SPORTS TRAUMATOLOGY - PART I

Arthroscopic treatment of antero-inferior instability

G. S. VAN: THIEl. I, A. A. RO;\·IEQ 2, M . T. PI{OVENCHEIP

The treatme nt of anterior shoulder instability IOl1bopedics continues to evolve. Advancclllcnt." in arlhro­ RlIs/) UII(/"erx(~ r Medical Cell"'I; Cb(c {/.~o. IL. USA scopic techniques have led to a rt.'(:cnt shift to .1Sectfoll vISbOulder mul arthrosco pic Bankart repair. TItis has been COll­ Rlls/) Ullil'f:rxU)' Medic(li Cellter pled with a development ornew instnlmenta· Oi1boper/iC Surgel)' lion, implants, and techniques. However, to Nus/) Ulliliel-sft)· .lIedic(l1 Celltel: Chicagu. IL. llSA obtain a successful outcome for patients with $SlJolllder Kllee ({lId SPO l'/s SIII'Sel), ante ri()r instability, it is imperative that the J\'(l/I(lI .Hetiic(l1 Cell lei: S(/II Oiego. Ci l. USA SlIrg(:oo be aware of prcopenltivc, intnlopcr;l­ live, and postopcnltivc factors associated with the recognition and pro per treatment of ins ta­ bility patholo~,.y . ln this chapter, we will present SC\'crnl import.1ot tcchniques, pathologies, and ev,llu:nion, ::t thorough diagnosl'ic :utllrosc:opy concepts regarding tllC effective diagnosis and treatment of patients with anterior insl;lbillty to evaluate for concomitant copmhology. and using arthrosco pic techniques. implement an effective postoperative ther.a­ py program tailored to the repair sn'Hegy. In Key words: Shoulder . Arthroscopy -Joint instability. addition to the Bankan lesion, the treating surgeon must be aware of other co-patholo­ gies. sllch as the HAGL lesion. ALPSA lesion. ('spite advances in the understanding of and SLAP lears. th:n can tlCClir in concert D

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Anterior View Posterior View

FiguI"C I ,-TI l(~ an;ltomic rdal;ol1ship of Ih" ~1;Hk r<:slr:rims for glenohullll"r:1l ~1;rbiliIY . SCI [L: ~up<:rior j.\k·nvhunwr:d lij.\­ ;"l1o:nl; .\IGH J ~ middle g[""lOhum"r:llligamt!nt: [GHI.: inr(:rior gtenohlllllCr:llligamcrlt. COlJrto;""sy 1mm Primal l'iclllTCs LId.

techniques, pathologies. and concepts regard­ It/urum ing the effective di:lgnosis and treatment o f The bbrum contributes in several ways 10 patients with anterior instability using arthro­ the overall stabiliry of the shoulder. leFirst, it ~copk techniques. provides the insertion fo r the capsule :1!"i well as the ligamentous structures, effectively sta­ bilizing (hem to the glenOid. In facl. in its Anatomy inferior hemisphere the labwm is attached to the glenOid through a narrow rim of fibro­ Improvements in our understanding of the cartibgenolls tissue that directly (r.:LnSitions biomechanical and p~ilhoanato m..i cal fc,Hurcs into the glenoid articular cartilage) The supe­ of anterior shoulder instability have led to rior hemisphere of the labrum is attacht:d advances in clinical diagnosis and recognition more loosely and with considerable vari­ o f associated pathology. The stability of the ability to the fa ce of the glenOid. This fa ct glenohumeral joint is conferred by three leads to several :1o

.\IINERVA O RTO I'E[)lCA f. TltAl~ I ATO I.OG L CA ().;Ivbcr 20lQ MlTflROSCOl'lC THEAT,\ILYr 01' Al\TIHQ-INTER10 R SI10lllOl;R fN STAIIll.lTY

bUity for two reasons; il creales Ihe concave· compression relationship and provides the insertion site for other stabilizing stnlClures, The labrum is the portion of fibrocartilage thaI is circllmferentially attached to Ihe lim of the glenoid. It is criticli for the orthopedic sur· gcon 10 recognize the normal anatomy and anatomic variants of the labrum to prevcnt misdiagnoses and inadvel1ent treatment. The normal superior attachment o f the labrum to the glenoid is loose, has tremendOliS anat(lm­ ic variation. and is complicated by the :utach· menl of Ihe long head of the biceps tendon as it originates from the supraglenoid mhcr· I'i;lun' L------Gknoid :md lh~' lolknohumcr:lt li),(:lnK'n1S. S(jHl: de. l.f> The function of the labrum as it relates supt:nor gknohulllcr:11 liganwnt: /IIGlll: middk ~dcn o· to swhility of the shoulder joint is threefold. hu!!\cr:ll Jig:um:nl: IGHl COl11l)k ....:: inkriv r l;:I<'no hulUl'ral ligamclll complex. (:ollftesy from Prim;!! PiCllIrl:S 1.t d. First. the labrum deepens the concavity of the glenoid up to 9 mm in the $uperior·infe­ rior direction :lI1d also doubles the antero­ glenoid , and insert on the posterior depth to 5 mm.- Second, the labntlll slightly inrerior to the " 'IGHL. However. increases glenohumer.:iI stability by increas· Ticker iN (11. 10 have suggested th:1I the posle­ ing the surf:lce area through which the gle· rior band has greater variation and is less noid contacts the humeral head through an evident than the other twO structures. arc of motion. rin:lIlv, the labrum is the site FUl1hennore. the IGHI, complex is extreme­ of atl~chment for the various glenohumeral ly impoltam in the context of shoulder sta­ ligamems th:1I confer Sialic Slability to Ihe bility, :llld can represent a r.:ommon source of join!.l ins(:!bilit)' pathology, The IGI-IL provides stability to the shoulder G!ellObllmera! Jigamell/s in difrerent planes of mOt ion wilh the syner­ of ils three compo nents. \,"!j th internal The glenohumeral capsuloligamenlous g~' rotation. the complex prevents posterior sub­ complex * Ives to statically restrain Ihe gleno­ luxation by shifting posterior. Suhsequently, humeral joim against excessive Iransla(ion. wilh alxluction and external rOlation the :ll11e­ It is composed o r multiple structme.5 \vith lim band provides stability and prevems ame· different roles based o n the position of the rior displacement. The lG HI. complex also . The middle glenohumeral provides anterior. posterior, and inferior st

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varies with arm rotation. The rOtator interv:tl decreases in size with i nternal rot.uion, emphasizing the concept that if the rotator intcrv.t\ is dosed with the upper extremity held internallv rotated (or less than 30° of external rot:lIi~m). significant losses of exter­ nal rol:uion may resultY:I The rotator inter­ val dimensions have been investigated in cas­ "' __ o[ es with clinical inswbility and have deter­

R ...' ''''''...... mined that although the rOlator interval size is increased in instability. the distances between tile supraspinatlls and subscapu­ Fi~un.: 3.-ROlator inlC('\~11. A dr:.lwin~ of rhe glenohumcr:ll laris tendons remain unchanged.l ') 'rhe main joint from Ih., ':;'1gill:l1 \'icw Ih:1I sh Qw~ the lumen L~ (,r the HI. 111~' n lllkms ind udc thl" SIJI)(!fio r gknolmlllerallig:" function of the rotator inter";ll is bdkved to menl. th ~ lo ng head of the b in'p~ tendo n . the (01';[(:0- be the prevenlion of inferior and posterior Inlllll~ral1ig:ullenl. ;lIld:t thin !:Iyei' o f ClPMI!c. This an.:;l 01 translation of the glenohumeral joint. ,ul;1t0 111y e.Ul be confusing and t hange~ Wilh I):tgiU;t1 posi. lion in the s h l) uld~· r.l~ Ilowever, the role of the rOlator interval in maintaining shoulder stability remains con~ trOversial. Ih~lt is bordered superiorly by the anterior Some authors have reponed the impor­ horder of the supr::lS pin~l1u s. inferiorly by the tance of rhe SG HI. in maintaining inferior sta­ SUIJelior border of the subscapularis. medially bility of the shoulder.-'IH! ,,,hereas other.; dailll by the base of the coracoid. and laterally by that the CHL is more irnponam and sliIl oth­ the sulcus for thl.: tendon of the long head of ers explain that the twO ligament::; work the biceps and the tr.lIlsverse humeral liga~ together as a unit to prevem inferior and pos­ ment. II- I $ The coracohurnel':l! ligamem (CHL) lerior tl1ll1sia lion of the humeral hC:ld.!J· N is a tr.l!x:zoid-sh3ped structure that originates The CHL h:ls also been cited as an ill'lpor~ at the b:lse of the coracoid and splits into tant Slalli1i%er to inferior glenohumeral trans­ two bands: one that ins(:lts on the anterior Imion in the adducted :lrm. In f;lct, several edge of the supraspinatus tendon and grealer ;nllhors have advocated that the Clil is the tuberosiry :tJld another band that inserts on mOSt important StnlClure preventing down­ the subscapularis, transverse ilul11er::iI liga­ ward translation of the adducted ann.!~ . ~ >. 2$ ment. and the lesser iuberosity (Figurt:! 3). Ilowever. the inferior capsule is abo :m The relatively smaller supelior glenohumer­ important slructure that prevents downward allig:lInent (SG I1L) originates from the labrum translalion of thl;.' adclucted ann and becomes :Kljaccnt to the supraglenoid tubercle, cross­ more impOrtant as the glenohumeral joint is es thl: 0001' of the rOtator inter",,1 deep to "bducted. These structures likely act in con­ Ihe CI IL. :mcl insel1s on the fovea capitis. an cert to provide inferior stability of the gleno­ area on Ihe superior aspect of the lesser humeml joint and emphasize Ihe importance tuberosity. 13 The tendon of the long head of of surgical imbrication of the inferior capsule the biceps lies between the CHI. ~tnd the verslls the rotator interval structures in Cases SGIIL (Figure 3). of anteroinferior. posteroinferior. and lllulli­ The c:' lpsuie of the rotator interval is a very directi()I1al shoulder instabililY. thin st ructure, measuring berwcen 0.1 and Although the rotator interval ca psule is :l 0 .06 mm in cada veric specimens. lo T he thin structure, it is import:lnt in maintaining importance of the rota£Or interval ca psu lar the capsular continuity that is vital ror main­ covering is to maintain the ncg::lIive intra­ taining neg:llive intr:t-:llticlllar pressure and :Ilticular pressure of the shoulder, which helps concavity compression of the glenohllmer:rl contribute to the stabililY of lile glenohumel~ll joint. The contribution of the anterior cap­ joiT11. 17 sule in shoulder stability was described by The dimensions of the rotator illlerval l\'l ologn~ e/ (.II.!". 2- in their review of failed

