Chapter 3 Instability

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CHAPTER 3 | Instability

FIGURE 3-104  Posterior viewing portal. A: The repaired capsule appears to be physiologically tensioned. B: After repair, the inferior capsule appears normal with no visible defects. G, glenoid; H, humeral head.

Pearls, Pitfalls, and Decision-making: ■ In most anterior HAGL lesions, the biggest problem is getting an angle of approach for anchor place- ment that is not so oblique that the bone cuts out or the drill skives off the bone. For HAGL lesions in the 4 o’clock to 5 o’clock region of the humeral neck (where most HAGL lesions are located), this area must be approached through a trans-sub- scapularis (5 o’clock) working portal. In this case, the lesion was so far inferior (5:30 to 6:30) that the best angle of approach for anchor placement was through a posteroinferior (7 o’clock) working portal. ■ For any HAGL lesion, if a satisfactory angle of approach cannot be achieved through a reasonable working por- tal, the repair should then be done through an open deltopectoral incision. ■ Ring curettes are excellent for bone bed preparation in HAGL repair. The Cowboy’s Conundrum: HAGLTear and Bankart Tear The Surgeon’s Solution: Knotless HAGL and Bankart Repair History: ■ A 19-year-old collegiate ski racer reports recurrent shoulder instability. ■ She first injured her shoulder at the age of 16 in a ski- ing accident.

■ She reports multiple subluxations but does not require formal reduction.

Physical exam: ■ Range of motion: ■ External rotation is 70° at the side bilaterally. ■ Forward flexion and internal rotation are full and equal. ■ Instability: ■ Positive apprehension on the right, which is reduced with a relocation maneuver. ■ Gagey maneuver produces hyperabduction 15° compared to the contralateral side. Imaging: ■ Plain radiographs are normal without evidence of bone loss. ■ MR arthrogram shows an intact labrum and a HAGL lesion (Fig. 3-105). Arthroscopy Findings: ■ An anteriorHAGL lesion is demonstrated (Fig. 3-106A). ■ A nondisplaced attritional anterior labral tear is also noted. ■ There is no glenoid bone loss or Hill-Sachs lesion. ■ Repair of the HAGL lesion is performed with LabralTape and two 3.5-mm BioComposite PushLock anchors (Fig. 3-106B). ■ Repair of the anterior labrum is performed with LabralTape and three short 2.9-mm BioComposite PushLock anchors.

Video 3-16