Traumatic Anterior Shoulder Instability (TUBS)

Author: David Abbasi

Topic updated on 04/23/13 5:25pm

Introduction

TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery)
Epidemiology
- incidence
  - one of most common shoulder injuries
  - 1.7% annual rate in general population
- demographics
  - have a high recurrence rate that correlates with age at dislocation
  - up to 80-90% in teenagers
Mechanism
- mechanism is a posteriorly directed force on the arm when the shoulder is an abducted and externally rotated
Associated injuries
- labral & cartilage injuries
  - Bankart lesion
    - is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid.
    - is present in 80-90% of patients with TUBS
  - Humeral avulsion of the glenohumeral ligament (HAGL)
    - occurs in patients slightly older than those with Bankart lesions
    - associated with a higher recurrence rate if not recognized and repaired
    - an indication for possible open surgical repair
  - Glenoid labral articular defect (GLAD)
    - is a sheared off portion of articular cartilage along with the labrum
  - Anterior labral periosteal sleeve avulsion (ALPSA)
    - can cause torn labrum to heal medially along the medial glenoid neck
- fractures & bone defects
  - Hill Sachs defect
    - is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
    - is present in 80% if traumatic dislocations and 25% of traumatic subluxations
    - is not clinically significant unless it engages the glenoid
  - Bony Bankart lesion
    - is a fracture of the anterior inferior glenoid
    - present in up to 49% patients with recurrent dislocations
    - higher risk of failure of arthroscopic treatment if not addressed
  - greater tuberosity fracture
    - is associated with anterior dislocation in patients > 50 years of age
  - lesser tuberosity fracture
    - is associated with posterior dislocations
- nerve injuries
  - axillary nerve injury
    - is most often a transient neurapraxia of the axillary nerve
    - present in up to 5% of patients
- rotator cuff tears
  - 30% of TUBS patients > 40 years of age
  - 80% of TUBS patients > 60 years of age

Classification

Anteroposterior translation grading scheme
- Grade 0
  - normal glenohumeral translation
- Grade 1+
  - humeral head translation up to glenoid rim
- Grade 2+
  - humeral head translation over glenoid rim with spontaneous reduction once force withdrawn
- Grade 3+
  - humeral head translation over glenoid rim with locking
Sulcus test grading scheme
- Grade 1
  - acromiohumeral interval <1cm
- Grade 2
  - acromiohumeral interval 1-2cm
- Grade 3
  - acromiohumeral interval >2cm

Anatomy

Glenohumeral anatomy
Anterior static shoulder stability is provided by
- anterior band of IGHL
  - provides static restraint with arm in 90° of abduction and external rotation
- MGHL
  - provides static restraint with arm in 45° of abduction and external rotation
- SGHL
  - provides static restraint with arm at the side

Presentation

Symptoms
- traumatic event causing dislocation
- feeling of instability
- shoulder pain complaints
  - caused by subluxation and excessive translation of the humeral head on the glenoid
Physical exam
- apprehension sign
  - patient supine with arm in 90/90 position
- relocation sign
  - decrease in apprehension with posterior force applied on shoulder
- sulcus sign
  - tested with patient arm at side

Imaging

Radiographs
- see imaging of shoulder
- a complete trauma series needed for evaluation
  - true AP
  - scapular Y
  - axillary
- other helpful views
  - West Point view
    - shows glenoid bone loss
  - Stryker view
    - shows Hill-Sachs lesion
CT scan
- helpful for evaluation of bony injuries
MRI
- best for visualization of labral tear
- addition of intraarticular contrast
  - increases sensitivity and specificity

Treatment Indications

Nonoperative
- acute reduction, immobilization, followed by therapy
  - indications
    - management of first time dislocators remains controversial
  - reduction
    - simple traction-countertraction is most commonly used
    - relaxation of patient with sedation or intraarticular lidocaine is essential
  - immobilization
    - studies show immobilization in external rotation decreases recurrence rates
      - thought to reduce the anterior labrum to the glenoid leading to more anatomic healing
      - subsequent studies have refuted this finding and the initially published results have not been reproducible
  - physical therapy
    - strengthening of dynamic stabilizers (rotator cuff and periscapular musculature)
Operative
- arthroscopic Bankart repair +/- capsular shift
  - indications
    - relative indications
      - first-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age
      - high demand athletes
  - outcomes
    - results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
- open Bankart repair +/- capsular shift
  - indications
    - glenoid defects > 25% (inverted pear)
    - engaging Hill-Sachs lesion
    - humeral avulsion of the glenohumeral ligament (HAGHL)
      - can also be performed arthroscopically but is technically challenging
- Bristow and Latarjet Procedure
  - indications
    - bony deficiencies with >20% glenoid deficiency
    - transfer of coracoid bone and strap muscles for sling effect
    - Latarjet procedure performed more commonly
- Putti-Platt / Magnuson-Stack / Boyd-Sisk
  - indications
    - historic purposes only
    - led to over-constraint and arthrosis
- Remplissage technique
  - indication
    - engaging large (>25%) Hill-Sachs defect
  - technique
    - posterior capsule and infraspinatus tenodon sutured into the Hill-Sachs lesion
    - may be performed with concomitant Bankart repair
- Hill-Sachs bony reconstruction
  - indication
    - engaging Hill-Sachs lesions
  - technique
    - allograft reconstruction
    - arthroplasty
    - rotational osteotomy

