Rockwood Adults CH34

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CHAPTER 34 • Glenohumeral Instability

C

D

Figure 34-33.  ( Continued ) C: The rotator interval is split to help identify the top of the subscapularis tendon. Subscapularis tenotomy is performed 1 cm from the bicipital groove to leave a cuff of tissue for repair ( red line ). D: The subscapularis muscle belly ( yellow arrow ) is separated from the capsule ( gray arrow ).

sign are also recorded. A deltopectoral or mid-axillary crease approach is used. For either surgical approach, the soft tissue is dissected down to identify the cephalic vein, which lies between the pec- toralis major medially and deltoid laterally. The authors pre- fer retracting the vein laterally with the deltoid musculature. A linked shoulder retractor (Kolbel self-retractor) is placed to split the deltopectoral interval (Fig. 34-33B). The clavipectoral fascia is incised to expose the coracoid (Fig. 34-33B, purple star ) and conjoint tendon (Fig. 34-33B, orange arrow ). The linked retrac- tor is repositioned between the conjoint tendon and the del- toid. Now, the biceps tendon is identified in the bicipital groove (Fig. 34-33B, blue arrow ). The lesser tuberosity is medial to the groove (Fig. 34-33B, yellow star ) and the greater tuberosity is lateral to the groove. The authors prefer a superior half or two-thirds subscapu- laris tenotomy that is made 1 cm medial to the lesser tuberos- ity (Fig. 34-33C, red line ) to allow for repair and separation of the capsule from the undersurface of the subscapularis mus- cle belly. The medial subscapularis tendon is tagged with no. 2 sutures. The rotator interval is also split to help identify the top of the subscapularis tendon (Fig. 34-33C, blue arrow ). External rotation of the arm will help better expose the subscapularis tendon. With traction on the no. 2 sutures, using both Metzen- baum scissors and an elevator, the capsule (Fig 34-33D, gray arrow ) is separated from the subscapularis (Fig 34-33D, yellow arrow ) muscle belly. A lateral-based “T” capsulotomy is made 1 cm medial to the lesser tuberosity to allow for further shifting of the capsule after the Bankart repair. The medial and lateral leaflet of the capsule is tagged with sutures to facilitate expo- sure to the glenohumeral joint. An anterior glenoid neck retrac- tor is placed to expose the Bankart lesion, and a humeral head retractor is placed in the glenohumeral joint to gently push the humeral head back to allow for a better exposure. The Bankart lesion is elevated off the glenoid rim with a soft tissue elevator. The anterior glenoid rim is superficially abraded with a burr.

Anchors (3 mm) are placed on the anterior glenoid rim (Fig. 34-34A) at the 5:30 position (6:30 in left shoulder). Depend- ing on the size of the tear, a minimum of three anchors should be used for the repair. The anterior glenoid neck retractor is removed and a suture passer is used to shuttle the no. 2 sutures from the anchor on the glenoid rim through the capsulolabral tissue (Fig. 34-34B) with horizontal mattress sutures (Fig. 34-34C). The same technique is repeated for the other anchors. All the sutures are tied starting with the most inferior anchor. The capsule is shifted ( arrow ) and repaired using no. 0 sutures in interrupted fashion with the arm in 30 degrees of flexion and 30 degrees of external rotation (Fig. 34-35A). Subscapularis tenot- omy is repaired back with no. 2 braided sutures in interrupted fashion (Fig. 34-35B). Deltopectoral interval is closed with run- ning no. 2 sutures and skin closed with 3-0 Monocryl and Derm- abond. The patient is placed in a sling and abduction pillow. Open Latarjet Procedure Preoperative Planning ✔ ✔ Open Latarjet Procedure: PREOPERATIVE PLANNING CHECKLIST

❑❑ Beach chair

OR table

❑❑ Spider (Tenet Medical Engineering)

Position/ positioning aids

❑❑ Kolbel linked retractor blades, anterior glenoid neck retractors, and humeral head retractor ❑❑ Steinmann pins ❑❑ Small frag set with 3.5- or 4.0-mm fully or partially threaded screws (we prefer the 5.0- mm partially threaded osteopenia screws for larger patients) ❑❑ 90-degree oscillating saw blade

Equipment

❑❑ Large pineapple burr ❑❑ Curved osteotomes