Chapter 3 Instability
CHAPTER 3 | Instability
at least 2 hours for each of three dislocations (total 6 hours of total dislocation time) puts him into a cate- gory that will probably require Latarjet reconstruction. ■ Since the open Latarjet is usually performed in a beach chair position, surgeons might prefer to do their preliminary arthroscopy in the beach-chair position. This would allow them to more easily tran- sition from the arthroscopic portion of the case to the open part of the case. However, the beach-chair position for shoulder arthroscopy is well known to be a very difficult position from which to repair posterior labral or capsular pathology. Therefore, we always do the arthroscopic part of the case in the lateral decubitus position and then reposition and redrape the patient in the beach-chair position for the open procedure. The Cowboy’s Conundrum: Anterior Instability in Contact Athlete (Wide Receiver) with >20 Subluxations and Dislocations; Significant Bone Loss plus SLAP Lesion The Surgeon’s Solution: Arthroscopic SLAP Repair plus Open Latarjet Reconstruction History: ■ A 21-year-old college football player (wide receiver) with initial anterior dislocation of the left (nondomi- nant) shoulder 1½ years ago. During the past season, the shoulder dislocated or subluxed during every game, but the athlete continued to have an outstand- ing season and was voted to the All-American team. ■ He is a top professional football prospect at wide receiver. Physical Exam: ■ Positive apprehension with combined abduction and external rotation Imaging: ■ Plain radiographs demonstrate a large Hill-Sachs lesion on the AP view (Fig. 3-23A) and suggest glenoid bone loss on the axillary view (Fig. 3-23B). ■ MRI shows an ALPSA lesion (medialized Bankart lesion) (Fig. 3-24A) and a SLAP lesion (Fig. 3-24B). ■ En face view on 3D CT scan shows ~30% loss of the inferior glenoid diameter in comparison with the opposite (normal) side (Fig. 3-25). Arthroscopic Findings: ■ A type II SLAP lesion was repaired with LabralTape (Arthrex, Inc., Naples, FL) and a BioComposite PushLock anchor (Arthrex, Inc., Naples, FL) (Fig. 3-26).
■ We performed an arthroscopic repair of the posterior HAGL lesion (Fig. 3-22) and an arthroscopic SLAP repair. Then, we repositioned and reprepped the patient and did an open Latarjet reconstruction. Pearls, Pitfalls, and Decision-making: ■ This patient has 25% glenoid bone loss and plans to continue with vigorous competitive athletic activities, so he definitely requires a Latarjet reconstruction. ■ A SLAP lesion associated with anterior instability should be repaired, since SLAP repair increases the ante- rior capsular stiffness of the shoulder. And of course, the preferred means of SLAP repair is arthroscopic. ■ Because of the high incidence of additional pathology associated with anterior instability that has significant bone loss, we always do a diagnostic arthroscopy prior to the open Latarjet. If we had not done an arthros- copy in this case, we would have missed a very impor- tant component of his pathology, the posterior HAGL lesion, that likely would have remained symptomatic if it had not been discovered and repaired. In addition, we would have missed the SLAP lesion, which is a compo- nent of the anterior instability and should be repaired. ■ Total duration of dislocation can suggest whether an instability can be addressed arthroscopically or whether it will require a Latarjet reconstruction with coracoid bone graft. We have found that a total disloca- tion time of 5 hours or more generally causes enough bone compression on the glenoid and humeral sides of the joint that a Latarjet procedure will be required if one follows the usual bone loss criteria (loss of >25% of the inferior glenoid diameter requires a Latarjet). 3 In this patient, his documented dislocation time of FIGURE 3-22 Right shoulder, anterosuperolateral viewing portal. Posterior HAGL lesion (capsular split variant) has been repaired arthroscopically with side-to-side sutures. G, glenoid; H, humeral head; P, posterior capsule.
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