High-yield overview

Deltopectoral approach with subscapularis takedown and repair | intermediate

Critical Danger Structures - NERVE Protection Essential

Axillary Nerve

Location: Passes from the quadrilateral space across the anterior surface of subscapularis and curves under its inferior border, lying closest to the joint at the inferior (6 o'clock) glenoid - typically within a finger-breadth (about 3-5mm to a few cm) of the inferior rim; the anterior circumflex humeral vessels mark its level

Protection: Keep dissection on the inferior subscapularis to a minimum, palpate the nerve and protect it with a finger or retractor during inferior capsular work, gentle subscapularis mobilization, avoid aggressive inferior Fukuda retractor placement

Musculocutaneous Nerve

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

Cephalic Vein

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

Long Head Biceps Tendon

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

Brachial Plexus

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

Mnemonic

SUBSCAPSUBSCAP Subscapularis Management Options

Hook:Examiners expect you to compare three subscapularis techniques with pros/cons and state your preference with rationale

Mnemonic

REPAIRREPAIR Steps for Open Bankart Technique

Hook:Systematic approach demonstrates understanding of critical steps and sequence - essential for operative viva

Indications for Open Bankart Repair

Primary Indications

Critical Yield Data

Failed Arthroscopic

Revision Surgery

Bone Loss 15-20%

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

Clinical Pearl

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.

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

Clinical Pearl

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

Clinical Pearl

Technical Tip: Taking cephalic vein laterally with deltoid preserves venous drainage from deltoid muscle, reducing postoperative swelling and improving patient comfort.

Dangers at This Step

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)

Clinical Pearl

Anatomic Pearl: The anterior circumflex humeral vessels ("three sisters") run transversely at the inferior subscapularis border. The axillary nerve lies just deep/inferior to them on the anterior subscapularis - ligate the vessels if needed and use them to find and protect the nerve before any inferior dissection.

Nerve Protection

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 a full-thickness bone wafer (roughly 1-1.5cm) carrying the subscapularis insertion; protect the long head of biceps laterally
Fixation: Reduce anatomically and fix with screws and/or heavy non-absorbable sutures over a bone bridge at closure
Advantages: Bone-to-bone healing, biomechanically the most robust construct at time-zero, anatomic footprint restoration
Disadvantages: Higher morbidity, small risk of osteotomy non-union/malunion, technically demanding, possible hardware prominence
Indications: Young active patients, contact athletes, revision cases (where a maximally secure construct is desired)

Option 2: Subscapularis PEEL (a reasonable default):

Technique: Sharply elevate the subscapularis insertion off the lesser tuberosity with a periosteal sleeve
Fixation: Transosseous tunnels through the lesser tuberosity, horizontal mattress sutures (or suture anchors)
Advantages: Good balance of exposure and repair strength, no hardware, reliable healing
Disadvantages: More dissection than tenotomy, requires bone tunnels/anchors
Indications: Most cases, balanced approach

Option 3: TENOTOMY:

Technique: Divide the tendon a short distance medial to its insertion, leaving a tendon cuff, and tag for repair
Fixation: Direct tendon-to-tendon repair with heavy interrupted sutures
Advantages: Simplest, fastest, least bone work
Disadvantages: Tendon-to-tendon healing relies on tendon quality; biomechanically the least robust, though comparative clinical series show outcomes similar to peel/osteotomy
Indications: Older lower-demand patients; many surgeons avoid it in young high-demand athletes on biomechanical grounds

Clinical Pearl

Decision Making: All three techniques have comparable clinical outcomes in the published comparative literature (largely from arthroplasty cohorts), so any can be defended. A common exam-safe stance is to favour PEEL or OSTEOTOMY in young high-demand patients (more robust bone/tendon-to-bone healing, better protection of internal-rotation strength) and accept TENOTOMY as simpler and adequate in lower-demand patients. State your preference and justify it - examiners reward a reasoned choice, not a dogmatic one.

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

Clinical Pearl

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 Alert

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

Clinical Pearl

Exposure Pearl: Vertical capsulotomy with a Fukuda (humeral head) retractor displacing the head and a Darrach/glenoid-neck retractor posteriorly gives excellent glenoid exposure. Keep the inferior retractor tip on bone and avoid driving it deep/inferior, where the axillary nerve is at risk.

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

Clinical Pearl

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.

Avoid Technical Failure

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

Clinical Pearl

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

Clinical Pearl

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.

Technical Errors

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

Clinical Pearl

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).

Common Errors

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

Clinical Pearl

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

Clinical Pearl

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.

