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Arthroscopic Anterior Shoulder Reconstruction

The glenohumeral joint of the shoulder is the most frequently dislocated joint accounting for 45% of all dislocations with an estimated annual incident of 1.1 per 1000.  The majority of patients are male in their second or third decade, sustaining the injury during contact sports.  Typically, injuries occur during rugby, football, martial arts or falls from cycles. 

Anterior shoulder dislocation usually occurs with the arm in the abducted and externally rotated position and leads to predictable patterns of injury to the labrum, capsuloligamentous structures, glenoid and humeral head.  The Bankart lesion is an avulsion injury of the labrum with or without capsular injury inferior to the equator of the glenoid is the most common but other pathologies are seen.  A lesion in which the anterior band of the inferior glenohumeral ligament (IGHL), the labrum and the anterior scapula periosteum are displaced as a sleeve from the anterior scapular neck (anterior labral periosteal sleeve avulsion – the ALPSA lesion) was described by Neviasier and less commonly a humeral avulsion of the glenohumeral ligament (HAGL lesion) can occur.  Complete mid-substance tears of the capsule and IGHL also occur. 

A Bankart lesion in itself is not sufficient to result in recurrent instability in pathological studies.  Plastic deformation of the IGHL occurs either at the time of initial injury or during subsequent instability episodes and it is the combination of the two that cause recurrent instability.  It is important to look for bony injuries such as glenoid rim fractures or the Hill-Sachs impression fracture of the posterosuperior lateral humeral head.  Soft tissue capsular labral ligamentous and labral injuries can occur during shoulder injury without dislocation or subluxation.  Associated injuries from shoulder injuries must also be excluded such as fractures to the greater tuberosity and acute rotator cuff tears whether partial thickness or full thickness. 

Typically, first time dislocations are treated conservatively with immobilisation in a sling in internal rotation however there is a trend towards offering early arthroscopic soft tissue repair and hence stabilisation.  Recurrent instability is common in younger patients with high risk activities.  Typically, such injuries are offered surgical stabilisation such as is described.  Risk of recurrent instability ranges between 26-95% after non-operative treatment.  The wide range reflects population differences between series of different lengths of follow-up.  Most of those with the highest recurrence rates have included highly selected groups such as military cadets and contact athletes.  A clinical assessment should include careful history taking, clinical examination and appropriate investigation initially with plain radiographs in three views (AP, lateral and axillary).  Subsequent investigations should involve an MRI with intra-articular contrast to provide an arthrogram.  This will allow contrast to delineate the damaged soft tissue structures within the glenohumeral joint.

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- Discussion:
- shoulder arthroscopy / acute dislocations / recurrent anterior instability / multidirectional instability /
posterior instability
- drive through sign:
- refers to the ability to pass the arthroscope easily between the humeral head and the glenoid at level
of anterior band of inferior glenohumeral ligament;
- considered diagnostic of shoulder laxity or instability;
- ref: Clinical significance of the arthroscopic drive-through sign in shoulder surgery.
- arthroscopic findings:
- SLAP tear
- ALPSA lesion:
- may have higher chance of dislocation because these may heal medially on the scapular neck;
Neviaser’s Contribution to the Treatment of ALPSA lesions
Anterior labroligamentous avulsions lead to higher recurrent dislocations vs Bankart following arthroscopic repair
- Results of arthroscopic capsulolabral repair: Bankart lesion vs anterior labroligamentous periosteal sleeve avulsion lesion.
- glad lesion
- glenolabral articular disruption;
- lesion consists of an anterior-inferior labral tear associated with an injury to the glenoid articular cartilage;
- references:
- The glenolabral articular disruption lesion: MR arthrography with arthroscopic correlation.
- Anterior shoulder instability: MR arthrography in the classification of anteroinferior labroligamentous injuries.

- perthes lesion:
                    - variation of the Bankart lesion;
- lesion occurs when the scapular periosteum remains intact but is stripped medially
- torn anterior labrum is displaced only minimally 
- Which labral lesion can be best reduced with external rotation of the shoulder after a first-time traumatic anterior shoulder dislocation?
                    - The HAGL lesion: An arthroscopic technique for repair of humeral avulsion of the glenohumeral ligaments.