Treatment Techniques

Arthroscopic Bankart repair +/- capsular plication
- approach
  - shoulder arthroscopic approach
- technique
  - drive through sign might be present prior to labral repair and capsulorraphy
Open Bankart repair +/- capsular shift
- approach
  - shoulder anterior (deltopectoral) approach
- technique
  - open labral repair and capsulorraphy
Open Capsular shift
- approach
  - shoulder anterior (deltopectoral) approach
- technique
  - inferior capsule is shifted superiorly
- complications
  - subscapularis injury or failed repair
    - post-operative physical exam will show a positive lift off and excessive ER
  - overtightening of capsule
    - leads to loss of external rotation
    - treat with Z lengthening of subscapularis
  - axillary nerve injury
    - iatragenic injury with surgery (avoid by abduction and ER of arm during procedure)
  - late arthritis
    - usually wear of posterior glenoid
    - may have internal rotation contracture
    - seen with Putti-Platt and Magnuson-Stack procedures
Bristow and Latarjet Procedure
- approach
  - shoulder anterior (deltopectoral) approach
- technique
  - coracoid transfer to anterior inferior glenoid bone defect
  - Latarjet: coracoid passed through a split in the proximal 1/3 subscapularis
- complications
  - nonunion
  - hardware problems
  - musculocutaneous nerve injury
Putti-Platt & Magnuson-Stack
- approach
  - shoulder anterior (deltopectoral) approach
- technique
  - Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule
  - Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater tuberosity)
- complications
  - both lead to decreased external rotation and loading on posterior glenoid
    - which leads to degenerative joint disease (capsulorrhaphy arthropathy)
Boyd-Sisk
- historic value only
- technique
  - transfer of biceps laterally and posteriorly
- complications
  - high rate of recurrence

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Qbank (20 Questions)

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(OBQ12.9) A 38-year-old former professional football player complains of longstanding right shoulder pain. He admits to multiple previous shoulder dislocations in the past which were treated conservatively with physical therapy. He now complains of symptoms of repetitive instability and a "catching" feeling whenever he abducts and externally rotates his arm. On physical exam he has a positive apprehension test and crepitus in the 90/90 position. A current MRI image of his shoulder is seen in Figure A. Which of the following surgical treatments is most appropriate to address his symptoms? Topic

Review Topic

FIGURES: A

1. Superior labrum anterior to posterior (SLAP) repair
2. Open approach for bone grafting of humeral defect with allograft
3. Open repair of humeral avulsion of glenohumeral ligament (HAGL) lesion
4. Remplissage procedure
5. Arthroscopic Barkart repair and Remplissage procedure

PREFERRED RESPONSE ▶

DISCUSSION: Arthroscopic Barkart repair and Remplissage procedure would stabilize the torn anterior labrum, and also advance the infraspinatus tendon into the Hill-Sach's defect thereby preventing recurring engagement of the posterior humeral defect and the anterior labrum in the 90/90 position.

The clinical scenario consistent with a chronic Bankart tear and an engaging Hill-Sachs lesion causing anterior shoulder instability and engagement of the Hill-Sachs lesion when the arm is in the 90/90 position.
The Remplissage procedure is indicated for patients with a large (>25%) humeral head deficiency.

Zhu et al reported on arthroscopic Bankart repair combined with Remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesions. They reported good results in 49 patients and concluded the procedure restored shoulder stability without significant impairment of shoulder function in patients with engaging Hill-Sachs lesions.

Purchase et al describe their arthroscopic technique for combined labral repair and Remplissage procedure to treat traumatic shoulder instability in patients with glenoid bone loss and a large Hill-Sachs lesion. The procedure consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion first, followed by Bankart lesion repair.

Figure A shows a T2 axial MRI with a large Bankart tear and large Hill-Sachs lesion. Illustration A shows an example of arthroscopic labral repair and Remplissage technique.

Incorrect Answers:
Answer 1: No information given to suggest SLAP tear.
Answer 2: Bone grafting of the humeral head defect alone would not address the large Bankart lesion.
Answer 3: MRI is not consistent with a HAGL lesion.
Answer 4: Remplissage alone would not address the torn anterior Bankart tear.

Illustrations: A

REFERENCES:

1. Zhu YM, Lu Y, Zhang J, Shen JW, Jiang CY. 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. Am J Sports Med. 2011 Aug;39(8):1640-7. PMID:21505080 (Link to Abstract)

2. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs ‘remplissage’: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy. 2008 Jun;24(6):723-6. PMID:18514117 (Link to Abstract)

Question Authors:

David Abbasi MD, Michael Hughes MD, Ben Taylor MD,

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(OBQ11.19) A 22-year-old collegiate football player has immediate onset of right shoulder pain after a tackle. He reports a history of multiple subluxations in the past, but this is the first time he had to "pop" his shoulder back into place. On examination 3 days later, he has weakness in the deltoid. Radiograph and MR axial image is displayed in Figure A and B, respectively. Which of the following is the MOST appropriate next step in management. Topic

Review Topic

FIGURES: A

1. Humeral avulsion of the glenohumeral ligament (HAGL lesion) stabilization and EMG/NCV studies
2. Immobilization in sling with external rotation and EMG/NCV studies
3. Anterior labral periosteal sleeve avulsion (ALPSA) stabilization
4. Bony Bankart lesion stabilization
5. Transfer of the infraspinatus tendon and greater tuberosity to the humeral head

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation and imaging is consistent with a bony Bankart lesion following a shoulder dislocation. The most appropriate treatment for this injury is open or arthroscopic bony Bankart stabilization. Approximately 48% of patients with an anterior dislocation will have EMG changes in the axillary nerve and this is treated with observation. Surgery (i.e.neuroloysis, grafting, or transfer) is typically only reserved in cases where there is no signs of recovery after 3 to 6 months.