J96 .\lll'ER\·'\ ORTO!'EDICA E TIt,\I;",,\TOLOG ICA Aln'HKQSCOI'IC TIU:AT,\'El'-"T OF ANTERO· '~FE I(J OI ( :> HOULl)~: K ,'S"Il\fIII.ITY VANTIIIF.l

;ltlhroscopic Iabr.:11 repairs. In their series, 20 ment that has been rendercd to dale. Also, if patients w ith recurrent instability after an patielUs experience ~111 initi:tl d islocation at :lIthroscopic anterior labral repair were treat­ more than 40 years of age, il is imperative to ed wilh an open stabilization procedure. At rule our an associated . the time of revision surgeTy, 15 patients (75%) In addition. the provoc;:ltive anterior inst:l­ were found to h;wc a redlll1<.lam amelior cap­ bility position Cilmost always the abducted sule that indicates an incompctent rotator exrern:llly rotated position) ~tnd the amount interval ca psule. of trauma necessary for the in:-;wbility episode Llstly. the rOtalOr cuff musculature and to occur has implications in management. IXmlSGlpular musdes :Ire critical to the over­ l'mients whose .s lip out during all function of the glenohumt:ra1 joint and sleep or with simple activities, such as reach­ (,."onfer important d yn:l!llic stability to thl;! ing overhead. ma y have an emireiy different shoulder. A careful evaluation of the rOtalor diagnosis (i.e., multidirectional insl;ibility. (""uff (e::;pecially in p:nients who present with glenoid hypoplasia. and so fonh) and Illay an initial dislocation more than 40-year-old) require a different surgic:tl pbn (:omp:lred ancl SGlpular function is paramount to ensurc with those who experience inswbiliry only that the dynamic slability d the glenC)humer.:11 with mo re significant trauma. If patients jOint is optimized. demonstr.:uc the ;:IbiliTY to easily disimpared with the humeral head. most often present with feelings of impend­ even :1 small loss of bone, such 35 ~I glenOid ing inst:lbility or p:1in in cxtTCllles of motion, rim frat:ture, can compromise stability by :lI1d may experience subluxation or even decreasing the bony sllrface :-Ire:! for gleno­ frank disloc".ltion during celtain shoulder pc)si­ humeral anicubtion ..!l-I..:!') Several clinical stud­ tions (namely alxluction and external rotmion ies have shown that bone loss of either {he :lnd with overhead aClivities). Although most hllmerdl head or glenOid :,;u rfat:e is the most patients compl:iin of subjective feelings o f common cause of f:lilcd :1I1hroscopic swbi­ instability during repetiTive overhead activi­ lization procedures and tl1;11 recurrence of ties, such as throwing or swimming, some glenollumeral instability is increased with patients nuy present \vitl1 reports of 11":111- even small amoums of glenoid bone loss. sient sharp p:tin. numbness, or weakness thm lly between 15% 10 200J0 .2II.l9. 30, '11 usua llsually resolves bricny :lS Iheir only symptom of instability.

Patient history Pbysiclil e.\"(/lIIimlfiOIl Understanding the SOllr<..."e :lnd type of insta­ After obtaining the appropriate histOI1', a bility that patients are experiencing i!'; critical complele physica1 examination is integral to (0 the ultimale Sllccess of surgical trcallllCnt. making the correct diagnosis and imple­ r\ thorough hi!';tory :-;hould always indude menting the appropriate treatment p l:tn. rype of inswbili(y (dislocatio n, !';ublux;nion); lbngc of motion, neurovascular examina­ direction of instability (anterior, posterior, tion. and overall strength (shoulder girdle Illuhidirectional); reqllircmcm for medically and P:II~ISc;lplllar l1lusdes) should ".Ill be nor­ assisted reduction versus self-reduction; age nul in the majority of patients with shoulder and amount of time thaI had elapsed from Ihe instability. Specific provO('ative lests are the first disloC:Hion; activir)' level. including con­ ha llmark of assessing anterior shoulder insta­ !:Jet versus non-contact sports: :lIld :1Il}' Ire;lt- bilit}l. including the apprehension, rcloca-

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diagnostic indicatOr of shoulder instability. A posilive sulcus sign thai does not decrease with external rot~tion at the side indicates a pathologic rotator interval (Figure 4) . Increased gener~tlized ligamentOllS laxity should also be assessed. including thumb to . elbow rccurvatulll, 1llcl:lcarpopha­ lange:.11 hyperextension. and increased extcr­ nal rotation in the ahducted position. Physical examination must always begin with both shoulders exposed for visual inSptXlion. Visu:1i inspection of the hack dur­ ing active shoulder forward l1exion with the examiner positiOned hehind the patient can detect subtle sctpuloti10r.:lcic dyskinesia or sGtpular winging. Active and passive r.mge of motion should be assessed and comp~red with the unaffected extremity. Deficits with internal rOl:> ' ognized anterior and posterior dislocations, il i>'~' "uk us sign Ilaal doe.~ nO! dl:LTease wilh ~·."':Icrn : . l rota· respectively. An assessment o f gcncr.:lli7.cd l ion ;1I the ~ i d c. laxity (e.g . hypcrmobile pa[CiI:l . hypcrex­ [ension of" , met:lcarpopha- 1:1I1geal lion. and anterior release tests. Especi,llly . and the ability to reach the ipsibteral important to investigate is the ease w ith forearm with the alxluctcd thumb) must be which Ihe humerus begins to dislocate and performed. engage on the glenoid: if this occurs at 30° of The physical examination for shoulder external rotation at the side, for example, it instability can be divided into tWO main is highly likely that there is a significant groups: l) tests for the asst::~sment of gleno­ engaging Hill-Sachs lesion or assocbted gle­ humeral laxity and 2) provot':lIive. or insta­ noid bone 10ss.29 Patients w ith engaging Hill­ bility. tcsts. Sachs lesions also usually rcpOIl a histoll' of shoulder insrability in midrange.s of tIle shoul­ LtixiO' fest ill!!, der abduction/ extern:tl rotation. AI'·:rI'I{IOll \)llAWEll n~<;, t' It is imperative Ihal the surgeon discerns between laxity and inst:lbiliry. Instability is '1111S lest :utempts to quantil)r amelior trans­ genemlly regarded as symptomatic laxilY and tllion of the htllneral he~d on the face of the is lhe perception L~y jJ(lfiell/s experiencing glenOid. The test should be performed with the shoulder subluxation or dislocation evcnt. the patient lying supine. The examiner stands Laxity is a nonllall1nding of the glenohumeral :11 the ipsilateral side of Ihe affected extrem­ joint. because the humerus needs to h:lve ,I iry. The shoulder is in 800 to 120° of abduc­ minimum obligate tr.lI1sl;lIion on the glenOid tion. 00 to 200 of forward l1exion, and 0° to tor normal Shollkler function}.!. 33 The amount 300 of external rot'llion. One of the examin­ of laxity and inslability ~re both assessed er's hands is used to stabilize the scapula by with translation testing for laxity (anterior. placing (he fingers on the scapular ~pin(;: and posterior, and inferior sulcus) and s}'mpto­ the Ihumb on the cor:l coid. The other hand matic direction~1 laxity. which is :'1 critical grasps the proximal humer:11 shaft. An ~nte-

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riar fo rce is applied to the proximal humerus ;Inc! (he amoum of 1r.lI1slation is quamificd.

