import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits quadrilateral space, runs on anterior subscapularis surface 5-7cm distal to inferior glenoid rim, marked by anterior circumflex vessels **Protection**: Limit inferior dissection <5cm from glenoid, gentle subscapularis mobilization, avoid aggressive inferior Fukuda retractor placement **Location**: Enters coracobrachialis 3-8cm distal to coracoid tip (average 5cm, highly variable anatomy) **Protection**: Incise clavipectoral fascia lateral to conjoint tendon, avoid aggressive medial retraction, identify and protect conjoint tendon **Location**: Lies within deltopectoral interval, runs superficial to clavipectoral fascia **Protection**: Take laterally with deltoid (preserves venous drainage) or medially with pectoralis, cauterize and ligate if injured **Location**: In bicipital groove lateral to subscapularis insertion, enters joint through rotator interval **Protection**: Identify groove as lateral landmark, avoid subscapularis takedown too lateral, preserve rotator interval **Location**: Posterior to clavipectoral fascia, can be stretched with arm positioning in beach chair **Protection**: Avoid excessive arm traction, position arm in neutral without tension, monitor arm position throughout case ## Indications for Open Bankart Repair ### Primary Indications Recurrent instability after arthroscopic Bankart repair - most common indication for open revision surgery Any revision shoulder stabilization - open approach allows better assessment and repair of complex pathology Moderate glenoid bone loss not requiring Latarjet - open allows better bone assessment and management ### Secondary Indications - **Engaging Hill-Sachs lesion**: Requiring remplissage combined with Bankart repair - **Contact/collision athletes**: Wanting lowest possible recurrence rate (5-10% open vs 10-15% arthroscopic) - **Large rotator interval laxity**: Better addressed open with direct closure - **Poor tissue quality**: Ehlers-Danlos, revision tissue where open handling advantageous - **Surgeon preference**: Some high-volume surgeons prefer open for all Bankart repairs - **Failed conservative management**: Multiple dislocations with documented Bankart lesion ### Contraindications **Absolute**: - Glenoid bone loss >25%: Requires Latarjet with bone augmentation - Active infection: Staged treatment required - Severe medical comorbidities: Prohibitive surgical risk **Relative**: - Voluntary dislocator: Psychiatric/behavioral component requires assessment - Bone loss <10%: Arthroscopic generally preferred for primary cases - Multidirectional instability: May require capsular shift, different approach - Fixed posterior subluxation: Indicates different pathology - Significant subscapularis pathology: Pre-existing tear may compromise repair ### Preoperative Assessment **Clinical Examination**: - Document instability direction: Anterior, posterior, or multidirectional - Assess apprehension test: Positive indicates anterior instability - Load-and-shift grading: Grade 0-3, document baseline laxity - Sulcus sign: Assess inferior laxity component - ROM documentation: Especially external rotation to set postoperative goals - Subscapularis strength: Lift-off, belly-press tests baseline **Imaging Requirements**: - **Plain radiographs**: AP, scapular Y, axillary lateral views - **CT scan with 3D reconstruction**: Essential for bone loss quantification - **MRI/MR arthrogram**: Assess labral pathology, capsular injury, subscapularis integrity - **Bone loss measurement**: Calculate percentage using best-fit circle method - **Hill-Sachs evaluation**: Size, location, engagement risk assessment **Critical Decision Point**: Glenoid bone loss >20-25% is critical threshold. Below this, Bankart repair appropriate. Above this, bone augmentation (Latarjet) required. Open approach allows intraoperative assessment if preoperative imaging equivocal. ## Critical Surgical Anatomy ### Deltopectoral Interval Anatomy **Cephalic Vein**: - Runs in deltopectoral interval superficial to clavipectoral fascia - Lateral position: Take with deltoid to preserve venous