Itoi et al present a cadaveric study of 10 specimens under 11 different testing conditions to determine effect of such glenoid defects on the stability and motion of the shoulder after Bankart repair. They found that a glenoid defect width that is at least 21% of the glenoid length may prompt instability and limit shoulder ROM after Bankart repair. Bony deficiencies involving >21% of the anteroinferior glenoid mandate interventions such as ORIF of acute fractures, structural bone grafting, and coracoid transfer procedures (Bristow-Latarjet).

Burkhart et al present level 4 evidence reviewing 194 consecutive arthroscopic Bankart repairs. They found that 66% of the 21 recurrent dislocations had a significant glenoid bone defect. In those patients without glenoid bony defect, there was only a 4% dislocation recurrence.

Illustration A displays an arthroscopic view of a bony bankart lesion from a posterior viewing portal in a right shoulder in the lateral decubitus position.

Illustrations: A

REFERENCES:

1. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000 Oct;16(7):677-94. PMID: 11027751 (Link to Abstract)

2. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000 Jan;82(1):35-46. PMID:10653082 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Dave Marcu MD,

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(OBQ11.220) A 24-year-old male gymnast is scheduled for arthroscopic repair of the right shoulder. His preoperative MRI is seen in Figure A and the initial arthroscopic examination as viewed from an anterior portal in the lateral decubitus position is demonstrated in Figure B. Based on these images, which of the following diagnoses is correct? Topic

Review Topic

FIGURES: A

1. Partial articular sided thickness rotator cuff tear (PASTA)
2. Anterior labral periosteal sleeve avulsion (ALPSA)
3. Humeral avulsion of the glenohumeral ligament (HAGL)
4. Glenoid labral articular defect (GLAD)
5. Superior labral anterior posterior lesion (SLAP)

PREFERRED RESPONSE ▶

DISCUSSION: The MRI and arthroscopic images are consistent with a humeral avulsion of the inferior glenohumeral ligament(HAGL). The standard HAGL lesion refers to the anterior band of the IGHL. In cases of posterior instability a reverse HAGL (RHAGL) involving the posterior band of the IGHL can be present. HAGL lesions are present in 7-9% of the time in anterior shoulder instability and can be a source of recurrent instability if not surgically addressed along with Bankart lesions.

Illustrations A and B are arthroscopic images showing a HAGL repair of the lesion seen in Figure B. The video illustrates the reapproximation of the avulsed anterior band of the inferior glenohumeral ligament to the humerus of a left shoulder viewed from a posterior viewing portal in the beach-chair position.

Illustrations: A

REFERENCES:

1. Gamradt SC, Warren RF. Glenohumeral instabilities. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:909-986.

2. Wright RW, Brophy RH, McCarty EC, Bishop JY. Acute shoulder injuries. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons: 2009:3-18.

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ10.63) A 25-year-old basketball player sustains a shoulder dislocation during a game that is closed reduced. An MRI will most likely show which of the following? Topic

Review Topic

1. Supraspinatus tear
2. Humeral avulsion of the glenohumeral ligaments
3. Long head of the biceps tear
4. Superior labrum anterior to posterior tear
5. Anteroinferior labral tear

PREFERRED RESPONSE ▶

DISCUSSION: Acute traumatic shoulder dislocations in young athletes are associated with a high rate of anteroinferior labral tears. Acute traumatic shoulder dislocations in older patients (>40yrs) are associated with concomitant rotator cuff tears (answer 1).

Bottoni et al showed in a prospective randomized trial that arthroscopic stabilization was more effective than nonoperative modalities for the treatment of traumatic, first-time anterior shoulder dislocations. They found 77% of patients treated non-operatively had recurrent instability, while only 11% of operatively treated patients had recurrent instability.

Arciero et al in their prospective study showed a higher rate of recurrent instability in patients treated non-operatively (88%) versus operative treatment (14%).

REFERENCES:

1. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994 Sep-Oct;22(5):589-94. PMID:7810780 (Link to Abstract)

2. Bottoni CR, Wilckens JH, DeBerardino TM, D'Alleyrand JC, Rooney RC, Harpstrite JK, Arciero RA. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med. 2002 Jul-Aug;30(4):576-80. PMID:12130413 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Patrick McCulloch MD, Ben Taylor MD, Mark Miller MD,

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Related Videos

Bankart repair

Sports - Educational Presentation - Traumatic Anterior Shoulder Instability (TUBS)

Arthroscopic treatment of an anterior shoulder dislocation.

