Chapter 3 Instability

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CHAPTER 3 | Instability

(Arthrex, Inc., Naples, FL) were passed through the two leaves of the posterior HAGL lesion (Fig. 3-107D). ■ An additional #2 FiberWire suture was passed through the posterior HAGL lesion (Fig. 3-107E). ■ The sutures were all tied “blind” through the posterior working cannula, and a strong anatomic repair was achieved (Fig. 3-107F). Pearls, Pitfalls, and Decision-making: ■ Posterior HAGL lesions are underreported and underdiagnosed. ■ A strong suspicion for a posterior HAGL lesion must be made if there are complaints of pain and instability with shoulder adduction. ■ The classic mechanism of injury for a posterior HAGL lesion is a fall on an adducted shoulder. ■ A posterior portal can be used for bone bed prepara- tion and anchor insertion. ■ An 18-gauge spinal needle can be used to create a percutaneous posterolateral accessory portal, which provides an excellent angle of approach for retrograde suture passage The Cowboy’s Conundrum: Anterior Instability with Significant Bone Loss plus Reverse HAGL Lesion and SLAP Lesion The Surgeon’s Solution: Arthroscopic Repair of Reverse HAGL Lesion and SLAP Lesion plus Open Latarjet Reconstruction History: ■ A 22-year-old athletic male had an initial dislocation 6 years ago playing soccer. ■ He has had four anterior dislocations in the past 6 years, and dozens of subluxations. Physical Exam: ■ Full range of motion ■ Normal strength ■ Apprehension with abduction of 45° plus external rotation Imaging: ■ X-rays (not currently available) show bony Bankart fragment and moderate-size Hill-Sachs lesion. ■ 3D CT scan (not currently available) shows loss of 30% of inferior glenoid diameter with erosive bone loss of glenoid. Hill-Sachs lesion is confirmed. ■ MRI scan (not currently available) shows bone lesions as noted on 3D CT scan, as well as SLAP lesion and ALPSA lesion.

The Cowboy’s Conundrum:Traumatic Posterior HAGL Lesion The Surgeon’s Solution: Arthroscopic Posterior HAGL Repair History: ■ A 19-year-old male with persistent pain in his domi- nant right shoulder after falling on his right arm in a horizontally adducted position during soccer. ■ He states that he cannot lift his usual weights, espe- cially bench press and military press without sig- nificant pain, weakness, and a feeling his shoulder is unstable. ■ Attempted 3 months of physical therapy, but there was no change in his symptoms. Physical Exam: ■ Range of motion: ■ Full active elevation, external and internal rotation ■ Strength: ■ 4+/5 strength with resisted elevation, external and internal rotation ■ Significant pain, weakness, and instability with resisted wall pushup ■ Special tests: ■ Slight discomfort with posterior load and shift of the right shoulder ■ Significant discomfort in the posterior shoulder with horizontal adduction ■ No anterior apprehension or sulcus sign Arthroscopy Findings: ■ Examination under anesthesia (EUA) revealed pos- terior glenohumeral instability that would spontane- ously reduce. ■ Diagnostic arthroscopic evaluation confirmed a poste- ■ A posterior clear 8.25-mm clear Twist-In hard cannula (Arthrex, Inc., Naples, FL) provides a good angle of approach for bone bed preparation and anchor inser- tion, whereas a percutaneous posterolateral accessory portal made with an 18-gauge spinal needle provides a good angle of approach for retrograde suture passage (Fig. 3-107B and C). ■ #2 FiberWire sutures (Arthrex, Inc., Naples, FL) from a 5.5-mm BioComposite Corkscrew FT suture anchor rior HAGL lesion (Fig. 3-107A). ■ No other tears were identified. Imaging: ■ Plain radiographs were unremarkable. ■ MRI did not reveal a specific tear.

Video 3-17

Video 3-18