Garcia, José Carlos Jr., Mendes, Berriel Ricardo,
Cindy Yukie Nakano, Cavalcante Paulo
(Sao Paulo, SP, Brésil)
Surgical procedures to treat anterior shoulder instability are essentially divided into those for significant bone loss and those without relevant bone loss. However, there is a gray area between these procedures that would not require bone grafting but would benefit from improved stabilization mechanisms. This study evaluates a technique based on the triple soft tissue block, the dynamic anterior stabilization of the shoulder, using an adjustable button.
Surgical technique:
The patient is placed in the beach chair position under general anesthesia with an interscalene block. A joint inventory is performed through the standard posterior portal. A needle should be directed to the 3-4 o’clock position (right shoulder) on the glenoid through the subscapularis. Next, an antero-infero-lateral portal is established by an outside-in technique. As an external reference, it is located 1-2 cm below and slightly lateral to the standard anterior portal. After that, through this same portal, a gentle division is made in the middle of the subscapularis tendon in the direction of its fibers using Kelly forceps and completed with electrocautery (Fig.2). From this portal, the neck of the glenoid is cleaned, and the subchondral bone is exposed.
An antero-lateral portal is created to access the rotator interval and the bicipital groove. The rotator interval is opened. Through this portal, a Metzenbaum scissor is introduced and directed to the bicipital groove to open it. The surgeon feels a different resistance when the scissor finishes opening. This should be opened enough so that the LHBT tendon can be easily displaced. A Kocher forceps is inserted from the antero-infero-lateral portal above thesubscapularis tendon, and the LHBT tendon is held. The LHBT tenotomy is performed, and this tendon is exteriorized through the antero-infero-lateral portal. The LHBT is sutured with Krakow technique with the button wires. After suturing, the diameter of the biceps is measured. An arthroscopy cannula is inserted into the antero-infero-lateral portal, passing through the subscapularis division. A drilling guide is inserted at 3 or 4 o’clock on the anterior glenoid rim near the joint. It is important to be less than 5mm medial to its edge to avoid instability. Then, a cannulated drill with the measured diameter of the biceps (usually 5 to 6 mm) is used to drill a hole in the position indicated by the guide, to a depth of 2 cm. The button guide is then passed through this pre-drilled hole to drill to the opposite cortex. After that, the cannula is removed, and the button with the sutured LHBT is inserted into the hole, through the subscapularis division. The LHBT is pulled into the hole and fixed. External rotation is performed to test if the LHBT is free through the subscapularis division. The cannula is reinserted through the antero-infero-lateral portal, and with 2 soft tissue 1.5mm all-suture anchors, one above and one below the LHBT on the glenoid, a modified Bankart repair is performed.
In conclusion, this current study, the proposed procedure demonstrated effectiveness and safety, being a viable option for treating anterior shoulder instability with glenoid bone loss of less than 20% and especially beneficial for athlete