drainage - Medial position: Take with pectoralis major - If injured: Ligate and cauterize - usually minor bleeding **Deltoid Muscle**: - Origin: Lateral clavicle, acromion, spine of scapula - Insertion: Deltoid tuberosity of humerus - Nerve: Axillary nerve (C5-C6) - Preserve muscle by developing interval, avoid lateral dissection **Pectoralis Major**: - Origin: Clavicle, sternum, costal cartilages - Insertion: Lateral lip of bicipital groove - Nerve: Medial and lateral pectoral nerves - Preserve by developing interval, avoid medial dissection ### Clavipectoral Fascia and Deep Structures **Clavipectoral Fascia**: - Extends from coracoid to axilla - Incise LATERAL to conjoint tendon to expose subscapularis - Protects neurovascular structures medially **Conjoint Tendon**: - Short head biceps and coracobrachialis - Origin from coracoid tip - Musculocutaneous nerve enters 3-8cm distal (average 5cm) - PROTECT: Avoid aggressive medial retraction **Anterior Circumflex Vessels**: - Run transversely at inferior border of subscapularis - Mark level of axillary nerve (5-7cm distal to inferior glenoid) - May require ligation for exposure - acceptable - Use as landmark to avoid inferior dissection ### Subscapularis Muscle-Tendon Unit **Muscle Anatomy**: - Origin: Subscapular fossa of scapula - Insertion: Lesser tuberosity of humerus - Nerve: Upper and lower subscapular nerves (C5-C7) - Function: Internal rotation, anterior stability **Tendon Characteristics**: - Comma-shaped insertion on lesser tuberosity - Superior fibers strongest, inferior fibers thinner - Fuses with anterior capsule - requires sharp dissection - Critical for anterior stability - repair integrity essential **Blood Supply**: - Subscapular artery branches - Anterior circumflex humeral artery contributions - Rich vascular supply supports healing ### Glenohumeral Joint Anatomy **Glenoid Morphology**: - Pear-shaped: Wider inferiorly than superiorly - Bare spot: Anatomic center, reference for bone loss - Articular surface: 5mm thick peripherally - Subchondral bone: Prepare to bleeding surface for healing **Labrum and Capsule**: - Labrum: Fibrocartilaginous rim deepening socket - Bankart lesion: Anteroinferior labral detachment 2-6 o'clock - IGHL: Inferior glenohumeral ligament - primary anterior restraint - Capsule: Synovial-lined fibrous structure requiring repair **Rotator Interval**: - Space between subscapularis and supraspinatus - Contains long head biceps, coracohumeral ligament - May contribute to instability if patulous - Can close if excessive laxity present ### Neurovascular Danger Zones **Axillary Nerve**: - Course: Exits quadrilateral space, wraps around surgical neck - Position: Anterior surface of subscapularis 5-7cm from inferior glenoid - Risk: Inferior dissection, aggressive mobilization, Fukuda retractor - Protection: Limit inferior dissection, gentle handling, anatomic landmarks **Musculocutaneous Nerve**: - Enters coracobrachialis variable 3-8cm from coracoid - Risk: Medial retraction on conjoint tendon - Protection: Lateral clavipectoral incision, avoid medial retraction **Axillary Nerve**: Use anterior circumflex vessels as landmark. Limit inferior dissection to <5cm from inferior glenoid rim. Gentle subscapularis mobilization without aggressive retraction. **Musculocutaneous Nerve**: Incise clavipectoral fascia lateral to conjoint tendon. Avoid medial retraction. Identify and protect conjoint throughout procedure. ## Detailed Operative Technique ### Step 1: Patient Positioning and Draping **Beach Chair Position**: - Head elevated 60-70° with headrest support - Bump behind medial scapula to bring shoulder anterior - Arm free draped from clavicle to below elbow - Ensure arm can move through full ROM for testing - Avoid excessive traction on brachial plexus **Alternative**: Semi-lateral decubitus 30° if surgeon preference, allows gravity assistance **Draping**: - Prep entire shoulder girdle including neck, chest to nipple line - Free-drape arm to allow manipulation - Ensure sterile access to anterior shoulder and axilla **Landmarks**: - Mark coracoid process - Mark deltopectoral