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When the pre-operative investigation suggests that the damage to the cartilage/bone structure is extensive with a bone defect either on glenoid side or on the humeral side, or if there is evidence of damage to the attachment of the capsule on the humeral side or indeed there is no structural damage but a very loose and ‘baggy’ capsule, then an open repair is considered.
Also open surgery with a bone block procedure is considered in cases of recurrent dislocation with larage bone defect, or after a failed surgery. The bone is usually harvested from corocoid or sometimes from iliac crest. (Latarjet procedure).
The aim of the operation is to reattach the cartilage element back to the rim of the socket and to tighten the soft tissue and capsule element of the shoulder.
The operation is usually performed as a day case procedure under general anesthetic. One may supplement this with a nerve block or using local anaesthetic around the wound and inside the joint. The first step in the operation is to examine the joint under anaesthesia to assess the vulnerable directions of dislocation.
The operation is performed with the patient lying on their back in a ‘deck-chair’ position. The shoulder joint is approached via 5 cm cut in the front of the shoulder. The tendon is carefully dissected off the capsule and the
capsule is then opened with a stay suture in the lower corner.
The joint is inspected and any damage in the front of the socket (including the need for re-attachment of cartilage rim) is addressed. This may involve using a couple of bone anchors. The capsule is tightened by either double breasting or by performing a ‘corkscrew’ shift. I tend to shift the capsule from the lower portion to a much higher position such that any ‘bagginess’ in the capsule is decreased. The tendon is reattached and the wound is closed in layers.
As we are dividing the muscle it is important that this repair is looked after well and protected until it heals. Therefore, during the post-operative phase, the arm is in a sling longer than what would be necessary had the repair been done arthroscopically.
The wound is closed with sutures and water resistant dressing is applied. This is covered with a further layer of pressure dressing. The arm is then placed in a sling. You will be given information regarding wound care and information regarding various exercises you need to do. Physiotherapy will be arranged if required.
If bone block procedure is done, then a piece of coracoid is shifted from its base and placed in the inferior aspect of the glenoid and secured with one or two screws. I tend to do ‘congruent arc’ modification as promoted by Mr. De Beer of Cape Town.