Objective: Full arthroscopic treatment of severe anterior shoulder instability due to glenoid bone loss, Hill-Sachs lesion and irreparable ligament damage.
Indications: Recurrent anterior dislocations or subluxations, previously failed Bankart repairs; patients with anterior glenoid bone loss, Hill-Sachs defect; patients with irreparable damage to soft tissues of labrum, capsule and ligaments; patients with chronic humeral avulsion of glenohumeral ligament (HAGL lesion); combinations of lesions above; young contact sport athletes, where Bankart repairs have high failure rates.
Contraindications: Presence of (arthroscopically confirmed) good preconditions for Bankart repair: good quality of labrum, capsule and ligament, labrum still present, no or minimal bone loss of glenoid, no engaging Hill-Sachs. Lack of requirements for complex arthroscopic procedure (e.g., special instruments and skills).
Surgical technique: Diagnostic arthroscopy. Removal of anterosuperior and superior capsule, middle glenohumeral ligament, anterior labrum. Preparation of glenoid neck, debridement. Opening of rotator interval. Preparation of coracoid process and conjoint tendons. Subdeltoid preparation of anterior coracoid with arthroscope moved to anterolateral portal. Tenotomy of pectoralis minor. Arthroscopic split of subscapularis tendon via deep anteromedial portal. Predrilling of 2 holes through coracoid, insertion of 2 special washers into predrilled holes ("top hats"). Arthroscopic osteotomy of coracoid at base. Mounting of coracoid to special coracoid cannula. Manipulation of coracoid/conjoint tendon through subscapularis to glenoid neck, prefixation with wires. Fixation of coracoid after drilling with cannulated special screws.
Postoperative management: Immobilization in a sling on postoperative day 1; pain-controlled active range of motion without limit starting postoperative day 2. Sling during the night for 4 weeks.
Results: Between 2007 and June 2013, 210 operations were performed. No intraoperative conversion to open operative technique. Revision required in 10 patients with postoperative complications. No intraoperative or neurovascular complications.