A~TF.RIOR AND POSTERIOR lO,\ D AND SHJ~T TF$ T The patient ca n be in either a su pine or scared position. In the supine position, the arm is pbcccl in 20° of abduction, 20° of for· ward flexion, and ncutr:ll rotation. If in the upright position, the examiner siands behind the patient on the ipsilateral side of the exam­ ined extremity. Assuming the right shoulder is being examined, the examiner places his or he r left hand on the scapula [ 0 stabili ze scapular motion. The examiner grasps the humera l head wilh his or her right hand C"".lrl with the glenoid ;mu se;'pui:t digitally ~ubtracted 1h:1( dl'monstr:lIl:s the hatch­ Instabilify tes/ing el- IYr

Vol. 61. r\o.; .\Ul'ERVA O RTOPEOICA E TR-1.U.\1,\TOLOG!("".A VA"': TIilEl ARTHllo:.col'lC T1UtAU1E.'T OF A.YIl-:IIO·J'1'fR101l ~11011U)ER 1;>;!>TAlllLl"l"'.·

T AIIU' I.-HICIQI":> S/l8Meslrl/~ Ibc PYl!SeIlC{'oj~/(!lIoid or bUll/em/bead bolle loss. p(.IiI!II/'S bil;/UI:r (/11(/ {·.WOII fl/(//loll -lnili.,1 ~ h {)\lldc r dislOC:l1ion t~luS<.·d Ill'" high.<;m::rgr lrJU· 1ll.:lIie evenl - Multiple inst:lbdit)' C\'cnt~ - RC'rum:nI :ml~'f'iur in:-l:"lhililr t..... ICOOlOg O\'~'r St...... :!":,] rO::\n; or ol,."currinj.t ;I~.:I ~ingle el'en! .'len'rJI rC;I[!> :"Iftcr Ih.., lIIi, li:l1 in~;,bi1ilr - I~"c ~";l.-'<; of ill"Jh,llI), (dl~n:;lI>ing I",d of :tnil 'I)' rt",:! s<.:cn on :•. ~iIl:lr)' 1:t1(."r:,1 r:.dio,l:r:'ph - Antcroinfc:rior j.tknoid In... , (on ....- orticl! rim or omlinc) !>Cen on AP or 1I'I'o! AI' r:.d'ogr:Jph - Bo .w!OSS SI....':n on .)!'j.tin:.1obli( IIIO: Mit! or IIL1!U\etic n;::;o­ nance :ut hroJotr:llll - livnc k):,.... :-IXn on cr. e;pcci:d1r Ihfl...... ~imension;aJ ...."('011- .>I.ruction wilh Ihe humcr.!1 h..,..ld digilally subtr:lCll'd Fi~ure 6.-MR anhrogr.nn dcmOlhU':llin~ glenoid bonc I~ un the ""~ill:11 uhlique im:lgc_ Arrow poilll'" 10 lX-lilt: d .... ft-ct. which i~ :thOllt 3{)'!t. elf Ih.... l:(knoid in thb eX:lll1pk. it}' episodes. :l long hisloty of inst:lbi1il }'. or progressive ease of instability s}'mptoms sug­ gests a larger anatomic problem. namely gk­ noid or hUlller.JI head bone loss. For a comprehensive cvalu:ilion of glenoid hone loss, advanced imaging is necess~Hy. A magnetic resonance imaging (l\IR T) and a magnet ic resonance :t rthrogr:11ll (~'IH A). although helpful in di.lgnosis o f soft-tissue pathology. may also be used (Q 3ssess the degree of bone loss by ev:duating the Illost latera l glenoid cut u n sagittal ohlique images ( Figure 6). I lowever. the most aCCllrall.: method to measure glenoid bone loss is :t three·dimensional c r scan with digital sub­ traction of (he hUTlleral head on sagittal oblique imaging. The JWlllerai he-.ld may ,lIsa be isolated in three-dimensional reconstnJc­ fi~un.: 7--<::f c\~.llu:uion uf :r "",/,:ill,'] oblillUC lotlellOid en lion to assess the size, depth. and orienla­ f:tcc "it·w dc.:moru.l.r.lling Ihl.' he;)l-fll circle:J~ :t loto1d Sian· tion of the Hill-Sachs defect. tbrd 10 d~'lerminc Ihe :.mntlm nf gkno.d bone 1Qs". lluysmans e/ al.J-1 ha ve described the infe­ rior two thirds of the glenoid as a well-eon­ selved drcle, and deficiencies w ilhin lhis cir­ the circle. The rcason ror the preciSion or de are llsed to qU:lIllif}, the ;1I110Unl of glenoid hone loss measurement is that the glenOid bone loss (Figure 7). A best-fit circle is drawn bone :-; tock from anterior to posterior is only on the inferior two thirds of the elljaces..1 git­ about 24 10 28 mm :Illd varies from patient to tal image. and is well conserved for normal p;llient); In addition, f()f approximately each glenoid geometr),.·H The amount of bo ne 1. 5 to 1.7 mill of glenoid bone loss. this cor­ missing is determined b)' assessing :-; urfacc re:-;ponds 10 a 5% increase in loss of glenoid :lr(';1 losses from thc :lIllcroinferior p:lI't of honlO' stock . or notc, glenOid hone los_s o f

MI''F.R\'A ORT()I'EDI(:A I! TRAI ~IATOLOGICA 0<"101,,:< !uIU ,\ R'niROSCOI'IC TRE.Al',\lEl\'T or Al\'1l;KQ 1 " ~'E K 10K ~ 1-I OU L OE K " $'li\1Jll.ITY \'''''·I1IIEI.

I'igllR' <).-Arthroscopic image rrom Ihe :ml('ruslIp<.'rior port;11 dcmo nslr.uing an iI1l'(:11('(1 pear glenoid w ilh ~i g · Figure 8.- A sagiltal oblique c r image {lemomtr:lling the n ifie.lIlt (>20--25%) gknoid Ixme tos:;. l),pi C":l lloc

\ 01.61, /1:0. S ,10 ] VA'" TIi!EL ARTI-JROsc.OP!C · 1~I ~Tl> If. NT OJ' M 1 'ERO.[l\FEIlIOR SI[O(;L[)ER I N~ I:'\II1 UT"

iiistorically. althroscopic treatment of gle­ bility evenL'). Active patients less than 30 years noid bone defects have had a high recur­ of age treared w ith a supervised physical rence nne (from 61-67%).19 Mologne el (f/.!f1 thempy program instead of surgically have demonsrrated a 14% recurrence rate in had reponed recunence ra tes of 17% to 96016, patients w ith a mean loss of 25% glenoid w hereas those treated with arthroscopic bone los....; treated anhroscopic:1l1y. and noted repair had f:lilure rates ranging from 4% to that all of their failures (three total) were in 22%:+2· 43 This data indicates early arthro­ pCHicnts deemed to have anritional bone loss scopic repair following first-time dislocation and no glenoid bone fragment to incorpo­ is applicable for young, h i ghl~' active p{ttienl.'i rate into the repair. In anmher study, Sugayn or those engaged in aClivities involving over­ el al.4fi demonstrated only an SVo recurrence head usc of their anns. Opemtive intetvt:ntion rate in patiems wirh a mean 25% bone loss should also be considered in patients wilh treated anhroscopicall}, when the bOil}' frag­ rccun·cnt episodes of instabilit}' after a CQUr-ie ment W5-7 mm in depth), pathologic lesions. the typical solution is glenoid bont.: aug­ mentation. In rnre circumstances, there arc a S UIlL... IlRAL FQ RAME..'< AND 11tl:O B UfORD CO;\II'tEX varielY of surgical management options for a Hill-Sachs injury thar range from soft-tissue As described previously, the superior half augmentation (Remplissage), glenoid-based of the labruTll is more loosely and variably bone :1llgmentation. humeral-head options, attached \0 the glenoid than the inferior hemi­ and occasionally both. sphere. The result ca n be the presence of a sublabml foramen, either in iso1mion or in conjunction with other va riant anatomy (Figure 10) . The anterosuperior quadrant is Treatment the most common location for :l sublabral fornmen, w ith an incidence of 11.9:1/0 to 18.5% NOli-opera t i ve in shoulders undergoing arthroscopy.47. '18 The naruml history of acute anterior insla­ These observational snrdies found that sub­ bility events has been evaluated through labral foramens do not contribute to insta­ numerous prospective studies with age at bility and should not be "repaired" in the the time of initial dislocation being the most majoriry of cases. This is especially true if significant prognostic f:lctor for t\mlre insta ~ they exist in the superior half of the glenoid.

402 l>][:-tATOLOGtCA MrrHkOSC01'lC Tkl'.ATME:-.,. Of ,\ l\'11:;KO·],\:I'EIUO]l MiOULDEK 1;":~T,\ mUn' VA=-- TllIEL

Figure IO.-Sublahral foramcn - A ~ u hlahr,ll for:mWll Fi~lIrt: I I.-Buford Com pIc;.: - nl)lc Ihc tldldcnq' of Ilw h :en :ullcro·-superior glcLlQid !:ibmm norm:!l \';Lri:Lnt :mK'ro$upcriof IJbrum, The Buford Comple;.: i~ :I nonnal Char:l.Clerized b~' dctachLllent of the 1:.l)ru11l from the \':tri:lliOIl of tho: bbruli!:pmcmuus ,,!e~'\'e of Ihe glenoid underlying glenoid. This .

The Buford complex ;:1 recogni7.ed normal :l superio r bbral :111lerior posterio r lesion. variant defined by a large defiCiency of the which is a detachment of the glenoid labrum aruerosuperior labrum in conjunction with a at the insenion of the long head of the biceps Ihickened. cord like MGH L (Figure 11). The lendon: a medial dispbccment of the labrum Buford complex can be mistaken for an ante­ and periosteal sleeve of the :nuerior glenoid rior labral avu lsion or superior labral tear !:tbrum :lncl Clpsule (amelior labml peliosteal when inte rpretcd o n lllagnetic resonance slceve :lvulsion. ALPSA): and Ihe humeral imaging U.. IRI). but is recognizable during avulsio n of the glenohumeral ligame nt or ;1I1hroscopy due 10 its chal

The superior labrum can have great Hllmeral mm/si()1l oflbeglellolmmemlliga­ anato mic variabilily owing to its loose gle­ menls noid attachment and its relationship with the long head of the biceps. Several varianrs of The HAGL l~s i on is a humeral avulsion of the aH:lchment of the long hC:ld of the biceps the inferior glenohumeralligamems and cap­ have been reported, St Thu~. Ihe presence of sule (Figure 12). Bach el a/. 52 first described a recess between the biceps and the superi­ thc presence of this humeral-sided ligament or labrum docs not always represent a SLA P and Glpsular disn.lption in patients with recur-­ tear. This should be full y cvalu:lted arthro­ n:: m dislocation. They sugge::itcd that this scopic:.]]), to cletermine if there is a solid pott:ntbl pathology should he evaluatcd in biceps attadlment. shoulders with rec.:urrem inslability and no lesio n evident in the labrum or glenoid.