4/21/2013

55 views

TAG

(OBQ10.77) A 23-year-old man acutely dislocates his shoulder for the first time while kayaking. His shoulder MRI is shown in Figures A and B. He undergoes arthroscopic Bankart repair and re-dislocates his shoulder within 1 month after surgery. What other pathology, besides the Bankart lesion, seen on the initial MRI is likely contributing to his recurrent instability? Topic

Review Topic

FIGURES: A

1. Superior labrum anterior posterior (SLAP) tear
2. Full thickness rotator cuff tear
3. Humeral avulsion of the glenohumeral ligament (HAGL)
4. Glenoid anteversion
5. Posterior labral tear

PREFERRED RESPONSE ▶

DISCUSSION: The clinical scenario of recurrent dislocation after isolated bankart repair suggests a failed bankart repair or a missed concomitant injury. The MRI images (labeled in Illustrations A and B) demonstrate a humeral avulsion of the glenohumeral ligament (HAGL) which is known to contribute to shoulder instability and is a likely culprit for recurrent dislocation as well as the bankart lesion. Other abnormalities which can contribute to instability, but are not seen on the MRI, are rotator cuff tears, engaging Hill-Sachs deformity (a small hill-sachs is seen on the axial MRI image but is likely too small to contribute to instability), and labral tears. The article by Bui-Mansfield et al reviews HAGL lesions while the paper by Rhee et al reviewed their series of traumatic anterior instability patients and identified only 2% with a HAGL lesion with the majority occurring in concert with a bankart lesion.

Illustrations: A

REFERENCES:

1. Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. PMID:17420506 (Link to Abstract)

2. Rhee YG, Cho NS. Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):188-92. PMID:17399624 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

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(OBQ10.264) Open anterior shoulder stabilization procedures have failed twice for an active 22-year-old patient. Most recently he had another episode of instability when reaching into the back seat while driving. He has weakness performing the physical exam maneuver shown in Figure A. Images from his MRI are shown in Figures B and C. What is the most appropriate next surgical treatment? Topic

Review Topic

FIGURES: A

1. Another course of physical therapy
2. Latarjet procedure
3. Lesser tuberosity transfer
4. Pectoralis major transfer
5. Latissimus dorsi transfer

PREFERRED RESPONSE ▶

DISCUSSION: This patient has recurrent shoulder instability and deficiency of the subscapularis tendon. Figure A shows a belly press test, weakness of which indicates functional subscapularis deficiency. Figure B is an axial MRI image showing that the subscapularis is retracted away from its insertion. In an acute case, subscapulars repair may be indicated. However, the sagittal MRI image (Figure C) shows significant atrophy of the subscapularis muscle. Traditional open approaches to address anterior shoulder instability may involve detaching the subscapularis to access the shoulder capsule and the labrum, followed by repair of the subscapularis tendon. In this case, the repair was either not successful or it subsequently re-ruptured. Due to muscle atrophy and retraction, a direct repair of the subscapularis tendon is not likely to be effective. More physical therapy will not repair the torn tendon. The most appropriate surgical option in this case would be pectoralis major transfer to the lesser tuberosity to substitute for the subscapularis tendon. Elhassan et al. studied patients with pectoralis transfer for irreparable cuff tears and found that results were better for instability patients than for arthroplasty patients. Resch et al. found that both pain and function improved in elderly patients who had pectoralis transfer for subscapularis deficiency. Latissimus dorsi transfer is for supraspinatus and/or infraspinatus deficiency (and those patients do poorly if subscapularis is not competent). Latarjet procedure (coracoid transfer to anterior glenoid) can be considered for those with anterior glenoid deficiency, but it will not substitute for an absent subscapularis. Lesser tuberosity transfer may be used to address a reverse Hill-Sachs deformity.

REFERENCES:

1. Elhassan B, Ozbaydar M, Massimini D, Diller D, Higgins L, Warner JJ. Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work? J Bone Joint Surg Br. 2008 Aug;90(8):1059-65. PMID:18669963 (Link to Abstract)

2. Resch H, Povacz P, Ritter E, Matschi W. Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am. 2000 Mar;82(3):372-82. PMID:10724229 (Link to Abstract)

Question Authors:

Dave Marcu MD, Patrick McCulloch MD,

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(OBQ09.133) Which patient would be ideal for an open shoulder reduction and glenoid bone augmentation? Topic

Review Topic

1. 25-year-old with first time acute traumatic dislocation
2. 78-year-old with a rotator cuff tear arthropathy with superior escape
3. 24-year-old with chronic dislocation and large engaging Hill-Sachs lesion
4. 30-year-old with an acute bony Bankart fracture-dislocation
5. 27-year-old with a chronic anterior dislocation and inverted pear-shaped glenoid

PREFERRED RESPONSE ▶

DISCUSSION: Open reduction and glenoid bone augmentation with graft or coracoid transfer is ideal for chronic dislocations with anterior glenoid deficiency (inverted pear-shaped glenoid) without significant Hill-Sachs (<20% of humeral head arc impaction). The algorithm to treat chronic dislocation was reviewed by Shahajpal. When the glenoid defect is greater than 20-30% then bony augmentation is indicated. The humeral head defect should be addressed if engaging or 20-40% head loss, and hemiarthroplasty should be considered if >40% of the head is involved. The Beran paper reviews management of glenoid bone defects.

REFERENCES:

1. Shahajpal DT, Zuckerman JD: Chronic glenohumeral dislocation. J Am Acad Orthop Surg 2008;16:385-398 PMID:18611996 (Link to Abstract)

2. Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elbow Surg. 2010 Jul;19(5):769-80. Epub 2010 Apr 14. Review. PMID:20392650 (Link to Abstract)

Question Authors:

Charles Jobin MD, Patrick McCulloch MD, Dave Marcu MD,

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(OBQ09.136) The pathology seen in Figure A is most likely to result from trauma that occurred with the shoulder in which of the following positions? Topic

Review Topic

FIGURES: A

1. Adduction, internal rotation
2. Adduction, external rotation
3. Abduction, external rotation
4. Extension, internal rotation
5. Axial traction in adduction

PREFERRED RESPONSE ▶

DISCUSSION: Figure A is an MRI arthrogram showing an anterior labral injury and a Hill-Sachs defect which are both characteristic of anterior shoulder instability. The classic position of anterior shoulder instability is abduction and external rotation. Posterior instability is associated with trauma in the position of adduction and internal rotation.