Subscapularis Failure Risk

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

Clinical Pearl

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)

Clinical Pearl

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

Clinical Pearl

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.

Viva Scenarios with Model Answers

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 28-year-old professional rugby player has recurrent anterior shoulder instability despite arthroscopic Bankart repair 18 months ago. He has had 3 redislocations. CT shows 18% glenoid bone loss and a moderate Hill-Sachs lesion. How would you manage this patient? Walk me through your decision-making."

PRACTICAL APPROACH

This is a failed arthroscopic Bankart in a high-demand contact athlete with moderate bone loss (18%) - I would offer open Bankart repair with possible remplissage. **Assessment**: CT 3D reconstruction to accurately quantify bone loss (18% quoted - at threshold for bone augmentation). MRI to assess soft tissue pathology, labral tissue quality, subscapularis integrity. Clinical exam for laxity, ROM, strength. Hill-Sachs engagement test critical - does it engage in functional position? **Surgical Planning**: 18% bone loss is borderline - could do open Bankart or Latarjet. In isolation, would favor open Bankart. However, if Hill-Sachs engages (track-off lesion), need to address both sides. Options: (1) Open Bankart + remplissage for Hill-Sachs, or (2) Latarjet for bone restoration which also addresses engaging Hill-Sachs by medialized glenoid contact point. **My approach**: Open Bankart with capsulolabral repair. Assess bone loss intraoperatively - if actually >20-25%, abort and stage Latarjet. Use subscapularis peel technique for secure repair. 3-4 suture anchors on glenoid face, capsulolabral shift tied in 30-40° ER. If Hill-Sachs engages, perform remplissage (posterior capsulodesis into defect) - can do arthroscopically same setting or open through separate posterior portal. **Postop**: Sling 6 weeks protecting subscapularis. No ER past neutral 6 weeks. Progressive ROM and strengthening. Return to rugby 6 months minimum, ideally 9 months. Counsel on recurrence risk 5-10% but lower than repeat arthroscopic which would be 20%+. **Alternative**: Given high-demand contact athlete and borderline bone loss, could argue for Latarjet as definitive solution with lowest recurrence risk 1-5%. I would discuss both options - Latarjet more invasive but lower recurrence, open Bankart less invasive but higher recurrence than Latarjet. Patient preference important.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"You're performing an open Bankart repair. You've taken down the subscapularis with a peel technique. Now ready to repair the subscapularis at the end of the case. Walk me through your subscapularis repair technique and how you assess adequacy of the repair."

PRACTICAL APPROACH

Subscapularis repair is the MOST CRITICAL step determining outcome. Failure leads to recurrent instability and internal rotation weakness. **Preparation**: I've tagged the subscapularis with 2-0 Ethibond horizontal mattress sutures at time of takedown. Typically 3-4 sutures for secure hold. Subscapularis mobilized to allow advancement to lesser tuberosity without tension. **Peel Repair Technique**: **Step 1 - Bone Preparation**: Prepare lesser tuberosity to bleeding bone using curette. Remove any remaining tissue/periosteum from peel to create fresh bone surface for healing. **Step 2 - Transosseous Tunnels**: Drill 3-4 transosseous tunnels through lesser tuberosity using 2.5-3.0mm drill bit. Tunnels parallel to each other, 5-7mm apart. Entry on tuberosity, exit through lateral cortex of proximal humerus. Tunnels oriented to match suture positions on subscapularis. **Step 3 - Suture Passage**: Pass tagged sutures (#2 Ethibond) through transosseous tunnels using free needle or suture passer. Retrieve sutures on lateral cortex. Creates horizontal mattress configuration through bone. **Step 4 - Reduction and Tying**: Reduce subscapularis to lesser tuberosity with arm in NEUTRAL ROTATION (not IR which overtightens, not ER which lengthens). Tie sutures over lateral bone bridge with sufficient tension to appose tendon to bone without overtightening. Multiple interrupted horizontal mattress sutures for strength. **Adequacy Assessment - CRITICAL INTRAOPERATIVE TESTS**: **Test 1 - External Rotation**: Passively externally rotate arm at side. Should reach 40° comfortably without excessive tension on repair. Less than 40° = overtightened = postop stiffness. More than 60° with laxity = undertightened = failure risk. **Test 2 - Lift-off Test**: Place hand behind back. Should have resistance to lifting hand away from back indicating subscapularis function. Lack of resistance = repair gap or failure. **Test 3 - Belly-Press Test**: Press hand against belly. Should maintain wrist extension. Wrist flexion = weak subscapularis indicating repair problem. **Test 4 - Direct Palpation**: Palpate repair. Should feel tendon firmly opposed to bone without gap. Gaps indicate inadequate reduction or suture failure. **If Tests Fail**: If cannot achieve 40° ER or tests show weakness, reassess repair. Options: (1) Release scar tissue restricting ER, (2) Add sutures if inadequate, (3) Reposition if too much tension, (4) Accept some limitation if tissue quality poor. **Documentation**: Record ER achieved, subscapularis strength testing results. Guides postoperative expectations and therapy.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"Compare and contrast the three subscapularis management options for open Bankart repair. Which do you prefer and why? What are the specific indications, advantages, and disadvantages of each technique?"

