Chapter 3 Instability


CHAPTER 3 | Instability

Pearls, Pitfalls, and Decision-making: ■ This patient’s posterior HAGL lesion was not detected on pre-op MRI. These lesions are difficult to diagnose on MRI, and the capsule, including its humeral attachment, must be thoroughly evaluated arthroscopically. ■ Posterior HAGL lesions are easier to repair than ante- rior HAGL lesions because they are more accessible; the surgeon does not have to work around the cora- coid and important neurovascular structures in carry- ing out the repair. ■ If there is a posterior labral tear in addition to the posterior HAGL, the labrum should be repaired first (working through the defect of the posterior HAGL lesion) and the posterior HAGL should be repaired last. ■ In this case, there was also an anterior Bankart lesion. It should be repaired first of all before the posterior structures are repaired, as the anteroin- ferior part of the shoulder is the tightest and least accessible. After that, the posterior (Kim) lesion should be repaired, followed by repair of the poste- rior HAGL lesion. ■ The pathology in this case probably represents both chronic and acute trauma. The bench press injury probably caused the posterior HAGL and posterior Kim lesions (because of the direction of the force dur- ing bench press). The Bankart lesion was probably sus- tained years earlier as the football-related injury that the patient described.

FIGURE 3-89  Left shoulder, anterosuperolateral viewing portal. The Kim lesion is being repaired with one double-loaded suture anchor.

■ The posteroinferior labral tear (Kim lesion) was repaired with one double-loaded SutureTak anchor (Arthrex, Inc., Naples, FL) (Fig. 3-89). ■ The capsular split HAGL lesion was repaired with inter- rupted side-to-side sutures (Fig. 3-90A,B).

FIGURE 3-90  A: A Labral Scorpion suture pastor (Arthrex, Inc., Naples, FL) is being used to pass a suture through one leaf of the posterior capsular split of the posterior HAGL lesion. B: After three side-to-side sutures, the posterior capsular defect has been completely repaired.

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