Pathology associated with instability AII/erior /aIJroIiStflnell/Olls periosleal sleelle (/{JII/sic)II The re :lre several intra-articular lesions The ALPSI\ lesion represents;l soft-tissue or ;:twx:iated with anterior instability and include bony llankart injury th:.tt has occurred and

\'01 (,1. \:0 ~ VAN THIEl. ARTI IROSCOI'IC TREADIE.NT OF ,,"'TIRO·I:>-1'ER[OR SHOULDE R l."SHmUTI'

figure 13.---GLAD Ix"ioll. A gk:llolahr:11 ;tnicular dismp· figure 12 . ~I -IAG I . I..:.-.iun - '111e Ilullwral A,'ubiun of thc tiull (GI.t\D) le~;Ol1l~1!I be (o11l~L~L l>~' a forn.. ~1 ;lddlKliun Glcnohumcr:J1 J.i~Ull\?lIl:< (I ["'(;1.) occu r.< when 1he inferi· inju/)' 10 Ihe ~hou l d('1' from an :tlxlllcled :md external rotal· or gknohunler:J1 liganlenl is disflIptcd :u iL~ hUnI('r:11 ori­ L'tl position. Courtesy from l'rim:lt l'il1urC.' I.td. gin, Co" r1c~~' from I'riltl;1I P;('lure~ IJd,

to the subcho ndral bone in severe cases. healed in a Illetlblly displaced position on the Arthroscopic deb ridement is a sllccessful glenoid neck. This was first described by treatment for these patients w ith good relief Neviaser el ClI.53 in 1993. The ALPSA lesion is of pain. :tlthough tile long-term sequelae of .s lightly different than IIle similar Bankan GLAD lesions remains undear. injury due to the intact sleeve of scapular periosteum, T his sleeve Ihen translate~ infe­ lilli/karl ill}1I ries rior and Illedi:dly becomes :l(lherent to the glenoid neck creating an :lIltcrior potential Bankan injllries consist of two variants: space. Often, this space can be defined by a Ihe hony injury and thl;: lesion crcasc between the glenoid border and the (Figures 14. 15) . Bankan etal.>" reponed his fibrosed labrum that represents th\;' sl:t rting observation that labf:l! dct:lchlllent in 4 point for :111hroscopic dissection.1i \,'e have paticms led to rCClln-ent instability. He tellllt: d dctermined that thc A LPSA lesion is associ­ Ihis the "essential lesion'·. I n contemporary :1I\;'c\ with an increased chance to have gle­ OrthOpedics the Bankm1 lesion refers to the noid bone loss, and thus. a pOlenti:llly high­ detachment of the :lJ1teroinferior labnull with er chance for failure after arthroscopic st;l­ the anterior band of tIle IGHl. 'I'his patholo­ hiliz:Hion. gy can be present in up to 90% of patients with a trauillatic anterior shoulder dislocl­ lion.Xi Bony Banka !"t injuries ca n involve :l Glenoid l(.Ihm 111 lll1iClllar disrupfion significant ponion of the l.Interoinferior gle­ The G LAD lesion r epresent~ an ankular noid and Lreatment should be based on the cartil:tgc injury of the anterOinferiQf glenoid aillount of glenoid involved. Thus, it is impor­ (Figure 13), L:.lbra l tears o n MI{l :Irc common tant to IX' clear when distinguishing a Bankal1 associated findings. However, some patients injul)' as either son tissue only Of :l Isa il1\'olv­ will not present with ins(;Ibility, but r

.\IINERVA OIiTOPEDllJ\ E "KAU~I ,\"OI.OGI CA ARmROS<:Ol'lC l'KL ..T\n :Kr OF \X1'ERO·IXFERJOR !lIIOI'1on~ I".IT,\ RIUW n.\: mtEl

Ope rative technjques

OI1l!rvie(lJ I. Appropri:ue preoper.Hive evaluation: ev:t1u:ue for glenoid/ humeral head bone loss. 2. Eval uation unde r anesthesia: this ev:tlu­ :lIion sho uld contiI'm the prcoper.Hive pbn and :lssist with amount or c:lpsular shift to perform. 3, Patient positioning: although it is sur­ geon preference. the l:ltl:r:: tI decubitus pro­ vides for ease or access to the superior, pos­ terior. inferior. :lnd anterior 13bnll11 and cap­ Figure 1'1 .-Bank:tn I.... ion. 'llle lIank:1I1 I~"ion n..·f\·f"l; to clle sule ( Figure 16). dct:tchm\'n\ of the :Int~ " ) i n fcrior !:ibnlln with the ant~rior b:lnd of Ihl' lCoH!. :md leads to fl'curf<:'nl inq:lbility. 4. AntCrosuperior portal: :!lwa)'s view the C(lUr1C~)' from I'rim;d I'ic t ure~ lid pathology from the :lIlterosliperior portal to avoid missing ALPSA lesions, il is heuer to evaluate anteroinferior glenoid bone loss :lIld Bankart el {{I. ~~ reported his obser\"al ion Ihal to :lssess extent or lear posteriorly, as well bhr:tI detachment in rour patients led 10 ;t~ :Lny inferior o r postcroinrerior p:ltholog},. recurrent instability. He termed this the 5. Glenoid prep:u,:uion: make sure that [hI;! ··cssenti:lllesion-. This p:lIhology c:.m be pre­ soft tissue is removed rrom Ihe intended scm in lip 10 900/0 of paticllIs with a Ir.:Ium:tI­ repair site and th:n there is :1 bleeding iX"'(i of ic anterior shoulder dislocation.56 Bon}, bone to cnh:Hlce healing. Visualization of the l3:mkU1 injuries can involve :1s ignificant por­ posterior subscapubris muscle fibers in(li­ tio n o r the :lIlteroinferior glenoid :-tnd trcat­ cites :1Il adcqu:nc p reparation or the l:tbrulll ment sho uld he based on the.:: amount or gle­ ::Ind c:lpsul:u :HI:lchments 10 the glenoid :lnd noid invoh·cd. allows ror ~ lLrnci e n l mobilization ror repair

FI,!!lIi"e 1';.- ,\ ) MRA :lxialllll~l,W of a .-oI"t -ti,.,.ue R.11lk:tn w:lr :mwriorly, "'rrv'" poin!>. 10 : Im~roinferior 1.lhrum; U) n.>r­ res ponding anhroS(.-vpk 1111:18<:' of tht: :lnteriQr Ihnk:1r1 ·,() ft · ti~'\1~ only t~'ar. PO!>terior \'jew or ~l~nohunwr.iI jUint \\ ith probe on ank'ruinr~rior I:IbOIlIl. S-I

\"ul. 61. .... " . S ;\ n;\:ER\''\ ORTOI'l't lIC.A l· 1'RAt \ IATOlQGIC,\ "Ai\" nrlEl ;\RTI-lROSCOI'IC TI!. I'.Anl~~'I;'· OF AI'.'1'F.RO·I:>'FEIUOI{ SllOlll.l'lEI{ 1X$TAIJIJJn'

I'i~"rc 1i .- ,\"hros(.."opic image of ,Ln :J(kU:>L~' rio r ~l.lhS<-':l p ularis t1befl:i (am)ws) :LfC iuS! '·~l. l :Lli7.(-d :md The bl)I\uU "rid G' I>:':>l.Ik· ~~ ' s­ ily nnat up 10 the }:lcnoid f;L~'lo i ndi t~ L!ing ade

9. Capsular plicatio n: abrasion o f the ca p­ sule should be pe rfo rmed to enhance healing to the !:tbrum. T he plication can be per­ formed to :ull "I<:: .... ,·c . SpCCUIcS

PXIlF.;"''T SF.·T- UP IN THE O PERATING ROO)I (Figure 17), 111C axillar)' nez' ·e is dosesl at the G-oodock pOSition, hcrwt:t:n 12.5 to IS mm, [hsed on the prefe rence of the su rgical patient. arthroscopy and should be avoided. team and shoulder can be performed w ith general anesthesia. inter· 6. Labral preparation: Usc :111 elevator scalene block or a combination of the I\VO. device and ensure labrum is visibleo release The alllho rs prefer regional anesthesia sup­ subperiostea lly to prepare the glenoid and plemented with a light general anesthetic to allow the ca psulolabral tissue to easily float facilit:uc I:uc r:ll decubitus positioning in the up to the glenoid t:1CC. outpatient setting. 7. SlHure anchor placement: Make sure \\l ith regard to set-up fo r patients under­ anchors :t r~ placed at the aI1icular cartilage going :lI'Ihroscopic anterior sho ulder insta­ ma rgin to avoid 1l0n-:m:1I0mic medi:11 scapu­ bility repai r. patients c:tn be p\:lccd in either lar neck pi:lcemeili. (lie lateral decu\litus or heach-chair position. 8, Suture anchor quantity: Fo r most The beach-chair positi(lI1 affords several ameroinferior labral tears a minimum of three advantages. including ease of access. ability suture anchors should be llsed (3-6 o'clock on ( 0 see the antc rosupcrior, inferior and ante­ a right shoulder; 6-9 o·clock on a left shoul­ rior aspect of the glenohumeral joint. and der). A standard rclxlir is three :lIlchors be low ability 10 easily convert to an op~n prot:i::­ 3 o'clock (the equ:Hor) . clure if indicated.