Sanders et al suggests that magnetic resonance arthrography is the study of choice for evaluation of soft tissue lesions associated with shoulder instability.

Illustrations A & B also show axial MRI arthrogram images. Note how A shows the labral tear at the level of the rotator interval, so the subscapularis tendon is not seen well. Image B is further inferior and clearly shows that the subscapularis is intact.

Illustrations: A

REFERENCES:

1. Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 301-311

2. Sanders TG, Morrison WB, Miller MD: Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med 2000;28:414-434 PMID:10843139 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Patrick McCulloch MD,

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(OBQ09.143) An 18-year-old football player sustains an anterior shoulder dislocation that is reduced on the field. When he presents to the office complaining of posterior pain, you suspect a Hill-Sachs defect. Which of the following is the best radiographic view for identifying a Hill-Sachs defect? Topic

Review Topic

FIGURES: A

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶

DISCUSSION: The Stryker notch view (Figure C) is best for identifying a Hill-Sachs defect. It is obtained by positioning the patient supine with the arm flexed toward the ceiling, flexed at the elbow, and the patient’s hand placed on top of the head and the xray beam is directed anteroposteriorly, with 10° of cephalic angulation. (Illustration A)

The “true” AP or Grashey shoulder view (Figure A) is obtained by tilting the x-ray beam in the plane of the scapula, approximately 45° laterally off the AP shoulder view to obtain an "end on" view of the glenohumeral joint. The scapular “Y” view (Figure B) is obtained by tilting the x-ray beam along the plane of the scapula, approximately 60° relative to the AP view.

The article by Sanders et al states the Stryker view is poor for detecting Bankart lesions and subluxation, but good for finding Hill-Sachs defects. The Zanca view (Figure D) is utilized to delineate Acromioclavicular (AC) joint anatomy and is a shoulder AP view focusing on the AC joint with a 10 degree cephalic tilt. An axillary view (Figure E) is the best option for detecting an anterior shoulder dislocation. The radiograph beam is projected in a distal-to-proximal direction through the shoulder with the arm in abduction and provides a view tangential to the glenohumeral joint.

Sanders et al lists 10 different variations of the axillary view with modifications to help with patient comfort (Velpeau view eliminates need to abduct arm) or delineate specific anatomic features (West Point view for Bony Bankarts). The 2 review articles by Sanders et al are excellent primers for obtaining and interpreting shoulder imaging.

Illustrations: A

REFERENCES:

1. Sanders TG, Morrison WB, Miller MD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med. 2000 May-Jun;28(3):414-34. PMID:10843139 (Link to Abstract)

2. Sanders TG, Miller MD. A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med. 2005 Jul;33(7):1088-105 PMID:15983127 (Link to Abstract)

Question Authors:

Michael Hughes MD, Eric Shirley MD, Patrick McCulloch MD,

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(OBQ08.45) A patient sustains the injury seen on the radiograph in Figure A. Which nerve is most likely to be injured? Topic

Review Topic

FIGURES: A

1. Suprascapular
2. Upper or lower subscapular
3. Musculocutaneous
4. Radial
5. Axillary

PREFERRED RESPONSE ▶

DISCUSSION: This is a scapular Y view which is a form of shoulder lateral radiograph. The humeral head should overly the intersection of the "Y" created by the scapular spine and the coracoid, which would indicate that it is centered on the glenoid. In this case, it is clearly anteriorly dislocated. The study by Visser et al showed the axillary nerve is most likely to be injured (42%)in anterior dislocations. Toolanen et al looked at anterior dislocations in patients over 40 years old, and found 6 of 55 cases had electromyographically verified axillary nerve or brachial plexus injury.

REFERENCES:

1. Visser CP, Coene LN, Brand R, Tavy DL. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br. 1999 Jul;81(4):679-85. PMID:10463745 (Link to Abstract)

2. Toolanen G, Hildingsson C, Hedlund T, et al. Early complications after anterior dislocation of the shoulder in patients over 40 years. An ultrasonographic and electromyographic study.Acta Orthop Scand. 1993 Oct;64(5):549-52. PMID:8237322 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Patrick McCulloch MD,

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(OBQ07.80) An athlete has recurrent anterior shoulder instability despite non-operative treatment including PT and bracing. What is the best indication for a coracoid transfer (Latarjet) procedure? Topic

Review Topic

1. Previous arthroscopic Bankart
2. Previous capsular shrinkage
3. Anterior glenoid deficiency of 25% of the articular surface
4. Hill-Sachs comprising 10% of the articular surface
5. Patient is a throwing athlete

PREFERRED RESPONSE ▶

DISCUSSION: Latarjet is a coracoid transfer from its native position laterally to be flush with the face of the glenoid. The Latarjet is a bony procedure. While it is an option for previous failed surgery, so is open or arthroscopic Bankart repair. However, bone deficiency should be addressed with a bony procedure. Bone problems leading to recurrent instability include a large Hill-Sachs lesions (> 30 % of head), any engaging hill-sachs lesion, or a glenoid bone deficiency. Glenoid bone deficiency (which is defined as 20 -30 % glenoid bone loss) cannot be addressed with a soft tissue or capsular procedure. The cadaveric biomechanical study by Wellman et al reported that the Latarjet procedure outperformed the contoured bone graft in reducing translation in anteroinferior glenoid bone defects. They found the Latarjet procedure is especially effective at 60 degrees of glenohumeral abduction.

