Treatment of shoulder instability: Bankart repair, open, and arthroscopic

The Bankart procedure is indicated when the labrum and capsule are separated from the glenoid rim or the capsule is thin; it is, however, technically difficult. Keys to the success of this procedure are: (1) maximizing healing potential by abrading the scapular neck, (2) restoring glenoid concavity, (3) securing anatomical capsular fixation at the edge of the glenoid articular surface, and (4) re-creating physiological capsular tendon by superior and inferior capsular advancement and imbrication; supervised goal-oriented rehabilitation also is essential.

Open bankart repair

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Make an incision along the Langer lines beginning 2 cm distal and lateral to the coracoid process and going inferiorly to the anterior axillary crease.
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Develop the deltopectoral interval retracting the deltoid and cephalic vein laterally and the pectoralis major muscle medially. Leave the conjoined tendon intact and retract it medially.
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Split the subscapularis tendon transversely in line with its fibers at the junction of the upper two thirds and lower one third of the tendon and carefully dissect it from the underlying anterior capsule. Maintain the subscapularis tendon interval with a modified Gelpi retractor (Anspach, Inc, Lake Park, FL) and place a three-pronged retractor medially on the glenoid neck.
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Make a horizontal anterior capsulotomy in line with the split in the subscapularis tendon from the humeral insertion laterally to the anterior glenoid neck medially. Place stay sutures in the superior and inferior capsular flaps at the glenoid margin ( Fig. 18.1 ).
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Insert a narrow humeral head retractor and retract the head laterally. Elevate the capsule on the anterior neck subperiosteally. Leave the labrum intact if it is still attached. Decorticate the anterior neck to bleeding bone with a rongeur.
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Drill holes near the glenoid rim at approximately the 3-, 4-, and 5:30-o’clock positions, keeping the drill bit parallel to the glenoid surface ( Fig. 18.2 ).
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Place suture anchors in each hole and check for security of the anchors. During this portion of the procedure, maintain the shoulder in approximately 90 degrees of abduction and 60 degrees of external rotation for throwing athletes. Maintain the shoulder in 60 degrees abduction and 30 to 45 degrees external rotation in nonthrowing athletes and other patients ( Fig. 18.3 ).
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Tie the inferior flap down in mattress fashion, shifting the capsule superiorly but not medially ( Fig. 18.4 A). The stay sutures help prevent medialization of the capsule. Shift the superior flap inferiorly, overlapping and reinforcing the inferior flap ( Fig. 18.4 B).
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Loosely close the remaining gap in the capsule. The reconstruction has two layers of reinforced capsule outside the joint ( Fig. 18.5 ).