")(, .\I1 ..... F.](\',\ ORT01·F.DIC,\ E l1!A LT~It\TOLOG I C" Octohcr :?IHO MrI1mOSCOr'rC 11U!AnrL", Of A"IERO·I:-':FEKIOII .')HOULDEK J1"Sli\llIun' \:A.,.... 'H1F.1.

For c:.1S€'S of shoulder insT3biliry, however, 10 facilit:ne ease of inslnl1nemation during the :Iuthor.-; prefer to place p3tiems in the l:u· the case. eral decubitus position because it allows ease Once :1 B;lIlk:'1I1 lesion h3S been idcmifled, of access and " i sua1i 7~lti on of the entire cap­ an anterior mid-glenoid portal ca n be estab­ sulol:Jbral complex. \Xlith the ability to pro­ lished in line with the 3-o'clock position on vide longitudinal and direct lateral suspen­ the glenoid lIsing an 18-0 needle for local­ sion, the I:ller:ll position affords greater dis­ ization JUSt ~lJper i o l' to Ihe SlIhSGlplilaris len­ tension of the glenohumer:11 joint :lnd bellcr don. Although :ICCUr.l te port:tl pbceme11l is :Ibility (Q m:lke the necessary passes with essenti:ll for 1:lbr:11 prep:II~lIion and :tnchor in:'itftllllent:lIion for optim:11 rcpair. One of the placement for :lIlteroinferior bbral defects, pitfalls of laleral decubitus positioning is the the 4· 10 6-o'c1ock lahr:ll pathology I..--an prove difficulty in achieving mlational conuul during to be increaSi ngly dirricuh 10 appropriately inst:lbility repair. For insta nce. proper ten­ repa ir through these st:lndard portals. A 7- sioning of the capsu le and inrerior gleno­ o'dock portal c:m be established approxi­ humer:'11 ligament is particlJl:trly challenging m:ucly 3 to 4 cm directly lateral to the pos­ in the 1:ller:iI (lecubilllS position and can lead tcrol:ilcr..Ll corner of the acromion :md pro­ 10 postope r ~ltive stiffnes."i and decI'C:lsed extcr· vides excelknt access to the inferior glenoid nal I'ot:ltion. In addition. suhsca pularis rep:lir :l11d 11'1:1)' be lI ~cd to percutaneously place in :.uhleles with shouldcr instability and rota­ suture :.Inchors in Ihe mOSt inferior aspect of lor interval closure :tre ideally done in 50° 10 Ihe glenoid (Figure 18). This can be per­ ... 5° of external rotation. which can be dillicuh formed percutanoously with only the anchor to :tchieve in patients in the lateral position. inserter device. or a sma ll-diameter pi:tstic 1.:15tly. the eX~lInin : Hion under :meslhesia is cannul:! Ill:!y be utilized. all impon:lIu (.'omponcnt to any instability repair. 1\ b uscd 10 confirm what i~ known l..aiJnllll pre/x/ro,ioll pn..'"Opcr:lti\'(:iy :11)()UI patientS, including direc­ lion of instability. symptoms, and assod:.ued Proper labral preparation is a critical por­ findings. Furthermore. thc EUA can offer lion of anterior shoulder instability repair :IS info nn:ttion about the amount of tra nsl:H ion in3dequ:ltel:ibral preparation c:ln lead to in the anterior. f)()slerior, :lIld inferior direc­ insuflicient capsulobbr::11 plil.':.llion and symp­ tions. :Ind can serve to t~ilor specific opel.l· loms of recurrent inswbility. It b imperative livc planning. such as how much c:lpsul:tr th3t the su rgeon spend time preparing and plication to perform. mobilizing the labnrm-bonc interface before ,mchor insert ion and nxation. The authors prefer to liS\.! :I n elevator device to peel the POl'/(lls labrum from the glenoid neck while view­ Propcr P011:11 place ment is pivot:d in per­ ing the l:ibr~1 1 pathology from Ihe ~m terosu · rorming ;In ; I CC U1 ~lte diagnostic arthroscop}1 periol' pOllal. :' 111d complete 13;l1lka n repa ir w hile providing 1.:lbr::tI pn.:; p: II ~H io n should he completed i':tdlc soft-tissl1l: mobilization and accur:IlC I)(.:fol'(, prep:uing the glenOid for anchor anchor placement. Aftcr patient positioning. placement ~lI1d special care should be t:tken the sta ndard po:-.terior and antcrior·superior to preserve the remaining labnJm for plicJ­ pOl1:1ls (hiAh in the rotator interval.directly lion. \\.:Iith either the shaver or sillall b(me,ut­ adj:lccm 10 the long head of the biceps) arc ting shaver on forw:lrd or the burr on re\'erse, made and :1 full diagnostic.: arthroscop}' is the glenoid c:ln he prepared. :tllowing ror performed. The initi:11 posterior portal in the adequate bone pn:serv:llion during glenoid 1:l\cr:11 decubitus position i ~ madt: in lint: with prt:paf:lIion. the latcral edge of the acromion :tnd 1 cm Besides hone loss. the most frequem rea­ inferior to the posterior tip. This position sons ror failure ;Iftcr instabitit}' rep=-tir include allows the posterior portal to have a slightly un;tddrcs."iL-'{1 c lpsui:lr I:!xity (especially infe­ downw:lrd tr:ljeclOry on the glenoid surface ri orl~' ). improper :lnchor pOsitioning. and

\UII:f.R\i\ QItTOI'F.r)[CA F TII"I·\lAT()I.O(;JCA ~- AIlTI-lROSCOI'1<.: TltEAT,\1f.~1 ' 01' A ~TIRO-l~FF.R1 0R ~ 11011UWII tWl'AIIIUTY

Figure I H.-'J1K' pc J ~lcrol:I1Cr:d i-o'do.:k puna1 :I~ \ i ~' Wl«J frulll nUL, idc (/\ ) :.lI1d in~i,k (JJ ) the _hvuidcr (Jemon,' Ir:l1ing ease of :lCC~':;S :md anchor pi:Kclllelll in Ihe in ferior a~p(..... h oj Ihe ~Jenoid .

ing spe::tks to well .. pi:tccd suture anchon; that c()rrc...->Ctly address the p:llho logy of instability. I..:-tstly. asymmetric h:: nsioning during o pen o r :lOhro::;copic capsulorrhaphy ca n also cre­ ~H e instability in th~ o pposit e direction.

I IIIC/)O/";'; The standard :tl1ilroscopic l3:tnkan repair typiCo n:11 of lh ~' final ;mlefOltl­ te:!r and posterio r plic:uio n sutures to the (eriOl" labral rt:p:lir wilh :malIJlllic rt."lc,r.J1 ion of Ih", b hr:ll­ I:t b rum . ~ l i j.\ :lIl1l·nlou~ complex. intact posterior The posterior i:tbnllll may not always be intact and may present as .111 exten::; io n of the anterior tl;:tr recurrent trauma in :Ul OIhcrwisc wcll ..donc posterio rly. In this c:lSC, sllture anchor.) are rcconstmction. Accurate positio ning of SlIIurc used to repair the i:lbrllm and perform pH­ :lIlchors o n th~ gleno id with penetration :1t c:ltion of the capsule as necess:lry. However. the margin of the articular Surf:"lCC :lllows if a halanced repair is desired and the pos­ recreation of the gleno id concavity during terior lahmn1 is intact, it has been shown bio ~ r<:=pair and avoids rep:tiring the bbrulll com­ mechanically that an int:tct labrulll p rovides plex too medblly down the glenoid neck , similar fixation strength to :t suture anchor.59 Boileau el (I/,S" recommend :\1 least four suture III perfo rming adequate Glpsuioiabral tell­ anchors, because less than three SUllJ rc sioning, th<:= surgeon can use knots from a am:hors in their study was a ssociated with suture anchor or knotless :ltlcho rs fo r fixatio n failure afler instability repair. 11leir ~;udy fin<.I .. of the labnllll to Ihe glenoid.

"" .\11:>'1.11\.·\ OIl"l"O I'I;OICA t: TII..\U L\TOLOGICA OlJoIJcr ! \)lO ARTIIROSCOPIC l1U~\n!E'T OFAXlT:RO·1I\FEIl10R SliOULDEII1NSTAIIIUn \j\;\ n 11H

Humerus

1._ __.1 Glenoid

Fi~'1 l re 2] .-In Ihis anhmSl.."opk vkw of It{' shoulder from !h~ po>ol~rior pon;t! wilh ;t ; 0" ~t)pe. Ih~ gr:Isp...'f ha~ bo:~ n Glenoid 1)1:1<;.,d thrOIl~h Ih(' :mwrivr midl:t ler.l! pM!:!1 1(, reduce the c:(p~ubr t ;"~lK' IV the humeral nC'Ck .

