Chapter 3 Instability

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CHAPTER 3 | Instability

The Cowboy’s Conundrum: Anterior Instability with Significant Bone Loss plus SLAP Lesion and Posterior HAGL Lesion The Surgeon’s Solution: Arthroscopic Posterior HAGL Repair; Arthroscopic SLAP Repair; Open Latarjet Reconstruction History: ■ An 18-year-old male soccer player who has just com- pleted his senior season in high school and plans to play college soccer. ■ In the past 2 years, he has sustained three anterior dis- locations, each requiring closed reduction. Each time, the shoulder was “out” for ~2 hours before the closed reduction. He has also had ~10 subluxation episodes. ■ Apprehension with abduction/external rotation, even at low angles of abduction Imaging: ■ X-rays show a moderate-sized Hill-Sachs lesion. ■ MRI shows an ALPSA (anterior labral periosteal sleeve avulsion) lesion with a type II SLAP lesion. ■ 3D CT scan shows 25% loss of the inferior glenoid diameter. Arthroscopic Findings: ■ Type II SLAP lesion with unstable biceps root. ■ PosteriorHAGL lesion(capsular split variant) (Fig. 3-21). ■ 25% glenoid bone loss. ■ Moderate-sized Hill-Sachs lesion. Physical Exam:

Video 3-4

Pearls, Pitfalls, and Decision-making: ■ We always perform arthroscopy prior to doing an open Latarjet for two reasons: 1. To confirm the percentage bone loss by direct measurement 2. To arthroscopically address any additional pathol- ogy (e.g., SLAP repair, posterior Bankart repair, pos- terior HAGL repair) ■ If glenoid bone loss is >25%, we perform Latarjet. ■ If glenoid bone loss is <25%, we consider arthroscopic Bankart repair ± arthroscopic remplissage (remplis- sage is added if direct measurements and calculations reveal that the Hill-Sachs lesion is “off-track”). FIGURE 3-19  Right shoulder, anterosuperolateral viewing portal. The glenoid has an “inverted pear” configuration. The anterior glenoid bone fragment is medially displaced. G, glenoid; H, humeral head.

FIGURE 3-20  Right shoulder, anterosuperolateral viewing portal. The Hill-Sachs lesion is “perched” at the anterior margin of the inverted pear glenoid. G, glenoid; HSL, Hill-Sachs lesion.

FIGURE 3-21  Right shoulder, anterosuperolateral viewing portal. A posterior HAGL lesion (capsular split variant) is identified. G, glenoid; H, humeral head; P, posterior capsule.