title: Dual-window subscapularis-sparing approach: a new surgical technique for combined reconstruction of a glenoid bone defect or bankart lesion associated with a HAGL lesion in anterior shoulder instability.
abstract: Combined bankart lesion and humeral avulsion of glenohumeral ligament lesion (HAGL) is a well-described pathologic complex in anterior shoulder instability; open surgical approaches with and without arthroscopic assistance have been suggested for simultaneous 1-stage repair of these lesions. Presence of a significant glenoid bone defect (inverted-pear glenoid) adds to the complexity of the problem and necessitates a bony reconstruction procedure. Open surgical approaches described for management of this combined lesion complex in anterior shoulder instability necessitate a subscapularis-cutting approach; suboptimal healing of the tenotomized subscapularis and subsequent delayed rehabilitation predisposes to late subscapularis dysfunction, and this compromises clinical outcomes. This study describes a new surgical technique that utilizes a dual-window approach through the subscapularis muscle; the dual window enables access to the glenoid and humeral lesions without the need for a subscapularis tenotomy. The approach can be used to perform a congruent-arc Latarjet procedure (for glenoid bone defects) or a Bankart repair (for capsulolabral lesions), in combination with a HAGL repair. Preliminary arthroscopy is essential to identify significant bone defects and HAGL lesions. The dual-window approach for reconstruction of the lesions involves (1) a lateral "subscapularis-sparing" window to identify and repair the HAGL lesion; (2) a medial "subscapularis muscle-splitting" window to perform either a glenoid capsulolabral reconstruction or a congruent-arc Latarjet procedure; and (3) a balanced inferior capsular shift and lateralization procedure of the glenohumeral capsule. Technical tips and guidelines to avoid complications are discussed, and a rehabilitation protocol is presented.
authors.affiliation: Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India. thebonesmith@gmail.com
authors.forename: Deepak N
authors.initials: DN
authors.lastname: Bhatia
mesh_terms: D001182:Arthroscopy; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D008023:Ligaments, Articular / Q000293:injuries / Q000601:surgery*; D018482:Muscle, Skeletal / Q000601:surgery; D019637:Orthopedic Procedures / Q000379:methods*; D012785:Shoulder Joint / Q000601:surgery*