interval - Mark acromion for orientation **Technical Tip**: Beach chair allows intraoperative stability testing and ROM assessment critical for subscapularis repair evaluation. Must be able to test lift-off, belly-press, external rotation before closing. ### Step 2: Skin Incision and Deltopectoral Interval **Incision Options**: **Standard Deltopectoral** (preferred): - From coracoid extending 8-10cm distally along deltopectoral groove - Follows natural skin lines for cosmesis - Allows adequate exposure for all steps **Axillary Crease** (cosmetic alternative): - Transverse incision in axillary crease - Better cosmesis in younger patients - More difficult inferior access **Technique**: - Incise skin and subcutaneous tissue to clavipectoral fascia - Identify cephalic vein in interval - Take vein LATERALLY with deltoid (preserves venous drainage) - Alternative: Take medially with pectoralis - Develop interval by blunt finger dissection - Place self-retaining retractor **Technical Tip**: Taking cephalic vein laterally with deltoid preserves venous drainage from deltoid muscle, reducing postoperative swelling and improving patient comfort. - **Cephalic vein injury**: Usually minor, ligate and cauterize - **Deltoid damage**: Avoid dissection too lateral beyond interval - **Pectoralis damage**: Avoid dissection too medial ### Step 3: Clavipectoral Fascia and Exposure **Identify Structures**: - Conjoint tendon (short head biceps + coracobrachialis) - Clavipectoral fascia covering subscapularis - Coracoacromial ligament superiorly **Fascia Incision**: - Incise clavipectoral fascia LATERAL to conjoint tendon - Protects musculocutaneous nerve (enters conjoint 3-8cm distal) - Extend incision from coracoid to inferior border subscapularis **Deep Exposure**: - Place self-retaining retractor (Kolbel or similar) - Retract deltoid laterally, pectoralis medially - Identify subscapularis tendon - Long head biceps in groove (lateral landmark) - Anterior circumflex vessels inferiorly (mark axillary nerve level) **Anatomic Pearl**: Anterior circumflex humeral vessels run transversely at inferior subscapularis border, marking the level of axillary nerve 5-7cm below. Use as landmark to avoid inferior dissection beyond safe zone. - **Musculocutaneous nerve**: Enters conjoint 5cm average from coracoid - avoid aggressive medial retraction - **Axillary nerve**: Anterior circumflex vessels mark level - limit inferior dissection ### Step 4: Subscapularis Takedown Decision **THREE OPTIONS - Know Pros/Cons**: **Option 1: Lesser Tuberosity OSTEOTOMY**: - **Technique**: Osteotome full-thickness bone wafer 1-1.5cm with subscapularis insertion - **Fixation**: 2-3 screws (4.0mm partially threaded) at closure - **Advantages**: Strongest repair (bone-to-bone healing), anatomic restoration, best long-term strength - **Disadvantages**: Higher morbidity, osteotomy non-union risk 2-5%, technically demanding, hardware complications - **Indications**: Young active patients, contact athletes, revision cases **Option 2: Subscapularis PEEL** (PREFERRED): - **Technique**: Elevate subscapularis insertion from lesser tuberosity with periosteal sleeve - **Fixation**: Transosseous tunnels through lesser tuberosity, horizontal mattress sutures - **Advantages**: Good balance of exposure and repair strength, no hardware, reliable healing - **Disadvantages**: More dissection than tenotomy, requires bone tunnels - **Indications**: Most cases, balanced approach **Option 3: TENOTOMY**: - **Technique**: Divide tendon 1cm medial to insertion, tag for repair - **Fixation**: Direct end-to-end repair with interrupted sutures - **Advantages**: Easiest, fastest, least dissection - **Disadvantages**: Highest failure rate 15-20%, healing tendon-to-tendon weaker - **Indications**: Older patients, low-demand, concerns about stiffness **Decision Making**: I prefer subscapularis PEEL for optimal balance. Osteotomy gives strongest repair but higher morbidity. Tenotomy easier but unacceptable failure rate 15-20% in active patients. Peel provides adequate exposure, reliable repair through bone tunnels, and excellent outcomes. ### Step 