Chapter 3 Instability

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CHAPTER 3 | Instability

and the passing suture from one of the anchors (Fig. 3-51B). The subacromial cannula is then angled ~30° away from the previous anchor (and toward the other anchor), and the Penetrator Suture Retriever is again passed through the tendon to retrieve the other set of sutures. There should be a 1- to 2-cm tendon bridge between the two suture pairs that have been retrieved, so that a substantial bridge of tissue will be inset into the Hill-Sachs lesion when the splices are cinched down (Fig. 3-51C). The surgeon must be careful to keep the two sets of sutures separated. Then, the working suture of anchor #1 is passed through the loop of the threading suture of anchor #2, and vice versa (Fig. 3-51D). The splices are threaded by pulling the free limb (nonlooped end) of the threading sutures until the entire threading suture has pulled through and is free of the anchor. Next, the knotless loops are cinched down onto the tendon by reciprocally pulling on the two work- ing sutures. As the knotless double-mattress sutures are tensioned over the infraspinatus tendon bridge, the surgeon will see the capsule being drawn into the Hill-Sachs defect, making it an extra-articular defect that is no longer capable of engaging the glenoid rim (Fig. 3-51E). The Cowboy’s Conundrum: Anterior Instability with ALPSA Lesion and Off-track Hill-Sachs Lesion The Surgeon’s Solution: Arthroscopic Bankart Repair plus Remplissage History: ■ A 36-year-old male who has had four anterior disloca- tions over the past 5 years. ■ He is an avid recreational soccer player. ■ He works at a desk job as a computer software engineer. Remplissage Conundra

FIGURE 3-52  AP x-ray shows a Hill-Sachs lesion.

Arthroscopic Findings: ■ The Bankart lesion was actually an ALPSA lesion, in which the capsulolabral complex had healed in a medialized position (Fig. 3-54). ■ Glenoid bone loss was measured arthroscopically and was found to be 16% loss of the inferior glenoid diameter. ■ The Hill-Sachs interval (distance from medial rim of Hill-Sachs lesion to the articular side humeral attach- ment of the rotator cuff) was measured arthroscopi- cally to be 18 mm.

Video 3-8

Physical Exam: ■ Full range of motion ■ Normal strength ■ Apprehension in the 90-90 position

Imaging: ■ 3D CT shows a Hill-Sachs lesion (Fig. 3-52). ■ MRI shows a Bankart lesion and Hill-Sachs (Fig. 3-53).

FIGURE 3-53  MRI scan confirms a Bankart lesion and also shows a Hill-Sachs lesion.