PRACTICAL APPROACH

Three subscapularis options: lesser tuberosity OSTEOTOMY, subscapularis PEEL, and TENOTOMY. Each has specific indications, pros/cons. Understanding all three is essential as choice impacts outcome. **OPTION 1: LESSER TUBEROSITY OSTEOTOMY** **Technique**: Use osteotome to create full-thickness bone wafer 10-15mm wide, 1-1.5cm thick including subscapularis insertion. Protect long head biceps laterally. Tag bone with sutures. At closure, reduce bone fragment anatomically, fix with 2-3 partially threaded 4.0mm screws. **Advantages**: (1) Most robust construct - bone-to-bone healing superior to tendon at time-zero, (2) Anatomic restoration - preserves the insertion footprint, (3) Reliable healing on radiographs, (4) Good long-term strength data, (5) Allows full subscapularis mobilization. **Disadvantages**: (1) Technically demanding - risk of inadequate bone or fracture, (2) Small risk of osteotomy non-union/malunion, (3) Hardware complications - screw prominence, loosening, (4) Longer surgery time, (5) Higher morbidity overall. **Indications**: (1) Young high-demand athletes (contact sports), (2) Revision surgery where strongest repair needed, (3) Poor tissue quality requiring bone fixation, (4) Surgeon comfortable with technique and accepts morbidity. **OPTION 2: SUBSCAPULARIS PEEL** (MY PREFERENCE) **Technique**: Elevate subscapularis insertion from lesser tuberosity as full-thickness periosteal sleeve using sharp dissection. Tag with multiple #2 Ethibond sutures. At closure, drill 3-4 transosseous tunnels 2.5-3.0mm through lesser tuberosity. Pass sutures through tunnels, tie over lateral bone bridge with arm in neutral. **Advantages**: (1) Good balance of exposure and repair strength, (2) Bone-to-tendon healing through tunnels, more robust than tendon-to-tendon, (3) No hardware - avoids implant complications, (4) Reliable healing, (5) Less morbidity than osteotomy, (6) Widely applicable. **Disadvantages**: (1) More dissection than tenotomy, (2) Requires drilling tunnels - technical step, (3) Slightly higher failure than osteotomy (but much lower than tenotomy), (4) Periosteal sleeve may be thin in revision setting. **Indications**: (1) Most cases - excellent balance technique, (2) Primary or revision Bankart, (3) Most activity levels, (4) My default choice for open Bankart. **OPTION 3: TENOTOMY** **Technique**: Divide subscapularis tendon 1cm medial to insertion using sharp knife. Tag ends with #2 Ethibond sutures. At closure, direct end-to-end repair with interrupted sutures, arm in neutral rotation. **Advantages**: (1) Easiest, fastest technique, (2) Least dissection - less trauma, (3) No bone work required, (4) Good in older lower-demand patients, (5) Less risk of stiffness (some argue). **Disadvantages**: (1) Tendon-to-tendon healing is biomechanically the least robust, (2) Relies on tendon quality - unpredictable in poor tissue, (3) Risk of lengthening and IR weakness if it fails, (4) Many surgeons avoid it in revision or high-demand cases. **Indications**: (1) Older patients, (2) Lower-demand patients, (3) Where simplicity is preferred and tissue quality is good. **Note**: comparative clinical series do not show tenotomy to have a clearly worse failure rate than peel/osteotomy - the caution against it in athletes is biomechanical rather than proven on outcomes. **MY PREFERENCE AND RATIONALE**: I prefer subscapularis PEEL for the majority of cases. It provides a good balance of: - Adequate glenoid exposure (equal to osteotomy) - A secure repair through transosseous bone tunnels (more robust than tendon-to-tendon) - No hardware complications (advantage over osteotomy) - Reliable healing across ages and activity levels - Lower morbidity than osteotomy (no non-union risk) I reserve OSTEOTOMY for young high-demand contact athletes where I want the most robust bone-to-bone construct and accept the added morbidity. I am comfortable with TENOTOMY in older lower-demand patients, acknowledging the comparative literature shows similar outcomes. **Key Principle**: Subscapularis repair integrity determines outcome. Technique choice should match patient demands and surgeon experience. The honest exam answer is that the three are comparable in published clinical series, so pick one and justify it - examiners reward a reasoned, evidence-aware choice.