Figur~· 20.-Arlhros\'opic vi" w of left shOllld~r frolll [XlS­ [(:rim portal with 70° Sl:Upt:. The free edge of the :lI'ul!i(:d from their glenoid/ l;;lbral ongm to their ink-riur gle nohull\er:11 (JG Hl.) complex c:m 1~ S<.·~· n in thb :1 anterior H,\G1. lesion. Subs(~(pubris rnu....::lc b ' ''1:11 ~Ilpc· attachment on Ihc humeral neck In humer­ rior :U1<.1 :U1tt" ri(Jf to free L-.:I,gJ: of ligamcn!:<. al :lVulsion o f the glenoh um er~ t l ligaments lesion, all or pan of the middle and inferior glenohumeral ligament complcxc!> are of note: avulsed from their humeral insertion. The - tension the ('~1psu lol:lbral S!nJctlires with humeral insenioll is IX!>I visualiz(;!d with a 70° the arm in slight external rowlion; scope in the poslerior ponal or ,vith ;t 30° - use a minimum o f lluee SUHlre anchors: scope placed in the anterosl1perior ponal - the anchors should be placed 2 mm (Figure 20). 0 11\0 the glenoid rim and not medially on the The capsular tissue avulsed off the humer­ glenoid neck; al head is identified 3ml reduced [0 the - pull on Slilurt:s before knOl t)'ing :1I1d humer:al nt:ck with :m anhroscopic gr:.lsper after the capsulolabr.l1 repair stitch has been (Figure 21). If a Jabral lear is ide11lified. the plact:d to vi s uali~(' ca psular plication and (Q humeral ~,vulsion of the glenohumeral liga­ t:nsure that adequate capsular tissuc has l::>een melus lesion is repaired first and then the incorporated: I:tbral tear is addre!>sed. This avoids over­ - a IXllanccd repair may be performed if tightening of the ca psule medially, w hich there is significant posterior laxity and cap­ may prevent or impair lateral repair. In order sular volume with dther plication stitches Of to prepare the lxmy bed. lhe original hUJller­ labnull int:lct) or suntrc anchor repair after an al insenion !>ite of the inferior glenohumeral :1.t1terior inslahility rep:li r. ligament complex is genlly debrided using :l hurr on reverse from (he anterior mid- gle­ noid porIa I to complete a light deconicalion H AGL Lesioll and Ohtain a bleeding surface, An IS-G nee­ Once the portals are established, Ihe dle is used under direct visualiz

\·oJ. 6 1. "\"0. 'j .\U"I:R\''\ OKTOt·E])tC.... Ii'l'RAU,\LATOI.QG1CA ,., VAN 11 111" 1. AR11IROSCOI'IC llU:An,IF:\" OF ,\;\;TFRO- I"ITRIOR SIIOI 'u)ER 1l\~"AmLm'

lhe humerus to minimize lisk of :lxillaI), nelve injury. This portal can be used to pbce an anchor percutaneously, or a small5-mlll ca n ~ nula G ill bt' used . It is impol1am to lise the rotation of the humerus to help controlling the ~LCc.:ess to all areas of the humeral GlpSU­ Jar avulsion site. Once lhe anchor is in place. slitures are passed through the torn capsule in

Fib'1.lfC 22.-Arlh r(~~lpil: view of the.: lefl "houlder frollllhe RolalOJ" illlen:a! l)("ISlerior 1](1r1:11 u~iu!!;1 70" S<.:Qpe . \'\'hell tht: Mllur.:~ w<;!rt;: broughl up through IhL· :mIL"rior pOrlaL IhL" !!Icilohumer­ Surgical rep:lir or the rotator intcrval ;Illig:lmcnt L'Omplcx \\,a,. :m;ut)U1i(';llir rcdlKt:d ontt> lhc remains a controversial subject (Figures 23, anLL"rior a~pcc t of the humeral h"ad. 24). Based on the latest biomechanic~ 1 and clinica l srudics. there is relati ve ly strong cvi­ delKe that an arthroscopic RI closure berween rhe st:J ndard posterior portal and improves anterior stability. ls. 19. 20 . 2- the accessory postero latcral po rtal (7 o· Indications for surgical rot~t()r intetval rcpair clock). This is obraincd in a pcrcUl:lncous remain poorly defined: however. there is a rash ion with lhe an<:hor inserting device and growing body of evidence that rOlator inter­ drill. val closure should be considered in: Once the appropriate traiectory is estab­ lished. a 3. 0-m111 bio:1bsorbable suture 1) patients w ith alUerior instability and a anchor is placed. One or the suture limbs is rolator inten 'alicsion (incompctCIlI sulcus): retrieved with a cnx'het hook out the al1lero­ 2) pat ients w ith sym ptom:Hic sho ulder superior porta l. The remaining su ture limb instabiliry and laxiry in the infcrior direction is left pusteriurly outside the skin. A straight (positive sulcus) that docs not lighten in exter­ Slllure repair device is advanced through nal rotation with the arm at rhe side; the 8.25-mm cannula in the 7-0· clock por­ 3) patients who have signifk:ant laxity and tal and passed Ihrough the inrerior/ lateral a l:Irge sulcus finding in the scuing of multi­ capsule just inside o f the avulsion borders. directional instability. A = I monofilament suture is adv:lnced into For arrhro!1copic rotator interval dosttre. lhe joint through the suture re pair dcvice the authors prefer a modifica tiOn 10 the: and retrieved th rough the anterosuperior method described bv Ta verna el apl This PO l"t:11. The mono filament i ~ tied [() the pre­ ·· a ll~in s i d c·· ICchnique :tllo\vs direct visual­ viously passed suru re limb and shuuled back iz:t1ion or the extent of rhe repair and preser­ through the 7-0· d ock port:tl through the v:nion o f the deltoid. The patient can either capsulolig:un entous compk.'x. This ca n be be in the beach-chair or lateral decubitus repeated, and :t mattress SUtllre is then tied position and the position of the glenohullleral through the 7 ~ o · clock portal w ith a knot joilU is adjusted to 30° or external rot arion pusher. with an assistant positioning the arm holder. As the rcpair continues ante- liody. an atces­ A:) to 7-nun c 1I1 1l uia is placed back into the SOl)' low anterior ponal is required for con·eCl middle aspect or the rotator interval and then anthOr placement. This ponal is created in a hacked out such that it is just :1I1tcrior to the tra ns-subscapularis rashion. staying latem] to ca psule. A sharp cresCent hook device is

'" :\tI:--:ER\,\ OttTOPEDtCA E TRAJ.::\tATOl.cxa(;.,\ \A \ TIIIU

Figull.· 23.-A lX·n~·tr:ltor tk.... ·l\"c is in:>t.'I1<."i1 IhrouJ,:h Ih., figure N.-l\\o .-.tildl l'OI:lIQr lm",.,.':)1 d~lIre - Ihe final ~\lperior J.:lell(lhllmer:Jl1i~lm.,m in Ihe superior :L~p<."i.' of repair. Ihe IUI:Uor 1nu,:1\,:11 :mu gr.I~i» the mOnOfu.llf1l.'1ll sun,ln: Ih.ll h.1S Ix.oen IXls...... ""( llhrouRh Ihe middle glenohumer:tllig:I' menl. The cannula is then repl:lct!d. just :Interi­ or to the capsule after the 1''-'0 medially loaded with :1 no. I monofilament suture. based sutures ar~ placed inside the cannu­ This b hrought in though the cannula. and la while it is external 10 (he body. Once then Ihe !issue adjaccl1I 10 the r... I GHL is pen· down on the capsule,:I knot pusher is used etraled wilh the sharp crescent needle. If the to tie a non-sliding k not w hile ,,,atching the !\'IGHI. is small. the superior aspeC( of the closlLre in an '"a ll-i nside" technique to ensure subscapularis or other tissues JU S! superior ndcqu:uc pliellion. The arm is then released to the subscapularis cm be grasped. The first from 30° of external rotation. :lnd stability st itch is placed medially. near Ihe level of :I nd postoperat ive range of mOl ion :Ire the glenoid b ee: one additional slitch \vill :Issessed. he placed more l:itcrally if necessa ry. The n. 1 monofilament sllture is shuttled into the Re/)tlbililflfion joim and then the crescenl hook removed. The ca nnula is mainl:lined in a pOsit ion just Proper pOSIOperupra spinatus. a~ain n few ogy (tr::lumatic us. :Hr.lUIll:ltic): direction o f millimeters laler.ll to the glenoid f.ace. The instabiliry (alllcrior. posterio r. muhidirec­ penetrator retrieves tht! n. I monofilamenl lional); integrity o f tissue ,Lt time of repair: slL ture and is brought out through the can­ comfort level with q ualifY of rep:Lir: and pos­ nula. l11is is changc..."'<.lto :1 n. 2 non-absorbable sihlt! :Issociatcd findings :md treatment (i.e.. suture although :Ibsorbable SUlu res may also biceps Tendon tt!ar, rot:ilor cu ff tear), Routine bl;! used. The n. 2 non-absorbable Suture is postoperative immobilizat ion varies based taken outside Th e ca nnula, and then the cnn­ on the procedures performed. The authors nub is removed and repbced such that the recommend an :l lx iuC1ion sling for most ante­ sutures are now external to the cannuln. A rior instability repairs (this type of sling keeps second stitch that is more l:Jterally placed in tht! shoulder in :l nelltr.LI position). the tissues Illay be passed :11 this point in a Physical Iherap), typicnlly starts 7 to 10 similar fnshion. days fo llowing most routine instability