REFERENCES:

1. Wellmann M, Petersen W, Zantop T, Herbort M, Kobbe P, Raschke MJ, Hurschler C. Open shoulder repair of osseous glenoid defects: biomechanical effectiveness of the Latarjet procedure versus a contoured structural bone graft.Am J Sports Med. 2009 Jan;37(1):87-94. Epub 2008 Dec 4. PMID:19059896 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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(OBQ07.130) A 22-year-old basketball player has recurrent instability of the left shoulder. Magnetic resonance imaging is shown in Figures A and B. Which of the following ligaments is injured? Topic

Review Topic

FIGURES: A

1. Inferior glenohumeral
2. Middle glenohumeral
3. Superior glenohumeral
4. Coracohumeral
5. Coracoacromial

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation and imaging studies are consistent with a humeral avulsion of the inferior glenohumeral ligament, also known as a HAGL lesion. If overlooked, HAGL lesions can cause a failure of Bankart repair (lesion is on the other end of the IGHL). The standard HAGL lesion refers to the anterior band of the IGHL, while with posterior instability you can have a reverse HAGL (RHAGL) involving the posterior band.

Abrams presents a review article on RHAGL lesions and associated posterior instability. They note that arthroscopic repair of the HAGL to the humerus, balanced capsular plication, and repair of associated labral tears reliably returns patients to their sport or vocation.

Wolf et al described their experience treating 64 patients with anterior shoulder instability. They identified a HAGL lesion in 9% of these patients and a Bankart lesion in 74% of patients.

Illustration A is an additional example of a coronal MR image demonstrating a HAGL lesion at the arrowheads. In this MRI arthrogram, contrast is seen extending down the humerus indicating a rupture of the inferior glenoid ligaments, which are seen attached on the glenoid side but not on the humeral side. Illustration B is an arthroscopic image of a HAGL lesion with the subscapularis muscle (SM) deep to the avulsed ligament off of the humeral neck (HN). Illustration C demonstrates the glenohumeral ligament anatomy. The video shows the inferior band of the glenohumeral ligament being reapproximated to the humerus.

Illustrations: A

REFERENCES:

1. Abrams JS: Arthroscopic repair of posterior instability and reverse humeral glenohumeral ligament avulsion lesions. Orthop Clin North America 2003: 34: 475-483 PMID:14984187 (Link to Abstract)

2. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995 Oct;11(5):600-7. PMID:8534304 (Link to Abstract)

Question Authors:

Michael Hughes MD, Derek Moore, Eric Shirley MD,

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(OBQ07.216) A 17-year-old football player sustained an injury to his shoulder. The MRI images are seen in Figures A and B. What is the most likely finding seen at the time of arthroscopy? Topic

Review Topic

FIGURES: A

1. Rotator cuff tear
2. SLAP tear
3. Bankart lesion
4. Glenoid fracture
5. Humeral avulsion of glenohumeral ligaments (HAGL)

PREFERRED RESPONSE ▶

DISCUSSION: The MRI shows an anterior labral detachment (illustration A) and a Hill-Sachs defect (illustration B). Hill-Sachs defects occur in shoulder instability when an anteriorly dislocated humeral head contacts the glenoid. This leaves an impression on the postero-superior aspect of the humeral head. The most common pathologic finding in shoulder instability is the Bankart Lesion, which is a tear of the anterior inferior labrum/anterior band of the IGHL (inferior glenohumeral ligament).

Hintermann et al showed that 87% of the shoulders they scoped after dislocation had labral tears at the anterior and anterioinferior margin of the glenoid; 68% had a Hill Sachs lesion.

In a study by Taylor et al, 63 of 67 (97%) had Bankart lesions, but none had rotator cuff tears. Hintermann’s study of 212 pts showed 30 (14%) rotator cuff tears.

Incorrect Answers:
1-Rotator cuff tears following anterior shoulder instability are much more common in older patients (>50 years old), but rare in the young patient. 2-SLAP tears are commonly seen in athletes with repetitive overhead activity (e.g. pitchers, volleyball players).
4-Glenoid fractures (e.g. Bony Bankart) can occur in shoulder instability, but these are much less common than Bankart lesions.
5-Humeral avulsion of glenohumeral ligaments (HAGL) can occur from shoulder instability, but is much less common than the Bankart lesion (only 1 of 67 in Taylor's study had a HAGL lesion).

Illustrations: A

REFERENCES:

1. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997; 25:306-311 PMID:9167808 (Link to Abstract)

2. Hintermann B, Gachter A: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995; 23:545-551 PMID:8526268 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Michael Hughes MD,

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(OBQ07.252) What nerve is the most frequently injured in the condition shown in the radiograph? Topic

Review Topic

FIGURES: A

1. Axillary
2. Median
3. Musculocutaneous
4. Radial
5. Suprascapular

PREFERRED RESPONSE ▶

DISCUSSION: The axillary nerve is the mostly commonly injured during an anterior dislocation because of its close association with the glenohumeral joint and its course around the surgical neck of the humerus.

