Chapter 3 Instability

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CHAPTER 3 | Instability

external rotation on the operated shoulder will be half that on the opposite shoulder. At 3 months postopera- tive, the patient begins strengthening with TheraBands. At 6 months, he or she progresses to weight lifting in the gym if the graft remains in good position and shows early signs of consolidation. Contact sports or heavy labor are generally allowed when the bone graft appears radiographically healed, which is usually 9 to 12 months postoperative.

Latarjet Conundra

The Cowboy’s Conundrum: Anterior Instability with 30% Glenoid Bone Loss and Moderate-sized Hill-Sachs Lesion The Surgeon’s Solution: Diagnostic Arthroscopy plus Open Latarjet Reconstruction History: ■ A 20-year-old college soccer player fell playing soc- cer 2 years ago and dislocated his right shoulder. It was reduced 2 hours later in the emergency room. Since that time, he has had four more dislocations and hundreds of subluxations. It now subluxes in his sleep. Physical Exam: ■ Full range of motion, but guards with overhead motion ■ Normal strength ■ Apprehension with combined abduction and external rotation Imaging: ■ X-rays show an anterior bony Bankart lesion (Fig. 3-17). ■ 3D CT scan shows 30% glenoid bone loss with step-off and partial resorption of anterior fragment (Fig. 3-18). Arthroscopic Findings: ■ Arthroscopic measurements with a calibrated probe confirmed 30% glenoid bone loss with an obvi- ous “inverted pear” configuration of the glenoid (Fig. 3-19). The bone fragment was atrophic and not united to the glenoid. ■ There was a moderate-sized Hill-Sachs lesion. The Hill-Sachs engaged the anterior glenoid rim in 45° of abduction plus 30° of external rotation (Fig. 3-20).

FIGURE 3-17  Axillary x-ray shows obvious bone deficiency of the anterior glenoid.

Video 3-3

■ There were no additional lesions that needed to be addressed arthroscopically. ■ Based on bone loss criteria (>25% glenoid bone loss), we performed an open Latarjet reconstruction.

FIGURE 3-18  3D CT en face projection of the glenoid shows an atrophic and partially resorbed bone fragment of the anterior glenoid that is medially displaced. The glenoid bone defect measures 30% of the inferior glenoid diameter.