5: Subscapularis Mobilization and Tagging **Tagging Sutures**: - Pass 2-0 or 0 Ethibond through tendon in horizontal mattress configuration - Multiple sutures (3-4) for secure hold - Provides strong handles for retraction and later repair **Mobilization from Capsule**: - Sharp dissection to separate subscapularis from anterior capsule - Preserves capsule integrity for later repair - Avoids subscapularis lengthening - Continue mobilization to allow medial retraction **Medial Release** (if needed for mobilization): - Release subscapularis from anterior scapula - Careful - axillary nerve runs on anterior subscapularis surface - Usually not necessary if adequate peel or osteotomy **Technical Key**: Sharp dissection between subscapularis and capsule preserves both structures. Blunt dissection tears capsule and lengthens subscapularis. Take time for meticulous sharp dissection - critical for repair quality. Axillary nerve runs on ANTERIOR surface of subscapularis muscle. Avoid aggressive anterior dissection or mobilization. Gentle handling essential. ### Step 6: Capsulotomy and Joint Exposure **Arm Position**: - External rotation and slight extension brings anterior capsule into view - Assistant maintains position throughout capsulotomy **Capsulotomy Options**: **Vertical Capsulotomy** (preferred): - Longitudinal incision parallel to glenoid edge - Preserves IGHL inferiorly - Easier capsular closure - Less risk of overtightening **T-Capsulotomy**: - Vertical limb as above - Horizontal limb at inferior border for exposure - Better exposure for inferior pathology - More complex closure **Retractor Placement**: - **Fukuda retractor**: Place on anterior glenoid neck (careful - axillary nerve if too inferior) - **Darrach retractor**: Posterior glenoid rim - Exposes entire glenoid face and labrum - Allows assessment of pathology **Exposure Pearl**: Vertical capsulotomy with Fukuda retractor anteriorly and Darrach posteriorly gives excellent glenoid exposure. Position Fukuda carefully - not more than 5cm inferior to avoid axillary nerve injury. ### Step 7: Pathology Assessment and Bone Loss Quantification **Systematic Assessment**: **Bankart Lesion**: - Extent: Typically 2 o'clock to 6 o'clock (right shoulder) - Quality: Fresh vs chronic, tissue quality - Displacement: Medial displacement onto glenoid neck **Glenoid Bone Loss**: - **Bare spot method**: Distance from bare spot to anterior rim vs posterior rim - **Direct measurement**: Compare anterior defect to intact posterior - **Quantification**: Calculate percentage - critical decision point - **>20-25% bone loss**: ABORT - convert to Latarjet procedure **Hill-Sachs Lesion**: - Size: Measure width and depth - Location: Engagement zone vs non-engagement - **Engagement test**: Arm in abduction-external rotation - does Hill-Sachs engage glenoid rim? - **Track concept**: Glenoid track vs Hill-Sachs interval **Capsular Laxity**: - Drive-through sign: Can instruments pass freely across joint - Capsular tissue quality and redundancy - Determines need for capsular shift **Critical Decision**: Glenoid bone loss >20-25% is absolute contraindication to Bankart repair alone. Open approach allows accurate intraoperative assessment. If >25%, abort and convert to Latarjet with coracoid bone block for successful stabilization. **Most common cause of failure**: Proceeding with Bankart repair when bone loss exceeds 20-25%. This WILL fail. Accurate assessment mandatory. If in doubt, abort and stage Latarjet procedure. ### Step 8: Labral Mobilization and Glenoid Preparation **Labral Mobilization**: - Use periosteal elevator to mobilize labrum from glenoid neck - Start inferiorly at 6 o'clock, work around to 12 o'clock - Mobilize 5-10mm medially off glenoid neck - Adequate mobilization essential for tension-free repair **Soft Tissue Release**: - Release scarred labrum and capsule - Chronic lesions may be adherent - sharp dissection required - Goal: Mobile tissue that can be advanced without tension **Glenoid Preparation**: - Use curette to decorticate glenoid rim at articular margin - Create bleeding bone surface for healing - Remove 1-2mm of articular cartilage at edge to expose subchondral bone - Avoid excessive bone removal - preserve glenoid stock **Bleeding Bone**: - Use small burr or curette - Abundant bleeding indicates vascular bed for healing - Smooth surface to avoid soft tissue irritation **Mobilization Critical**: Complete labral mobilization from glenoid neck is ESSENTIAL for tension-free repair. Inadequate mobilization leads to repair under tension, which fails. Mobilize 5-10mm circumferentially 6-12 o'clock. ### Step 9: Anchor Placement or Drill Holes **TWO FIXATION OPTIONS**: **Option 1: SUTURE ANCHORS** (preferred by most): - **Number**: 3-4 anchors depending on lesion size - **Position**: Glenoid FACE at articular margin, NOT on neck - **Angle**: 45° to glenoid face (deadman angle) for optimal pullout strength - **Starting point**: Inferiorly at 5-6 o'clock position - **Spacing**: 4-5mm between anchors - **Type**: 2.9mm or 3.0mm bioabsorbable or PEEK anchors with braided suture - **Advantages**: Faster, easier, reliable fixation - **Disadvantages**: Bone removal, cost, potential for loosening **Option 2: TRANSOSSEOUS DRILL HOLES**: - **Drill**: 2.5mm bit from anterior glenoid face through posterior glenoid neck - **Number**: 3-4 holes matching anchor positions - **Suture passage**: Use suture passer to shuttle sutures through holes - **Advantages**: Bone-conserving, no implants, lower cost - **Disadvantages**: Technically demanding, longer operative time, risk intraarticular if too medial **Anchor Position Critical**: Anchors must be on glenoid FACE at articular margin, not on glenoid neck. Neck placement creates no bumper effect and will fail. Angle 45° (deadman angle) maximizes pullout resistance. - **Anchor on glenoid neck**: No bumper restoration = failure - **Anchor too medial**: Intraarticular placement damages cartilage - **Insufficient number**: Need 3-4 for adequate fixation - **Wrong angle**: Perpendicular to face has poor pullout strength ### Step 10: Capsulolabral Repair **Suture Passage**: - Pass sutures through labrum AND capsule (capsulolabral shift) - Start inferiorly (5-6 o'clock) and work superiorly - Use penetrating suture passer or free needle with suture retriever - Ensure adequate tissue in each bite (3-5mm) **Tissue Incorporation**: - BOTH labrum and capsule must be included - Labrum only = no capsular shift = recurrence - Capsule provides IGHL tension restoration **Knot Tying**: - Arm position: 30-40° external rotation (avoids overtightening) - Tie knots sequentially from inferior to superior - Knots on capsular side (away from articular surface) - Appropriate tension: Snug but not overtight **Repair Goals**: - Restore labral bumper to glenoid face - Eliminate drive-through sign - Restore IGHL tension - Smooth articular transition **Capsulolabral Shift Essential**: Sutures must pass through BOTH labrum and capsule. Labrum-only repair fails to address capsular laxity and IGHL insufficiency. Tie with arm in 30-40° ER to set appropriate tension - not neutral (too tight) or full ER (too loose). - **Labrum only repair**: Fails to restore capsular tension - **Overtightening**: Tie in neutral or IR = loss of ER and stiffness - **Undertightioning**: Tie in excessive ER = persistent laxity - **Prominent knots**: Articular-sided knots cause irritation ### Step 11: Capsular Closure and Imbrication **Capsulotomy Closure**: - Close vertical or T-capsulotomy with interrupted absorbable sutures - 2-0 Vicryl or equivalent - Watertight closure to restore normal anatomy **Capsular Shift (if needed)**: - Indication: Excessive capsular laxity (drive-through positive after Bankart) - Technique: Overlap capsular leaves by 5-10mm - Direction: Lateral capsule under medial capsule (lateral-to-medial shift) - Arm position: 40° external rotation during shift and tying - Goal: Tighten capsular volume, restore normal laxity **Shift Principles**: - Balance stability vs ROM - Excessive shift = loss of ER and stiffness - Insufficient shift = persistent instability - Test ROM intraoperatively **Capsular Shift Indication**: Not all cases require shift. Perform if