Chapter 3 Instability

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CHAPTER 3 | Instability

FIGURE 3-114  Arthroscopic view of a right shoulder from an anterosuperolateral viewing portal shows (A) a Bankart lesion with recent hemorrhage into the labrum and capsule. (B) After repair and plication with four double-loaded suture anchors (BioComposite SutureTak; Arthrex, Inc., Naples, FL), the humerus is centered on the glenoid. G, glenoid; H, humeral head.

in order to avoid repetitive dislocations that might cre- ate significant bone loss necessitating a bone grafting procedure such as Latarjet. Furthermore, this patient had a relatively small “on-track” Hill-Sachs lesion that did not demand a remplissage by our paradigm (“off-track” lesions require remplissage; “on-track” lesions do not). We prefer not to do remplissage on the dominant shoulder in overhead athletes, as this will significantly restrict external rotation with the arm in the abducted position, thereby preventing the athlete from getting the arm into the full “cocked” position. ■ Capsular plication was done in addition to labral repair because of the notable hyperlaxity exhibited by the patient on exam. In lax individuals, plication is easily done bimanually by the surgeon by pinching a tuck of capsule with a suture retriever while using a Labral Scorpion suture passer (Arthrex, Inc., Naples, FL) to penetrate that tuck of capsule (Fig. 3-116). ■ The criterion for an “on-track” Hill-Sachs lesion is that the width of the Hill-Sachs interval (HSI; consisting of the width of the Hill-Sachs lesion plus the width of the intact bone bridge between the Hill-Sachs lesion and the rotator cuff attachments) is less than the width of the glenoid track (GT). In such cases, the Hill-Sachs lesion always is “nonengaging” and therefore does not need to be specifically addressed (e.g., by remplissage). In this case, HSI was arthroscopically measured to be 12 mm, while the glenoid track was calculated to be 21.58 mm (GT = 0.83D − d; in this case, D = 26; and since there is no bone loss, d = 0; so GT = 0.83 × 26 = 21.58 mm). Therefore, HSI (12 mm) < GT (21.58 mm), so this is an “on-track” Hill-Sachs lesion. (Note: In cases where glenoid bone loss is <25%, indicating that arthroscopic

■ A small Hill-Sachs lesion was identified, but no rem- plissage was done because this was an “on-track” lesion (Fig. 3-115). Pearls, Pitfalls, and Decision-making: ■ The fact that this injury involved the dominant shoul- der in an overhead athlete certainly plays a role in the decision-making process. In overhead athletes, with an anterior dislocation, we usually perform an arthroscopic Bankart repair after the first dislocation,

FIGURE 3-115  Arthroscopic view of a right shoulder from an anterosuperolateral viewing portal demonstrates a small, shallow Hill-Sachs lesion that was determined to be “on track.” G, glenoid; H, humeral head.