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Open Surgery

Open surgery for instability remains an acceptable method of treatment when the surgeon lacks the equipment, experience, or technical expertise to perform an arthroscopic repair. Furthermore, open surgery is indicated in situations where current arthroscopic methods are likely to fail—namely, in the setting of large bone or soft tissue deficiencies or in the context of revision surgery.

The degree of bony deficiency or capsular laxity that obviates an open procedure continues to be debated in the literature. Rowe’s suggestion that glenoid loss of up to 30% was amenable to a soft-tissue procedure was largely based on qualitative visual inspection and anectodal experience. Burkhart and DeBeer have reported that significant bony loss of the anterior glenoid at the time of arthroscopy, termed an “inverted pear glenoid,” was associated with a high failure rate after arthroscopic stabilization.

A growing body of evidence is bringing attention to the significance of alterations in biomechanical stability brought about by glenoid and or/humeral bone loss or dysplasia. For instance, Gerber has provided a method to quantify the risk of dislocation based on the degree of glenoid bone loss using three-dimensional CT scan to assist in operative planning.

Specifically, if the length of the glenoid defect exceeds the maximum radius of the glenoid, the force required for anterior dislocation is reduced by 70%. Based on this criteria, Gill and Warner has reported favorable results (ASES 2004, Neer award paper), on surgical reconstruction of patients with recurrent instability using intra-articular tricortical iliac crest bone graft contoured to restore the bony architecture of the deficient glenoid.

Most open procedures employ a combination of “anatomic” and “non-anatomic” repair based largely on Speer’s work that indicated in a cadaveric model that injury to both the labrum and capsule was a necessary prerequisite for complete dislocation. For this reason, most open procedures involve, for example, a classic Bankart repair (anatomic) in conjunction with a capsular shift (non-anatomic).

Nonanatomic surgical procedures utilize a bony or soft-tissue checkrein to block excessive translation and substitute for capsulolabral or bony injury. The Bristow and Latarjet, for instance, transfer either the tip or entire coracoid process to the anterior glenoid to buttress the humerus from subluxating anteriorly . The Magnuson-Stack procedure is an advancement of the subscapularis that was popularized by DePalma. Finally, the Putti-Platt procedure, which was reported by Osmond-Clarke in 1948 , is an imbrication and shortening of the subscapularis.

Many series have reported excellent outcomes with non-anatomic type stabilizations, but the reported complications such as loss of motion, recurrent instability, and premature arthritis have led many North American surgeons to avoid them as an initial form of treatment

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