Visser et al showed that the axillary nerve is injured in 42% of dislocations as evidenced by clinical exam and EMG. Musculocutaneous and radial nerves are not as close to the joint as the axillary nerve, but the distance between the anchorage points in the upper arm is short which makes them vulnerable to traction. Median and ulnar nerves are less likely to be injured because of their unencumbered pathway on the upper arm. Traction on the suprascapular nerve between its origin from the suprascapular plexus to the suprascapular notch can cause damage to the nerve, usually during abduction beyond physiological range of motion.

Illustration A depicts the axillary nerve's course posterior around the humerus and its close proximity to the humeral head during anterior shoulder dislocation.

Illustrations: A

REFERENCES:

Question Authors:

Doug Nowak MD, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ07.259) What factor has highest risk for recurrent instability following a traumatic anterior shoulder dislocation? Topic

Review Topic

1. History of contralateral shoulder dislocation
2. Young age (<25-years-old) at time of dislocation
3. Dislocation of the dominant shoulder
4. Family history of shoulder instability
5. History of patella instability

PREFERRED RESPONSE ▶

DISCUSSION: Regardless of the period of immobilization, a specific exercise program, or immobilization/activity restriction, recurrence rates remain high. The only consistent predictor of recurrence has been the age of the patient, reflecting the activity demands of the patient. In young patients (<25 years old), recurrence rates have ranged from 60-94%. Family history confers a 34% risk of recurrence, while dislocation in the contralateral shoulder is seen in 25% of recurrently unstable patients according to one study in JBJS (Hovelius et al, 2008). No difference in dominant and non-dominant extremities was noted.

REFERENCES:

2. Hovelius L, Olofsson A, Sandström B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, Nowak J, Sennerby U. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 2008 May;90(5):945-52. PMID:18451384 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD,

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(OBQ06.49) A patient undergoes an MRI arthrogram for recurrent shoulder instability. Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. What is the most likely diagnosis? Topic

Review Topic

1. Glenolabral articular disruption (GLAD)
2. Humeral avulsion of the glenohumeral ligament (HAGL)
3. Superior labrum tear from anterior and posterior (SLAP)
4. Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)
5. Partial articular-sided supraspinatus tendon avulsion (PASTA)

PREFERRED RESPONSE ▶

DISCUSSION: Humeral avulsion of the glenohumeral ligament (HAGL) occurs when the IGHL tears away from its humeral insertion without an associated subscapular tear. The classic teaching is that HAGL lesions requires open repair of the capsule, whereas the other lesions listed are felt to be better addressed with an arthroscopic approach.

According to the literature review by Stein et al., patients with significant glenoid bone loss, attenuated capsulolabral tissue, engaging Hill-Sachs lesions, and HAGL lesions are contraindicated for arthroscopic repair. They state that while arthroscopy has better cosmesis, decreased perioperative morbidity, decrease loss of external rotation, and is valuable in the confirmation of the extent and severity of shoulder instability, for these lesions open techniques are the gold standard.

The Neviaser article discusses good results for arthroscopic debridement of GLAD lesions for pain relief.

REFERENCES:

1. Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: A review of the literature. Arthroscopy 2002;18:912-924. PMID:12368791 (Link to Abstract)

2. Neviaser TJ. The GLAD lesion: Another cause of anterior shoulder pain. Arthroscopy 1993;9:22-23. PMID:8442825 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Eric Shirley MD, Ben Taylor MD,

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(OBQ06.59) A 23-year-old offensive lineman had an arthroscopic anteroinferior labral repair 1 year ago for shoulder instability. He has continued to have recurrent instability. Below is the preoperative MRI from 1 year ago. What is the most likely cause of the recurrent instability? Topic

Review Topic

FIGURES: A

1. Anteroinferior labral nonunion
2. Unrecognized humeral avulsion of the glenohumeral ligament (HAGL)
3. Anteroinferior glenoid bone defect
4. Engaging Hill Sachs defect
5. Untreated SLAP lesion

PREFERRED RESPONSE ▶

DISCUSSION: The MRI reveals an anteroinferior glenoid fracture (bony Bankart). This was not addressed at initial surgery as the patient only underwent a soft tissue Bankart repair.

Burkhart et al performed a combined cadaveric and cohort study of patient's without shoulder instability. They examined the use of the glenoid bare spot as a reference point for determining anterior glenoid bone loss. They concluded that the glenoid bare spot is reliably found at the center of the glenoid.

Edwards et al performed a Level 4 review of shoulder instability patients. They found that 73% had the presence of a Hill Sachs lesion and 8% had anterior glenoid bone lesions found on radiographs.

Lynch et al performed a Level 5 review of shoulder instability in the setting of concomitant osseous defects. Soft tissue procedures have a high failure rate when glenoid bony deficiency >25% exists.

