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CURRENT CONCEPTS

Formal postoperative rehabilitation commenced at 2 weeks

with institution of gentle passive range of motion (ROM) limited
to 90 degrees of flexion and abduction with “subscapularis

precautions” (no active internal rotation or passive external
rotation beyond neutral) x 6 weeks. Sling immobilization was

discontinued at 6 weeks with commencement of progressive
active ROM and strengthening thereafter.

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Plain film imaging was obtained (Figure 1). MRI demonstrated
a recurrent Bankart lesion with further capsulolabral injury

consistent with an anterior labral periosteal sleeve avulsion
(ALPSA) as well as insufficiency and near complete fatty

degeneration of the subscapularis.(Figure 2,3) By both CT
and MRI anterior glenoid bone loss was calculated to be 22%
using the circle method.(Figure 4)

A decision was made to proceed with revision stabilization
utilizing a fresh oseochondral distal tibia allograft for bony
glenoid reconstruction which was fixated utilizing 2 parallel
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3.5mm fully threaded cortical screws with a washer (Synthes
Inc, West Chester, PA, USA).(Figure 5) as described by

Provencher, et al.

As the subscapularis was not able to be mobilized or repaired,
a pectoralis transfer was performed. A modification of the

technique described by Resch, et al was performed based
on the anatomic study of Fung, et al where the anterior

and posterior leaflets of the pectoralis major attachment
to the humerus were separated and the anterior leaflet
(including the clavicular head and upper 3 to 5 sternal head

attachments) was mobilized and transferred.(Figure 6) The
split pectoralis was then passed subcoracoid, anterior to the

musculocutaneous nerve and posterior to the conjoint tendon
and was secured to the lesser tuberosity with two 4.5mm

double-loaded suture anchors (Arthrex Inc, Naples, FL, USA).

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ISAKOS NEWSLETTER 2013: Volume II 31