411 \~\ .'\ THIEL AIfI1 11t0$(;01'IC ThF.AThIEl'-'l· Of ,\i"TERO·II\I'fRIOIt SIIOI!LDEH [I\:>TAII!LI'I'Y

repairs. Unidirectional instability repair will Refer ences progre:;!j with passive and active-assisted I. Meiero RA. T:I~' l l) r DC. I'rim:l!'y :ll1lerivr distOC:lIion of t:mgc of motion for the first 4 wcck~ (forward lh., "Imulder in rotln).: p;lli"'UL~ . A len-yelf pro~p..'<.·­ elevation [FE1 to 130°; external rotation fE R! IiI'., "tudy. J Hone Joinl Su~ Am 1998:80:291)·300. 2. B;t('h fiR. \'\';t!Ti:n RF. Fronek J. Dismption of Ihe I:m:r· to 30°). From 4 to 6 weeks these range:; will :tll':lp~\lle uflile shoutder. A Cluse of recurrent distu­ be increased to FE 130° to 180° and ER 30° to Cllion, J I:kJne Jvilll ~Ul}: Hr 1986:70:274-6. 60°. Active range of motion exerdses 3. B'lI1brt AS. c'1nlah Me. IkCllrR·m vr h'lbilu:11 disll)+ I,.~ llion ofd~ ~hould.:r-joinl . 1923. C;:lin Onhop Rebl RC$ progress thereafter with resisti ve strength­ 1\Y)3;(.!'}1):3·('. ening from 8 to 12 weeks and the return to 4. m/:h~ni LU. "dbr H. ~']; Il Qw EI.. t'ollock HG , Mow Vc. Gknohumcr:tI ~tabiJilr . lJiontt:chanic;11 properties fu ll sports and activities at 4 to 6 months in of p:lssive ;Ind ;u:ti\'c s1aiJilil.crs. Clin Onhop Rdal fkS most cases. 19'.>6:(350): 13·30. 5. Bigliani LU . Newlon I'M . SI.:imn:l11 n SI'. C.orlnor P;.t. ;\(c[JVttrl $). Glenoid rim lesions a",;oci:tl ..-d wilh r<.'Cur­ I'(:nt anterior dbttll.~ l lion of Ihe shoulder. Am J Sport" Conclusion s ;\!cd 199H: l 6:4 1· 5. G. Boardm:m ND. Deb~ki RI::. \\'"rncr JJ , T'lskiran E. Maddox L. Imhoff All. I'll rH. \\'00 SI.. Tcn.~il c prop­ The successful ma nagement of p:uients ertic.~ of the superior ~k-noh\lmer:lI ;md CQr.II:0hwncr:11 lig:lI1tent:<. J Shoulder Elhow Surg 19".>6;5:249·54. w ith anterior shoulder inswbility C;1 n he a 7. l:kJik:lu 1'. Vill:do:r M. Hery JY. Jl;Jlg 1', Ahrens 1'. 1'C}'lOn significant challenge :1Ild is predicated ()11 L Rbk f:I<:lOh for recurrence of shoulder ill.~[:tbility the ;1CCll rare ;1ssessmem and treatment of 'Ifler :mh~'Opk' B:lIlk:ln rep"ir. J Bone JOilll Surg Am 2006:&!, L7,, ·63. Ihe o ffending pathologies. It is essential 8. JkllU}!li CR. Wilckcns JI t. Ddkr.trdtnv TM. D'AHerr.tnd thm the surgeon have an underswnding of )C, \looney RC. H3rpS[rilc J". Areicro 1M. A prml)Cc" the pathoanalOmy of recurrent anterior IiH'. r.mdomiz<:d cV;ILu:uion of arthroscopil' sl~ l hi l il~I' [ion n'hUS I"on·opcr.tlive Ife:llrllenl in patients wilh shoulder instability :lnd 10 recognize the :Icule, [r:Ium:uic, first-lime ~ho\tllkr ~1i~I (I(':llions. ,\m J :I~socia [ ed conditions. \'/ilh :l Ihorough Sport.'> ~Ied lOO2:306i6-80, 9. Burnh:L1't 55. Do: Ik-cr .I E Tr,llI matic g1cnohumo:r:tl bone understanding of the principles of anhro­ dcfL'<.1s :mcl [heir rd:llion~ltip 10 failure of :Irthroscop· scopic inSta bility repair, the pearls provid­ Ie Uank:trt n·pairs: ~ignitk; r n{'e c)f Ihe im cned-pear ed should :lllow a comprehensive approach glenoid and [h(· humcr:l1 {'ng:lging Hill"S;I('h< le:houl· dt:r imwbitilY. Mlhroscopy 200l:1H:4RH·91. pa tient outcomes. II . Bushnell BD. Crei!,(hlun HA. Hcrrin~ ~ IM . Bony in'la· hility of Ihc shoulder. Arthros<:op}' 2()1)8: l ·j, 1061· n. 12. Cole BJ . Rodeo SA. O 'Brk'n SJ. Altl:llek D. Lee n , DiC .. rlo F.F. POIler H. 111e an:ltomr and hblOlogr of Riassunto Ihc 1U!:lIor i me n~tl {~Ipsulc of lite ~houlder, Clin Orthop Rd:1l Hcs 2001:(390): 12<}·>7. L>. Coop{'r DE , AfIlOCzkr SI'. O ' Hricn S), W:lrren HI', 7iw/lmllelllo ar(roscopico de//'i IISlabililii (lJlfero-i /lfe­ DiClrlo E. ,\!len AA. Anatomy. histology. and l~tSCll ­ livre de//a spalla taril}' of [he gknOid bbrum. An an;uomic;ti sludy.) 111r:1II:1rnenl(I deJrinSI:lhilil:\ :11l1c rion' dell:! sp:!ll:I Donl· Joint Su~ Am 1992:'·H6.'52. I'i. I)dkr:mJino T:-' I, Arderu RA. Tal'lof n c;:. Uhorrhak e in comiml:J (:\·olu7.ion<.:. Progres."i ndl'amhilo delle JM. Prospectiv" e\,:llu:llion of :trthroscopit' ~ ! :tbitiza­ tecniche :lrtroseopiche h:mno pcnm:sso di svilup­ lioll ()f "cllie. inlli:11 an1erior shoulder dL~tOCl!ions in pare rCCCllle1llCnle 1:1 riP:1T3z ione :trtroscopiC:l di roung :uhleles. T\\'o· to live· year follow-up. Am J B:lI1kart. Cio si :Issoci:l :!Ilv sviluppo di nUO" i Slru­ Sport:> Med 2001:29:;86-92. menti. impi:lllli. e lecniche. Tuuavi:!. per a Hem.'re 15. Filzpatrick .\1) . I'owdl SE. TiboneJE. Warren tW. The :m:tlomy. p;uhology. ,md ddini[i\'C IrcalnR'1lI of rot:t­ COil buoni risullali nei p:tzicnli insl:thilil:l amcriore, ~ lOr imer",,1 1csi(>Ils: curren t ~oncepls . Arthroscopy fond:lInenlale che il chirurgo Si;! a conos<;enl'.=! dei 2003: I9(Suppl l):i().9. hnori prcopcr:nori, inlr:lOper:llori e postoperalori in t6. Gerlx:r C, Werncr eM. ;\[:llT JC. J:ll'ob HII. Nyfrel~r assod:lzionc con il rieonosei11l<.:nlo <.: i] COrrellC) lr.ll­ I!W. Err~C1 of So;·tttti\·c capsulorrh:lphr on Ihe p; r ~ivc lamenlO deUa p.. 1101ogia rd:uiva all'in:;t:lbilil:'l, In questa r:Ingt:!" of Ill00ion oflhc gto:.'1lnhumcral join!. J Bone Joim Surg ,\m 2003:8')·1\(1):48-';5. capilolo. gli :Jutori presenlano diverse e import:lIi t7. 1l:1IT}'man DT, 2ml. SidlesJA. H~rris Sl.. Mmscn I'll. tccniehc, p:nologie e conceni rebl!"j :t lb correna 3rd. The rolc of Ihe TO!:\fOr illlen'a! o:.~tpsul<.: in p:t",~ivc diagnosi C Ir.HI:UllenIO dd pazienti can inSlallilil:\ motion :rnd ~1:ll.Jilily of Ihe shoulder. J BOne Join[ Surg anlerior<.: im picg:ll1do lecniehe :lrtroscopiche. All! 19")2:74:53-66. 18. Himcnn:ulrl B. G:lChler 1\ . Arthro.

l>lI1\"ERVA ORTOl't:I)]CA E TlL\UMATOLQG[G\ Octob :r !()10 ARTIIROSCOI'IC TRI"'T.\IEYr OF ,\"'TIRO·II'FEIUOIl ~HOI ) l. fJLH INST,\lHun' VA;>: TtUU.

