurs more often at the shoulder than at any other joint. According to McLaughlin and Cavallaro (1950), recurrence occurred in 90 per cent of patients under the age of 20 years, in 60 per cent of patients between the ages of 20 and 40 years but in only 10 per cent of patients over the age of 40 years. Clearly, at any age recurrent anterior dislocation of the shoulder will severely interfere with work and sporting activities. The pathogenesis of recurrent anterior dislocation of the shoulder is probably multifactorial (Saha, 1971; Morrey and Janes, 1976), and in our series the common pathological finding was neither the Hill-Sachs nor the Bankart lesion but laxity of the front of the capsule. Because of this laxity it is justifiable to shorten subscapularis (Osmond-Clarke, 1948; Symeonides, 1972). On the other hand, if a Bankart lesion is demonstrable, either suturing or stapling of the labrum to the anterior margin of the glenoid should be satisfactory. The placing of adequate sutures in the anterior margin of the glenoid is technically difficult and often time consuming. The advantage of the modified staple capsulorrhaphy as described here is that it combines repair of the detached anterior part of the labrum with shortening of the subscapularis; it is technically a much easier procedure and therefore reduces operating time and yet produces comparable long-term results without serious complications. The staple holder, which was designed by one of the authors (D.B.C.), allows leverage of the distal portion of the capsule and subscapularis over the anterior rim of the glenoid, ensures stability of the staple during positioning and aids insertion of the staple. Positioning of the staple is not difficult provided that the initial vertical incision into subscapularis and the capsule leaves a distal cuff of at least 3cm. If the distal cuff is less than this, then placing of the staple through subscapularis and the capsule with leverage over the anterior rim of the glenoid may cause the staple to cut out. It is possible to use more than one staple if required, but we have not found it necessary in this series. It has not
REFERENCES Adams J. C. (1948) Recurrent
dislocation
of the shoulder.
J. Bone Joint Surg. 30B. 26.
Bankart A. S. B. (1938) The pathology and treatment of recurrent dislocation of the shoulder joint. Br. J. Surg. 26, 23. Boyd H. B. and Hunt H. L. (1965) Recurrent dislocation of the shoulder: the staple capsulorrhapy. J. Bone Joint Surg. 47A, 1514. Brav E. A. (1960) Recurrent dislocation of the shoulder: ten years’ experience with the Putti Platt reconstruction procedure. Am. J. Surg. 100,423. Dickson J. W. and Devas M. B. (1957) Bankart’s operation for recurrent dislocation of the shoulder. J. Bone Joint Surg. 39B, 114. Du Toit G. T. and Roux D. (1956) Recurrent dislocation of the shoulder: a twenty-four year study of the Johannesburg stapling operation. J. Bone Joint Surg. 38A, 1. Eyre-Brook A. L. (1948) Recurrent dislocation of the’ shoulder: lesions discovered in seventeen cases, surgery employed and intermediate report on results. J. Bone Joint Surg. 30B. 39.
McLaughlin H. L. and Cavallaro W. U. (1950) Primary anterior dislocation of the shoulder. Am. J. Surg. 80, 615. Morrey B. F. and Janes J. M. (1976) Recurrent anterior dislocation of the shoulder. Long-term follow up of the Putti-Platt and Bankart procedures. J. Bone Joint Surg.
%A, 252. Nicola T. (1949) Acute anterior dislocation
of the shoulder.
J. Bone Joint Surg. 31A, 153.
Osmond-Clarke H. (1948) Habitual dislocation of the shoulder: the Putti Platt operation. J. Bone Joint Surg. 3OB, 19. Rowe C. R. (1963) The results of operative treatment of recurrent dislocations of the shoulder. Surg. Clin. North Am. 43, 1667.
Saha A. K. (1971) Dynamic stability of the gleno-humeral joint. Acta Orthop. Stand. 42, 491. Symeonides P. P. (1972) The significance of the subscapularis muscle in the pathogenesis of recurrent anterior dislocation of the shoulder. J. Bone Joint Surg. 54B, 476. Watson-Jones R. (1948) Note on recurrent dislocation of the shoulder joint: superior approach causing the only failure in fifty-two operations for repair of the labrum and capsule. J. Bone Joint Surg. 30B, 49.
Paper accepted 6 March 1986.
Requestsfor reprintsshould be nddressed to: Mr D. B. Case, Royal Preston Hospital, Sharoe Green Lane, Preston, Lancashire PR2 4HT.