Rockwood Adults CH34

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CHAPTER 34 • Glenohumeral Instability

inferiorly, where there is more distinction between the two lay- ers (Fig. 34-46B). Proximally, these structures can be blended into one layer. The subscapularis is then released completely and reflected medially, exposing the capsule. The capsule is incised approximately 5 mm medial to the stump of the subscapularis, leaving enough tissue for eventual repair. Alternatively, the capsule can alsobe incised at the humeral insertionwitha shift done laterwithsutureanchors (Fig. 34-46C). The capsular incision begins superiorly and extends inferiorly. Tagging stitches are placed in the lateral edge to gain control of the tissue. Working inferiorly on the humeral neck, the arm is placed in progressive external rotation as the capsule is sharply released. At this point, the surgeon must judge the amount of inferior capsule to be released. Some advocate placing tension on the tagging suture with the surgeon’s finger in the pouch to see if the pouch becomes obliterated with this motion. If so, the capsule has been adequately released. 9 A humeral head retractor should be placed into the gleno- humeral joint to retract the humerus posteriorly and inspect for an anterior labral tear. If a labral tear is present, it should be repaired with suture anchor fixation after preparing the ante- rior glenoid rim with a curette or rasp. The sutures from these anchors should be passed from inside the labrum to outside and then tied on the capsular side (see Open Bankart Repair technique). Crimping mattress stitches can be used to reduce anterior capsular redundancy by passing the sutures from out-

side the capsule to inside the joint in a vertical mattress fashion and then tying on the capsular side as well. The arm is then positioned into 20 to 30 degrees of abduction and 20 to 30 degrees of external rotation. A horizontal split is made in the capsule so that the final capsulotomy resembles a “T.” Prior to performing the horizontal split, tagging stitches should be placed in both the superior and inferior limbs. The inferior limb is brought superiorly first and repaired back to the resid- ual capsule or with suture anchors (Fig. 34-46C,D) and then the superior limb is repaired in a pants-over-vest fashion to the inferior capsule. If the patient exhibited a positive sulcus sign that persists in external rotation, then the rotator interval is also routinely closed with no. 2 braided suture fixation. The sub- scapularis is repaired with nonabsorbable no. 2 braided sutures, and the skin is closed in layers. Rehabilitation is usually similar regardless of open and arthroscopic techniques and consists of sling immobilization for 6 to 8 weeks to protect the repair. Pendulum exercises are typi- cally allowed after 7 to 10 days. Gentle passive ROM can begin after 2 weeks and are allowed to progress throughout the 6- to 8-week period. No aggressive stretching is allowed in the early period of rehabilitation, and strengthening against resistance is delayed until the 3- to 4-month mark. Many clinicians follow an even more conservative approach and delay the initiation of therapy until the 6- to 8-week mark, allowing only pendulums during that time.

Authors’ Preferred Treatment for Multidirectional Glenohumeral Instability (Algorithm 34-4)

Multidirectional shoulder instability

Physical therapy rehabilitation

Failed > 1 year of formal PT and rehabilitation and home exercises

Anterior, posterior and inferior

Posterior and inferior

Anterior and inferior

Arthroscopic vs open anterior and posterior inferior capsular shift é rotator interval closure

Arthroscopic vs open anterior inferior capsular shift é rotator interval closure

Arthroscopic vs open posterior inferior capsular shift é rotator interval closure

Algorithm 34-4.  Authors’ preferred treatment for multidirectional shoulder instability.