Chapter 3 Instability


CHAPTER 3 | Instability

Posterior (reverse) HAGL lesions may also be capsular avulsions from bone or capsular splits. Repair of posterior HAGL lesions is easier than anterior HAGL lesions because the coracoid does not obstruct the approach and there are no nearby neurovascular structures to avoid.

HAGL Conundra

The Cowboy’s Conundrum: HAGL Lesion and Bankart Lesion in the Same Patient The Surgeon’s Solution: Arthroscopic Bankart Repair and HAGL Repair History: ■ A 35-year-old man who works as an electrician. ■ He fell 6 feet from a ladder and sustained an anterior dislocation of his left shoulder. This was reduced in the emergency room 2 hours after the injury occurred. Physical Exam: ■ Strength and range of motion are normal. ■ The patient has a positive apprehension sign in a posi- tion of abduction and external rotation. Imaging: ■ X-rays showed a medium-sized Hill-Sachs lesion. There was not a bony Bankart lesion. ■ MRI scan showed a soft tissue Bankart lesion. ■ From an anterosuperolateral viewing portal (left shoulder), a HAGL lesion was unexpectedly discovered (Fig. 3-75). ■ After repair of the HAGL lesion (Fig. 3-76), the Bankart lesion was repaired. Pearls, Pitfalls, and Decision-making: ■ The HAGL lesion is most easily visualized through an anterosuperolateral portal. ■ Anchor insertion can be problematic because of the often acute angle of approach to the humerus (“killer angle”) through an accessory anterior portal (Fig. 3-77). ■ Even if is a Bankart lesion is present, the surgeon must be vigilant and search for a HAGL lesion. We have fre- quently seen Bankart lesions and HAGL lesions in the same patient. Arthroscopic Findings: ■ A Bankart lesion was identified.

Video 3-11

The Cowboy’s Conundrum: Anterior Dislocation with HAGL Lesion and SupraspinatusTendonTear The Surgeon’s Solution: Arthroscopic HAGL Repair and Supraspinatus Repair History: ■ This is a 67-year-old female who dislocated her right shoulder during an exercise class. It was reduced in the emergency room 45 minutes later. ■ This was her second episode of anterior dislocation. The first occurred 20 years earlier. ■ Because of persistent pain, her family doctor ordered an MRI and found that she had a rotator cuff tear. Physical Exam: ■ Full range of motion, but guards with overhead motion ■ Mild weakness with resisted ER ■ Apprehension with combined abduction and external rotation Imaging: ■ Plain x-rays were normal. ■ MRI scan showed that the patient had a full-thickness tear of the supraspinatus tendon (Fig. 3-78). FIGURE 3-75  View of HAGL lesion from an anterosuperolateral viewing portal. The muscle of the subscapularis is visible anteriorly. SSc, subscapularis muscle; H, humeral head; HAGL, humeral avulsion of the glenohumeral ligaments.

Video 3-12

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