- Technique Considerations:
- preparation: considerations include need to document:
- completeness of the diagnostic examination
- adequacy of capsulolabral mobilization
- variation in the use of accessory portals
- use of additional capsular or labral plication or fixation.
- importance of portal placement:
- portals are as perpendicular as possible to the anterior glenoid surface (other wise there will be a tendency to
skive off of the osseous surface);
- in the case of a Bankart lesion, this may mean placing the anterior portal through the substance of subscapularis muscle;
- it is also important to keep the instrument portal as lateral as possible (again to be as perpendicular as possible);
- ref: Arthroscopic repair of anterior-inferior glenohumeral instability using a portal at the 5:30-o'clock position: analysis of the effects of age, fixation method, and concomitant shoulder injury on surgical outcomes..
- assesment:
  - superior labrum (slap)
- remember that with significant (inferior instability) any superior labral tear will cause Superior GHL looseness;
- ref: Arthroscopic suture repair of superior labral detachment lesions of the shoulder.
- rotator interval lesion
- hill sachs lesion
- remplissage: partial transfer of infraspinatus into defect;
- ref: Anatomical and Functional Results After Arthroscopic Hill-Sachs Remplissage

    - Anterior Bankart Repair / capsular shift;
           - arthroscopic inferior capsular shift: (arthroscopic knots)
- surgeon establishes an antero-superior portal and a antero-inferior portal;
- arthroscopic graber is inserted through the superior portal and grasps the inferior capsule and then elevates this superiorly;
- guide wire (or hollow trochar - depending on the specific technique used), is passed through the elvated inferior capsule;
- this technique allows the surgeon to perform as much capsular shift as necessary in a controled fashion;
- anatomic considerations: rim angle is narrow over the anterior inferior glenoid and carefull drill placement is essential;
- references:
Variations in glenoid rim anatomy: implications regarding anchor insertion.
- Anatomy of the axillary nerve and its relation to inferior capsular shift
- Arthroscopic glenohumeral folds and microscopic glenohumeral ligaments: the fasciculus obliquus is the missing link
- Arthroscopic Suture Anchor Capsulorrhaphy Versus Suture Capsulorrhaphy in a Cadaveric Model (SS-01)
- anchor insertion site:
- it is important to insert bone anchor right at the edge of the articular surface;
- if anchor drill hole is inserted slightly away from articular edge, there will be a tendency to skive off osseous surface;
- arthroscopic repair often tends to repair the torn labrum too medially (away from the glenoid rim);
- ref: Anchor Placement on the Glenoid Faceplate Does Not Improve Stability With Bankart Repair (SS-02)
- remplissage
The Effect of Remplissage Procedure on Shoulder Stability and Range of MotionAn in Vitro Biomechanical Assessment
- Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up.
- Anatomical and functional results after arthroscopic Hill-Sachs remplissage
- A prospective, comparative, radiological, and clinical study of the influence of the "remplissage" procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair.
- Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with Hill-Sachs defects
- Outcomes of arthroscopic "remplissage": capsulotenodesis of the engaging large Hill-Sachs lesion.

- thermal shrinkage; (role unclear)

- Complications:
- recurrent instability;
- note that recurrent anterior instability + restriction of external rotation is a risk for not returning to high level sports;
- references:
Revision of Failed Arthroscopic Bankart Repairs.
- Glenoid Rim Fracture After Anchor Repair. A Report of 4 Cases
- Arthroscopic revision Bankart repair: a prospective outcome study.
- Arthroscopic Bankart repair: results and risk factors of recurrence of instability
- Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair

   - axillary nerve injury;
          - ref: Arthroscopic perspective of the axillary nerve in relation to the glenoid and arm position: a cadaveric study.

    - complications from bone anchors:
          - Osteolysis and Arthropathy of the Shoulder After Use of Bioabsorbable Knotless Suture Anchors. A report of four cases.
- Intraosseous foreign body granuloma in rotator cuff repair with bioabsorbable suture anchor.
- Glenoid osteolysis after arthroscopic labrum repair with a bioabsorbable suture anchor

- References:

Arthroscopic Treatment of Anterior-Inferior Glenohumeral Instability. Two to Five-Year Follow-up

Arthroscopic manifestations of shoulder subluxation and dislocation.

Effect of a chondral-labral defect on glenoid concavity and glenohumeral stability. A cadaveric model.

Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first time, traumatic anterior dislocations.

Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation.

Arthroscopic resection of glenoid labral tears in the athlete: a report of 29 cases.

Arthroscopic posteroinferior capsular plication and rotator interval closure after Bankart repair in patients with traumatic anterior glenohumeral instability-A minimum follow-up of 5 years.

Arthroscopic staple capsulorrhaphy for anterior shoulder instability.

Arthroscopic versus open Bankart procedures: a comparison of early morbidity and complications.

Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations.

Pathologic changes associated with shoulder dislocations: arthroscopic and physical examination findings in first time, traumatic anterior dislocations.

Arthroscopic Bankart suture repair: Technique and early results.

Arthroscopic Bankart suture repair.

Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: Long-term evaluation.

- case example:
- 35 year old male with anterior instability, w/ obvious drive through sign demonstrated at arthroscopy;
- arthroscopic grasper is inserted through the anterior-superior portal and is used to grasp the anteior-inferior capsule and to draw it superiorly;
- a suture passer is then inserted through the elevated capsule, which then sets up the Mitek knotless system