This case series describes a surgical option for a rare, difficult problem: recurrent anterior shoulder instability when the subscapularis is completely destroyed and cannot be repaired. Most patients had multiple failed prior reconstructions. The authors transfer the pectoralis major or minor to substitute for the absent subscapularis and report outcomes at a mean of five years.
When an anterior shoulder keeps dislocating after several operations, look for a destroyed subscapularis as the missed driver of instability. The subscapularis is the key anterior/inferior stabilizer in the low range of abduction (45 degrees or less), so its complete loss leaves ligament repairs to fail over time.
Repairing the capsule alone is not enough here. You must restore a dynamic anterior restraint, and a pectoralis major transfer provides that checkrein when nothing is left to repair. Expect good outcomes in most patients, but counsel the multiply-operated shoulder that results are worse and recurrence usually follows a reinjury.
One durable teaching point: do not reach for a Bristow or other bone block when the subscapularis is gone. The coracoid screw threatens the humeral head cartilage, and a soft-tissue transfer avoids that risk.
This case series describes a surgical option for a rare, difficult problem: recurrent anterior shoulder instability when the subscapularis is completely destroyed and cannot be repaired. Most patients had multiple failed prior reconstructions. The authors transfer the pectoralis major or minor to substitute for the absent subscapularis and report outcomes at a mean of five years.
When an anterior shoulder keeps dislocating after several operations, look for a destroyed subscapularis as the missed driver of instability. The subscapularis is the key anterior/inferior stabilizer in the low range of abduction (45 degrees or less), so its complete loss leaves ligament repairs to fail over time.
Repairing the capsule alone is not enough here. You must restore a dynamic anterior restraint, and a pectoralis major transfer provides that checkrein when nothing is left to repair. Expect good outcomes in most patients, but counsel the multiply-operated shoulder that results are worse and recurrence usually follows a reinjury.
One durable teaching point: do not reach for a Bristow or other bone block when the subscapularis is gone. The coracoid screw threatens the humeral head cartilage, and a soft-tissue transfer avoids that risk.