19. Ilovdill~ l. Olofs.son A. Sand~ l rUm ll. "lI~lIl'l;n; Be, :m;1I01ll)' ;IIld hi~lolog)' of Ih" inferiOr gicnohunwr:ll Kr:ml;( I•. Fredin I [ £'1 (ff. Non·oper:nil-c tr':::llm~nt of li~mlcnl complex of tlw ~houlder. Am} :-ilxJIll' "kd prim;lI)" :lnt~riur "houk!.::r di~loc:uion in p;ui .. nb forty 1990:18:4'19-56. )"\':trS of ;I;.:9-22. 2l. HUY"IIl;m~ I'E. I l a~n I'S. Ki(ld ,\I, Dhert W), Willems II. I'ro"L'ndler ,\IT, [)eu",rlin", AJ. G1H)d:<(] r:, N. Rome'O JW. Tlw shape of Ihe inferior pan of Ihe ;.l\Ip:tri~on of m~"";(~uremen1 ('ITor oj. octwL·.. .-n 45 degrL"c~ and 0 degn..~ oone los~ moods 13. Id<.: J, ,\I:leda S. Tak:.gi 1\. " "rm,t! I ' ari,nion~ of Ihe :Uld wilh ditTerI'm po~lniur arthro.~cop)' IXlTl:tl lucl­ gl"nnhumer:.[ lij..\:lm"nt (Olllrlcx: :In :U1:llolllic ~Iudr tiun~. Am.! Sport., I>lcd 2(lOH;3(}: I ]31-8. fur a r thro~copk ll:mk;trl r~p"ir . Arthrosl'Upr '12. Pml"encher /liT. I)"wing "n, lIel! SJ. IIkCurmkk 1'. !OO-I:!O: ] 6-1-8. Solumon OJ. !looney Til. :-ilaniL-y /II. An ;1Il; l ly .~i~ of 11K' ilahl 0"'. An:l1omical varianl.' in Ihe :mte1O~lIperiOr r()!~tor int"n',,1 in pa l iL'lll~ with ;Ulterior, po~wriur. ;mJ :lSPCCI of Ih" j..\lcnoid 1:lbrulll. J Ik)IJe Joint Surj..\ Am multidire<,:liunal shoulder iml:.biliIY. ,\nhr(IScop), 200.'i:l"l6-:\: d!-5. 2000:21:921-9. 15. [[ahi OA. Coscullud:1 I'E. Ho [),1, \.Ias~;r;c:ltion of I'rol"enchcr li lT, C.hOOadr:. N. l{om~.... .,,\A . A,throscopi( :l1lk'fo.~uperior gl"nuid bbrutll l':lri:n1L~ :mu thdr asso- man:lg<;ntent of anwrior ins!ahiltty: pt.-arls. pilr:ln~. and ("iation with "houlder pathology. Onhupedk~ 2008:31: Ic~n~ 1c;lTn~ d . OrthOPL-Uil' Clinil'S of North AmcriGI 1!6. 20 ]OAU25-37. 2("i. [10 II. T:o kapm" A. Shir:li Y. Radiographic eV:llu;uion -14. I'ro\"~ndK'r /l IT, Mulogn.: "l"S. Hnngo ,\1. Zhao K. T;'~!o of Ihe Hill-S:u:;IL~ k-~iun in p;llient' wilh l"I.""(:llITCnt :Int,,· Jr. An Ii.~N. Arthro-.copic versus OPl,n rOI:Ilvr i nlcr,~,1 rior ~ho,,[d~r inslability.J Shoulder Elho'" ~urg 2000.9: dosure; biomcl'h:mk,,1 el':II":lI ioll of st;lbilil)" :u\(1 495-7. mOlion. AnhruS("Up}, 2007;23:"51>3-9::1. Hui E. ]1:u"l.:ey;una Y, Saw T, Kido T. ,\!in:lg;"'~' H. '15. l'rovcnclwr lilT. V"nn" N, Ohopil"",, E. Rinnm J~\l. Y:Ulc ulll)iO N. \'\~lkah:l\~I.,hi I. N()7~1k:t K. h\Un,)bili~~l!ion Tr:lq J. RonK"o .'\...... 1>l:!zzO<.·c' ,\. A hi(JlllcchanicJi in "xlcrn,l1 1Olalion "Iter ~hollidcr di.~loau;()n rL'(lucL's an.1 1ysis of clpsubr pli'~lli(ln I'.:rsu~ anchor rq):lir ufllte the risk of IL"ClIm:nc", A randol1liz(...d contmll~'lcF3rl:md EG. ,'spt."U.'; of the mt:ltor intL"rv:ll..1 Shoukkr El1x>"" Surg An;uomil':t! 1':lri~nll' in Ihe anlt"rosupcrior ,tSlx'("l of the 2.000;9,jj6-4 ] . ;:I.:noid l:thrum: a ~ ! :lIiSlil~tI :m"l}'s~~ of s...-l'en!Y-litrl'<: 29. L~,' ;ne\V!". Flatow 101.. '111" p;"h'-lphj~i()log\, of ~houl­ Gl!.<.'~. J Bune Join! Surg ,\ m 2003:85·'\,65,3-9. der ill!>l :o hililj·. ,\ m J SpOTl~ /lk-u ! OOO:28:910- 7. :;,,;10 H. 1I0i E. Sug"y:o 1 [. /Ilin:k-u Arthroscopy 200·1:20: 169-74. J j!. ,\!ilkr liS, Sunn:lhend DH, H:ltrick C. O'lL"ln' S. 2005:jj:s89-93. GoldbergJ. I l:o rper \"". W:llsh \\lR. Should :I(lIle :"nt<:~ 48. Snyder SJ. K:.r/.d RI'. Ix"l l'il.W w. I'\:rkd I{[). Friedman SLAP lcsions of th" ~hu"lder. Arlhro~copy ri.->r di.~locations of th" shuulder lx' inllnohilized in MJ. 1y<)O:6:!i4·9. extern:ll rotation~ .t\ Gldaveril' ~llId}' . J Shoulder Elhow Sllrg 2004; l j;5!l9·92. Sn}'d"f 5J. SIr:.ff(lrd BB. ArlitroscQpk m:m:tj..\"mclll of j2. /l!oluj..\ne "l'S. Pnwenchcr 1I 1T. ;tk'n;(d KA. \': , ~hun TA. inslabilily of the ~houl~kr. Onh('I~lic~ 1993:10:9')3- lx'\\"ing Cll. Anllr~'opic sl:lbili7~lIion in pati(nL~ wilh loo!. :m illl"ened p',-':!r glenoid: n:~lIh~ in Ix,ticnlS wilh hone ;0. S"K" P II. Mod;,hi J. g""i""". I. T., .. ,hiy" A. h,,,$ o f Ihe anterior gknoid. Am } Sp<.>rl~ Med ,\nh1Os<."upk u~:«)Us Ihnk:tn rqxlir for ('hronk n.'Cur· 2007;,3;: 127f>.!:!j. r"m tr..Hlllla lk" :uu"rior gi<:llohumer..11 instability.) [J.on" /IIolOl{lle 'r.;. Zh:,,, 1\. Hongo,\l, Romeo AA, An K-N. Joint Sur;.: Am 2005:87: 1i52·60. Provencher /lIT. Th" "ddilivn of rot:Hor interl':tl cJo;;urc ;1. Tau!:>cr /II, Resch [I. FurSlnL'r It 1(:lfIl M. S(haucr J. ;lfter anhfQSCopic fL'pai r uf clilwr :tm"rior or po~tcrior ]k:t»ons ror f;lilur" ;.ft...-r surgic:.1 r"p" ir \.If anterior ~hou l dcr in~t:lhility ; effeci on gk nuhumn:!l Ir;HI~l:l­ .~hollldl'r in"':lhili!}'.} Shuull.k'r Elboll' Surg 2O().j: 1:i:279· lion :Hld r-Jnj..\L' vf motion. Am J Spons )' k d Ri. 200iU1 2):]0;·'). the ~lloukkr. ,\rthroscop)' 19')3:'): 1i-21. 53. Tkker JB. Bi).:1i:mi 1.[J, Sos ows~' IJ.l'awluk H,j.,"1:S ct· Jr. J0fg<::l\son 55. W:'L-«lll T. Jullll>OJI DL. Shouldl'r Elbow 2ooj;4:174·84. Th,~ ori~in of !he long 1K':td uf Ihe bi<:ep~ frol\l the 37. O'Brien SJ, Neves /lie, Arnuczky Sl'. l!o;(l)nlck SIl. ."-~ l pub :too gll110id l:Jl>nulI. An an:llomit":l1 studr of 100 D ic:ulo 1:1', Kam:n fU', Schw;om·l{. Wl<"kil'wl<-; 'n _ nn' .,h,,,.lders.J Jlone Joint Surg Br 19')·1:76:/)')1-4.

\"01. 61. ;';0. 5 .\UI'EINA OH"\'OI'EfJl('.A E ll{,\Uo\IATQlOGIC,\ VAN TIUm. ART! IRO~I'IC TRI'..A'I'.\If.N"r OF "'-""ERO.INFERIOn SHOL"l.[)ER II\.1>TAllI lITY

')'). Wanler 11. Deng XI I. W:,rrcn RE Ton:iIIi I'A. Static C':.tp· :m:lIolllic C':lpsulolahr:11 ... arian!. Mthroscop\, 1994:10: ~u l oli!:pm~ntous rc:Mr.tints 10 ,"upo..'rior.inft:rior Ir:m"b­ ! 'il-7. tion of tht: glcnohum~r:ll joint. Am J Sport' M.::d 'is. Y:lln;I11\OI(, N. Itoi E. Abc H. Min;,).:;! wa H. Scki N. L9')2;! O;67;·ti;. Shim:tda Y. Okada K. Contact lx,tween the glenoid 56. Willi""" MM. ,,,,dcc,, A ",,,,,,,",, rO~m"" "''''' "" :md the hlllll<:r:d head in :Iixlu(:t;on. <:xtcr!l;l l rVl:lIiorl. bt.. l'onfus~'d with a U:tnkaft ksion. Arthroscopy :lIld hOri7.0ll!al extension: ;1 new concept of glenoid L9'}:I; LO:586. Ir,,('k. J Shoukk-r Elbow Surg 2007: 16:649·56. S7. \,;ri1li:I1l\~ M.\I. Snydn SJ. Uuford [J Jr. 11K" Burord (;Oll1' 59. YinB. vell:I J. I.evine WN. Arthroscopic :llph:lbe[ :;our: plex_ the "cord·like" middle ~lenohlLlllt:r,d n"anwnl fl",-~lilion of normal. nomlal \·ariant~. and p~thology . • :mcl allSt:nl anlcl'Qsupol.!rior labnllll complex: :1 normal Orthop Clin Nonh Am 2QIO;·11 :2I)7·3OH.

'" \!I /1:ERVA ORTOPf.J)IC,\ E TRAU.\IATOLOG1CA