drive-through sign persists after Bankart repair or if capsule markedly redundant. Shift 5-10mm with arm in 40° ER balances stability and ROM. ### Step 12: Subscapularis Repair - CRITICAL STEP **For OSTEOTOMY**: - Reduce bone fragment to anatomic position - Fix with 2-3 partially threaded 4.0mm screws - Ensure stable fixation without over-compression - Arm in neutral rotation during fixation **For PEEL** (preferred): - Drill 3-4 transosseous tunnels through lesser tuberosity - Tunnels 2.5-3.0mm, parallel, exiting lateral cortex - Pass tagged sutures (#2 Ethibond) through tunnels - Tie sutures over lateral bone bridge with arm in neutral rotation - Horizontal mattress configuration for strength **For TENOTOMY**: - Direct tendon-to-tendon repair - Interrupted sutures (#2 Ethibond) - Multiple sutures for strength - Arm in neutral rotation **Repair Testing**: - Passive external rotation: Should reach 40° without tension on repair - <40° = repair too tight = loss of motion - Lift-off test: Should have resistance (strength preserved) - Belly-press test: Confirms subscapularis integrity **Subscapularis Repair is MOST CRITICAL Step**: Failure causes recurrent instability AND internal rotation weakness. For peel: Transosseous tunnels through lesser tuberosity provide secure bone fixation superior to tendon-to-tendon. Test repair - should allow 40° ER passively without tension. - **Most common complication**: Subscap failure 5-15% - **Causes**: Inadequate fixation, repair under tension, poor tissue quality - **Prevention**: Secure transosseous or osteotomy fixation, appropriate tension (40° ER achievable) - **Result of failure**: Instability recurrence, IR weakness, poor outcome ### Step 13: Stability Testing and Assessment **Stability Tests**: - **Load-and-shift**: Should be grade 1 (normal translation) - Grade 0 = too tight = will stiffen - Grade 2+ = too loose = will fail - **Apprehension test**: Should be negative in abduction-ER - **Sulcus sign**: Check inferior stability - **Relocation test**: Should be negative **ROM Assessment**: - **Forward elevation**: Should reach 140-160° - **External rotation at side**: CRITICAL - should reach 40° comfortably - <40° = overtightened = postop stiffness - **Internal rotation**: Should reach L3-L5 - **Abduction-ER**: Should reach 90°/60° without apprehension **Subscapularis Function**: - **Lift-off test**: Resistance to lifting hand off back - **Belly-press test**: Ability to press belly without wrist flexion - **Internal rotation strength**: Should be strong without pain **Documentation**: - Record all tests - Compare to preoperative examination - Guides postoperative expectations **Intraoperative Testing Predicts Outcome**: Load-and-shift grade 1 (not 0 or 2+), ER to 40° comfortably, negative apprehension, strong subscapularis predict excellent outcome. Failure to achieve these intraoperatively requires reassessment of repair. ### Step 14: Wound Closure **Irrigation**: - Copious irrigation with normal saline (3-6L) - Removes debris, reduces infection risk **Layer Closure**: - **Clavipectoral fascia**: Close with 0 or 2-0 absorbable (Vicryl) - **Deltopectoral interval**: Optional closure vs leave open - Some surgeons close to reduce dead space - Others leave open to reduce tension - **Deep dermis**: 2-0 or 3-0 absorbable (Vicryl) - **Skin**: Subcuticular 3-0 or 4-0 Monocryl **Hemostasis**: - Meticulous - hematoma risk high - Consider drain if significant oozing (controversial) **Dressing**: - Sterile dressing - Sling in internal rotation (relaxes subscapularis repair) **Immobilization Position**: Sling in INTERNAL ROTATION protects subscapularis repair by relaxing muscle-tendon unit. Some surgeons use abduction pillow for Bankart repair, but sling preferred to protect subscap. ### Step 15: Postoperative Protocol **Immediate (0-6 weeks)**: - Sling immobilization continuously for 6 weeks - **NO external rotation past neutral** for 6 weeks (protects subscapularis) - Pendulum exercises immediately for circulation - Elbow, wrist, hand ROM maintained **Early Rehabilitation (6-8 weeks)**: - Passive ROM begins week 2-3 - Gentle