Exam Day Cheat Sheet

Open Bankart Repair - Rapid Recall for Exams

Clinical summary

References

Pelet S, Jolles BM, Farron A. Bankart repair for recurrent anterior glenohumeral instability: results at twenty-nine years' follow-up. J Shoulder Elbow Surg. 2006;15(2):203-207. doi:10.1016/j.jse.2005.06.011
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
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
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
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
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
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
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
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
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
Fabre T, Abi-Chahla ML, Billaud A, et al. Long-term results with Bankart procedure: a 26-year follow-up study of 50 cases. J Shoulder Elbow Surg. 2010;19(2):318-323. doi:10.1016/j.jse.2009.06.010
Aibinder WR, Bicknell RT, Bartsch S, Scheibel M, Athwal GS. Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy. J Shoulder Elbow Surg. 2019;28(10):1942-1947. doi:10.1016/j.jse.2019.02.022
Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg. 2014;23(9):1309-1317. doi:10.1016/j.jse.2013.12.009

Theme	Global consensus / named-society position
First-time dislocation in young athlete	High redislocation risk untreated; early stabilisation increasingly favoured (AAOS, BOA, ESSKA/ISAKOS)
Procedure selection	Use validated risk tools (ISIS, glenoid track / on-track-off-track) rather than a single threshold
Glenoid bone loss	Bone block (Latarjet) once loss approaches/exceeds 20-25%; subcritical loss worsens outcomes (Shaha)
Antibiotic prophylaxis	Single dose of a first-generation cephalosporin (e.g. cefazolin) within 60 min of incision; glycopeptide for beta-lactam allergy or MRSA risk - consistent across SIGN, NICE, AAOS, WHO surgical-site-infection guidance

Open Bankart Repair for Anterior Shoulder Instability

Critical Danger Structures - NERVE Protection Essential

Axillary Nerve

Musculocutaneous Nerve

Cephalic Vein

Long Head Biceps Tendon

Brachial Plexus

SUBSCAPSUBSCAP Subscapularis Management Options

REPAIRREPAIR Steps for Open Bankart Technique

Indications for Open Bankart Repair

Primary Indications

Secondary Indications

Contraindications

Preoperative Assessment

Critical Surgical Anatomy

Deltopectoral Interval Anatomy

Clavipectoral Fascia and Deep Structures

Subscapularis Muscle-Tendon Unit

Glenohumeral Joint Anatomy

Neurovascular Danger Zones

Nerve Protection Strategy

Detailed Operative Technique

Step 1: Patient Positioning and Draping

Step 2: Skin Incision and Deltopectoral Interval

Dangers at This Step

Step 3: Clavipectoral Fascia and Exposure

Nerve Protection

Step 4: Subscapularis Takedown Decision

Step 5: Subscapularis Mobilization and Tagging

Axillary Nerve Alert

Step 6: Capsulotomy and Joint Exposure

Step 7: Pathology Assessment and Bone Loss Quantification

Avoid Technical Failure

Step 8: Labral Mobilization and Glenoid Preparation

Step 9: Anchor Placement or Drill Holes

Technical Errors

Step 10: Capsulolabral Repair

Common Errors

Step 11: Capsular Closure and Imbrication

Step 12: Subscapularis Repair - CRITICAL STEP

Subscapularis Failure Risk

Step 13: Stability Testing and Assessment

Step 14: Wound Closure

Step 15: Postoperative Protocol

Complications Recognition and Management

Most Important Complications to Prevent

Evidence-Based Practice and Exam Pearls

Key Evidence Points

Key Evidence (Verified)

Bankart repair for recurrent anterior glenohumeral instability: results at twenty-nine years' follow-up

Redefining 'critical' bone loss in shoulder instability: functional outcomes worsen with 'subcritical' bone loss

Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from 'engaging/non-engaging' to 'on-track/off-track' lesion

The instability severity index score: a simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation

The open Latarjet procedure is more reliable in terms of shoulder stability than arthroscopic Bankart repair

Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy

Guidelines, Registries & Global Practice

High-Yield Exam Points

Viva Scenarios with Model Answers

Clinical Decision Scenarios

Exam Day Cheat Sheet

Open Bankart Repair - Rapid Recall for Exams

References