Rockwood Adults CH34

1114

SECTION TWO • Upper Extremity

A

B

C

D

Figure 34-41.  A: Open posterior Bankart or capsular shift procedure can be performed either in the lateral decubitus or in the beach chair position. This figure demonstrates the procedure in the beach chair posi- tion. Posterior open incision is centered over the posterior joint line. The surgical prep area must be medial so that the posterior glenohumeral joint is exposed. B: The deltoid fibers are split in line to expose the posterior rotator cuff musculature ( star ). C: The deltoid is tagged with no. 2 braided sutures with the spinal needle pointing to the posterior axillary nerve. D: The infraspinatus musculature ( blue arrow ) is split hor- izontally in line with the teres minor muscle ( yellow arrow ) to expose the posterior capsule and joint line.

in exposure. A shoulder linked retractor (Kolbel self-retractor) is placed to hold open the deltoid split. The axillary nerve and posterior circumflex artery are identified in the quadrangular space and protected (Fig. 34-41C). The interval between the infraspinatus and teres minor is opened and these tendons are partially elevated from their insertions laterally (Fig. 34-41D). The infraspinatus can be detached or partially elevated as can the teres minor to enhance exposure. Separation of the underlying capsule from the rotator cuff is important. Scissors and a Cobb elevator are used to separate the capsule from the infraspinatus and teres minor muscles in a medial-to-lateral direction. A horizontal capsulotomy or “T” capsulotomy is performed from 1 cm lateral to the glenoid rim to the greater tuberosity to facilitate the capsular shift (Fig. 34-42A). Tagged sutures should be placed on each layer

to aid in retraction and exposure (Fig. 34-42B). Homan retrac- tors are placed over the superior and inferior glenoid rim and a humeral head retractor is placed in the glenohumeral joint to gently push the humeral head back to allow for optimal expo- sure (Fig. 34-42C). The labral lesion is elevated off the glenoid rim with a soft tissue elevator. (A curved glenoid neck retractor can be placed, but great care must be taken not to damage or compress the suprascapular nerve as it passes through the spinoglenoid notch.) The posterior glenoid rim is superficially abraded with a burr. A 3-mm double-loaded suture anchors are placed on the posterior glenoid rim along the extent of the tear. Depending on the size of the tear, two to four suture anchors should be used for the repair. Either a free needle or a curve or straight suture passer is used to shuttle the sutures from the anchor