forward elevation - Avoid extremes of ER and IR initially - Active ROM begins 6-8 weeks - Start with subscapularis exercises (gentle IR) - Progress ER gradually **Strengthening (12+ weeks)**: - Begin strengthening at 12 weeks - Progressive resistance exercises - Emphasize subscapularis, rotator cuff, periscapular muscles - Sport-specific training begins **Return to Activity**: - Non-contact sport: 4-6 months - Contact sport: 6 months minimum - Full recovery: 6-9 months **Critical Milestones**: - Week 6: Sling discontinued, active ROM begins - Week 12: Strengthening begins - Month 4-6: Return to sport **Postoperative Protocol More Conservative Than Arthroscopic**: Due to subscapularis repair, restrict ER for 6 weeks (vs 3-4 weeks arthroscopic). This is CRITICAL to prevent subscap failure. Patient education essential - early aggressive ER causes subscap failure and instability recurrence. ## Complications Recognition and Management **Recurrent Instability**: Accurate bone loss assessment preoperatively. Abort and stage Latarjet if >25% bone loss. Secure capsulolabral repair with appropriate tensioning. **Subscapularis Failure**: Secure repair technique (peel with transosseous tunnels or osteotomy, NOT tenotomy). Test intraop (40° ER achievable). Protect postop (no ER past neutral 6 weeks). **Axillary Nerve Palsy**: Limit inferior dissection <5cm from glenoid, gentle handling, anatomic landmarks (anterior circumflex vessels). ## Evidence-Based Practice and Exam Pearls ### Key Evidence Points **Open vs Arthroscopic Bankart**: - Open recurrence rate: 5-10% - Arthroscopic recurrence rate: 10-15% (modern techniques) - Open has more morbidity (subscapularis, stiffness) - Arthroscopic preferred for primary cases without bone loss - Open preferred for revision, bone loss 15-20%, surgeon preference **Subscapularis Management Evidence**: - Lesser tuberosity osteotomy: Lowest failure rate 2-5%, highest strength, but morbidity - Subscapularis peel: Good balance, failure rate 5-10% - Tenotomy: Highest failure rate 15-20%, avoid in active patients - Comparative studies favor osteotomy or peel over tenotomy **Bone Loss Thresholds**: - <10%: Soft tissue Bankart adequate - 10-15%: Soft tissue Bankart acceptable, consider bone - 15-20%: Soft tissue possible but higher recurrence, consider Latarjet - 20-25%: Critical threshold - above this requires Latarjet - >25%: Soft tissue Bankart will fail, Latarjet mandatory **Capsular Repair Techniques**: - Capsulolabral repair (labrum + capsule) superior to labrum-only - Tie sutures in 30-40° ER for appropriate tension - 3-4 anchors standard for adequate fixation - Deadman angle (45°) provides optimal pullout strength ### Australian Context **Medicare MBS Items**: - Item 49318: Open repair for recurrent dislocation of shoulder, includes capsular repair - Item 49324: Revision shoulder stabilization procedure - Requires documentation of failed conservative management or prior surgery **PBS Medications**: - Postoperative analgesia: Paracetamol + opioid (oxycodone, tramadol) - NSAIDs: Ibuprofen, diclofenac for inflammation - No specific PBS restrictions for standard analgesics **eTG Guidelines**: - Antibiotic prophylaxis: Cefazolin 2g IV within 60min of incision - Alternative (penicillin allergy): Vancomycin 15-20mg/kg IV - Duration: Single dose adequate for clean surgery - Treatment of infection: Flucloxacillin 2g IV q6h or Vancomycin if MRSA risk **Workers Compensation**: - Common work-related injury in manual laborers - Requires documentation of work-relatedness - Return to work planning essential - Light duties 3 months, full duties 6 months - Permanent impairment assessment if residual instability ### High-Yield Exam Points **Indications You Must Know**: 1. Failed arthroscopic Bankart repair (most common) 2. Revision shoulder stabilization 3. Glenoid bone loss 15-20% (not enough for Latarjet) 4. Engaging Hill-Sachs requiring remplissage 5. Surgeon preference in contact athletes **Technique Decisions Examiners Ask**: 1. **Subscapularis**: Osteotomy vs peel vs tenotomy - know pros/cons, state preference (peel) 2. **Fixation**: Anchors vs transosseous - know both techniques, state preference (anchors) 3. **Capsulotomy**: Vertical vs T - know indications for each (vertical preferred) 4. **Capsular shift**: When indicated (persistent laxity after Bankart), how much (5-10mm) **Numbers You Must Know**: - Recurrence rate: 5-10% open, 10-15% arthroscopic - Subscapularis failure: 5-15% overall, 2-5% osteotomy, 15-20% tenotomy - ER loss: 10-20%, average 10° - Axillary nerve injury: 1-2% transient, <1% permanent - Bone loss threshold: >20-25% requires Latarjet **Danger Anatomy**: - Axillary nerve: 5-7cm distal to inferior glenoid on anterior subscap - Musculocutaneous nerve: Enters conjoint 3-8cm from coracoid (variable) - Anterior circumflex vessels: Mark axillary nerve level - Cephalic vein: Take laterally (preserves drainage) **Postoperative Protocol**: - Sling 6 weeks (vs 3-4 weeks arthroscopic) - NO ER past neutral for 6 weeks (protects subscapularis) - Active ROM 6-8 weeks - Strengthening 12 weeks - Sport 4-6 months **Viva Scenario Response Template**: "For open Bankart repair, my indications are failed arthroscopic, revision cases, and bone loss 15-20%. I use deltopectoral approach with beach chair positioning. For subscapularis, I prefer PEEL technique - elevate insertion from lesser tuberosity and repair through transosseous tunnels. This balances exposure with secure repair. Osteotomy is strongest but higher morbidity. Tenotomy has unacceptable 15-20% failure rate. I use 3-4 suture anchors on the glenoid face at 45° deadman angle. Pass sutures through labrum AND capsule for capsulolabral shift. Tie in 30-40° ER to set appropriate tension. Critical steps: assess bone loss intraop - abort if >25%. Protect axillary nerve - limit inferior dissection, use anterior circumflex vessels as landmark. Secure subscap repair tested to 40° ER intraop. Postop protocol protects subscapularis: sling 6 weeks, no ER past neutral for 6 weeks. Active ROM 6-8 weeks, strengthening 12 weeks, sport 4-6 months. Complications: recurrence 5-10%, subscap failure 5-15%, ER loss 10°, axillary nerve 1-2% transient." ## Viva Scenarios with Model Answers ## Exam Day Cheat Sheet ## References 1. Stein T, Mehling AP, Reck C, et al. Long-term outcome after open Bankart repair for recurrent anterior shoulder instability. Am J Sports Med. 2021;49(1):64-71. doi:10.1177/0363546520968273 2. Bessiere C, Trojani C, Carles M, et al. The open Latarjet procedure is more reliable in terms of shoulder stability than arthroscopic Bankart repair. Clin Orthop Relat Res. 2014;472(8):2345-2351. doi:10.1007/s11999-014-3550-9 3. Hurley ET, Manjunath AK, Bloom DA, et al. Arthroscopic Bankart repair versus conservative management for first-time traumatic anterior shoulder instability. Arthroscopy. 2020;36(9):2526-2532. doi:10.1016/j.arthro.2020.04.046 4. Shaha JS, Cook JB, Song DJ, et al. Redefining "critical" bone loss in shoulder instability: functional outcomes worsen with "subcritical" bone loss. Am J Sports Med. 2015;43(7):1719-1725. doi:10.1177/0363546515578250 5. Miller SL, Hazrati Y, Klepps S, et al. Loss of subscapularis function after total shoulder replacement: a seldom recognized problem. J Shoulder Elbow Surg. 2003;12(1):29-34. doi:10.1067/mse.2003.128195 6. Porcellini G, Campi F, Pegreffi F, et al. Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment. J Bone Joint Surg Am. 2009;91(11):2537-2542. doi:10.2106/JBJS.H.01126 7. Boileau P, Villalba M, Hery JY, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8):1755-1763. doi:10.2106/JBJS.E.00817 8. Balg F, Boileau P. The instability severity index score: a simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89(11):1470-1477. doi:10.1302/0301-620X.89B11.18962 9. Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging" lesion to "on-track/off-track" lesion. Arthroscopy. 2014;30(1):90-98. doi:10.1016/j.arthro.2013.10.004 10. Provencher MT, Bhatia S, Ghodadra NS, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92 Suppl 2:133-151. doi:10.2106/JBJS.J.00906

Open Bankart Repair for Anterior Shoulder Instability

Open Bankart Repair for Anterior Shoulder Instability