Chapter 3 Instability

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CHAPTER 3 | Instability

■ Arthroscopic Bankart repair was performed along with arthroscopic remplissage, using a knotted double-pul- ley technique (Fig. 3-62). Pearls, Pitfalls, and Decision-making: ■ This patient had two previous anterior dislocations. Each one was “out” for 2 hours prior to reduction, so he had a total time of dislocation of 4 hours. We have reported that in our practice, a cumulative disloca- tion time of >5 hours causes enough bone compres- sion and erosion that a Latarjet procedure is necessary to adequately address the bone loss. In this patient, even though he has an off-track Hill-Sachs lesion, he FIGURE 3-60  Right shoulder, anterosuperolateral viewing portal. Nondisplaced Bankart lesion with minimal bone loss. G, glenoid.

can still be treated arthroscopically with an excellent chance of success. However, one more dislocation with a “dislocation time” of >1 hour would put him at risk for needing a Latarjet. So it makes sense to go ahead and treat him arthroscopically at this point. ■ Although there are now some very good knotless tech- niques for remplissage that expedite the procedure, the technique of creating a knotted double-pulley construct, as used in this patient, gives a strong and reliable reconstruction. For those surgeons that prefer knotted anchors, this repair is the best. FIGURE 3-62  Right shoulder, anterosuperolateral viewing portal. Final view of remplissage, after capsule and infraspinatus have been inset into the Hill-Sachs defect. H, humeral head. The Cowboy’s Conundrum: Anterior Instability with Off-track Hill-Sachs Lesion The Surgeon’s Solution: Knotless Anterior Labral Repair with Knotless Remplissage History: ■ A 17-year-old football player (defensive tackle) was injured when another player landed on the back of the arm. ■ He reports a dislocation on the field, which reduced spontaneously after several minutes. ■ He completed the season in a Sully brace with pain. ■ He failed conservative routes and wished to proceed with surgery. Physical Exam: ■ Positive labral findings including Jobe apprehension/ relocation exam, O’Briens, and Mayo shear test. ■ Normal strength.

Video 3-10

FIGURE 3-61  Right shoulder, anterosuperolateral viewing portal. Hill-Sachs lesion, which has been calculated, by arthroscopic measurements, to be an “off-track” lesion. H, humeral head.