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.
Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Mumbai, India
Conflicts of Interest and Source of Funding: The author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Address correspondence and reprint requests to Deepak N. Bhatia, MS (Orth), DNB (Orth), Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Parel, Mumbai 400012, India. E-mail: firstname.lastname@example.org.