Chapter 3 Instability

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CHAPTER 3 | Instability

addressing this other significant pathology, we believe that these patients likely would have remained symptomatic from their unaddressed lesions. Our general philosophy is that the surgeon should treat all pathologic elements when the patient is under anesthesia, and the only way to be sure that all the pathology has been discovered is to do a diag- nostic arthroscopy. Another general conundrum is whether to do arthroscopic instability surgery in the beach-chair position or the lateral decubitus position. The senior author (S.S.B.) spent the first 5 years of his “shoulder arthroscopy career” performing shoulder arthroscopies in the beach-chair posi- tion. After 5 years, he switched to the lateral decubitus posi- tion and immediately noticed two things: 1. Visualization for posterior instability repair was much better in the lateral decubitus position. 2. Access to the anteroinferior, inferior, and posteroinfe- rior labrum was much easier in the lateral decubitus position. Therefore, we strongly recommend the lateral decubitus position for all arthroscopic instability surgeries.

found a relatively high incidence of additional pathology that would have gone undetected and untreated without arthroscopic inspection. 1 Unexpected concomitant lesions that we have discovered and repaired include SLAP lesions, rotator cuff tears, posterior Bankart lesions, and posterior HAGL (humeral avulsion of the glenohumeral ligaments) lesions. If we had gone straight to an open Latarjet, without FIGURE 3-1  Load-and-shift test with the patient sitting. The examiner places his middle finger over the patient’s coracoid tip to serve as a reference point for translation of the humeral head as he applies first an anteriorly directed force, followed by a posteriorly directed force. If the test is positive with an anteriorly directed force in the sitting position, it suggests injury to the superior glenohumeral ligament (SGHL).

Anterior Instability Arthroscopic versus Open

Some authors have recommended open repair for contact athletes, citing unacceptable recurrence rates if arthroscopic repairs are performed; 2 however, that has not been our expe- rience. We have found that the critical factor in predicting recurrence is to determine whether or not the athlete has significant bone loss. If our criteria for significant bone loss

FIGURE 3-2  Load-and-shift test with the patient in the lateral decubitus position. A: A positive anterior load-and-shift test with the arm in 0° abduction signifies injury to the superior glenohumeral ligament (SGHL). B: A positive test at 45° abduction suggests damage to the middle glenohumeral ligament (MGHL).