REFERENCES:

1. Burkhart SS, Debeer JF, Tehrany AM, et al: Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18:488-391. PMID:11987058 (Link to Abstract)

2. Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy. 2003 Sep;19(7):732-9. PMID:12966381 (Link to Abstract)

3. Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA 3rd. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28. PMID:19218054 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ06.128) A 19-year-old right hand dominant male high school wide receiver complains of recurrent right shoulder subluxation. Clinical examination is remarkable for a postive apprehension sign and a positive sulcus sign. A T2 coronal MRI is shown below in Figure A. What is the diagnosis? Topic

Review Topic

FIGURES: A

1. Bankart lesion
2. SLAP tear
3. Rotator cuff tear
4. ALPSA lesion
5. HAGL lesion

PREFERRED RESPONSE ▶

DISCUSSION: The humeral avulsion of glenohumeral ligament (HAGL) is a rare cause of anterior shoulder instability. The prevalence among unstable shoulder is reported as 7-9%. The term HAGL was coined by Wolf in 1995. In 64 shoulders undergoing surgery for instability, they found 6 shoulders had HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). Taylor found an even lower occurrence of HAGL in instability (only 1 of 67). The gold standard repair is by open repair although small case series of arthroscopic repairs have been described recently. Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA) is when the IGHL complex, labrum, and periosteum are stripped and displaced medially and infereiorly on the scapular neck

REFERENCES:

1. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995 Oct;11(5):600-7. PMID:8534304 (Link to Abstract)

2. Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997; 25:306-311 PMID:9167808 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ06.256) What is the most common finding during surgery for traumatic anterior shoulder instability? Topic

Review Topic

1. Anterosuperior labral tear
2. Anteroinferior labral tear
3. Posterosuperior labral tear
4. Posteroinferior labral tear
5. Hill Sachs lesion

PREFERRED RESPONSE ▶

DISCUSSION: Hintermann et al conducted a prospective study to evaluate the arthroscopic findings of the unstable shoulder to provide insights in the causes and mechanisms of shoulder instability. 212 patients who had at least 1 documented shoulder dislocation. Of these 87% had anterior glenoid labral tears (the Bankart lesion), 79% had ventral capsule insufficiency, 68% had Hill-Sachs compression fractures, 55% had glenohumeral ligament insuffiency, 14% had complete rotator cuff tears, 12% had posterior glenoid labral tears, and 7% had SLAP tears. Similairly, In a study by Taylor et al, 63 of 67 (97%) had Bankart lesions, but none had rotator cuff tears. Thus, the right answer here is anterior labral tears, choice 2.

REFERENCES:

1. Hintermann B, Gachter A,: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551 PMID:8526268 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD,

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(OBQ05.42) A 21-year-old rugby player has recurrent pain and instability of the right shoulder recalcitrant to conservative management. Figure A is an image taken during diagnostic arthroscopy in the lateral decubitus position viewing from the posterior portal with instrument through a rotator interval anterior portal. In addition to the pathology seen in Figure A, what other associated intra-articular condition is most likely present? Topic

Review Topic

FIGURES: A

1. Rotator cuff tear
2. SLAP tear
3. Posterior labral tear
4. Hill-Sachs lesion
5. Buford complex

PREFERRED RESPONSE ▶

DISCUSSION: The lesion shown in Figure A is a Bankart lesion, or avulsion of the anteroinferior fibrocartilaginous labrum adjacent to the IGHL. There is also the presence of a GLAD lesion or glenolabral articular disruption. Hill-Sachs lesion are the most common associated intra-articular findings.

Bankart lesions frequently result from traumatic anterior shoulder dislocations and may result in recurrent instability, especially in younger patients. Because of the violent mechanism of injury, compression fractures of the posterolateral humeral head (Hill-Sachs lesions) may also result as the soft humeral head impacts against the relatively hard anterior glenoid. It is important to note that the presence of a Hill-Sachs lesion may destabilize the GH joint and predispose to subsequent dislocation if it engages the glenoid.

Hintermann et al conducted a prospective study to evaluate the arthroscopic findings of the unstable shoulder to provide insights in the causes and mechanisms of shoulder instability. In 212 patients who had at least 1 documented shoulder dislocation; 87% had anterior glenoid labral tears (Bankart lesion), 79% had ventral capsule insufficiency, 68% had Hill-Sachs compression fractures, 55% had glenohumeral ligament insuffiency, 14% had complete rotator cuff tears, 12% had posterior glenoid labral tears, and 7% had SLAP tears. Thus, of the choices, Hill-Sachs lesions are the most common finding.

Kralinger et al found that the only factor associated with instability recurrence following an initial dislocation was age between 21 and 30 years (immobilization and physical therapy were not associated with recurrence).

Illustration A shows the 2cm loose body removal from the GLAD lesion. Illustration B shows suture anchor placement within the GLAD lesion on the anterior glenoid. Illustration C shows the completed bankart repair.

Illustrations: A

REFERENCES:

1. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002 Jan-Feb;30(1):116-20. PMID:11799007 (Link to Abstract)

2. Hintermann B, Gachter A,: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551 PMID:8526268 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Ben Taylor MD,

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Bottoni CR, Wilckens JH, DeBerardino TM, D'Alleyrand JC, Rooney RC, Harpstrite JK, Arciero RA. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. Am J Sports Med. 2002 Jul-Aug;30(4):576-80. PMID:12130413 (Link to Abstract)

Level of Evidence 2 (Prospective Cohort Study)

Hintermann B, Gachter A,: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551 PMID:8526268 (Link to Abstract)

Level of Evidence 4 (Case Series)

Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000 Oct;16(7):677-94. PMID: 11027751 (Link to Abstract)
Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy. 2003 Sep;19(7):732-9. PMID:12966381 (Link to Abstract)
Elhassan B, Ozbaydar M, Massimini D, Diller D, Higgins L, Warner JJ. Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work? J Bone Joint Surg Br. 2008 Aug;90(8):1059-65. PMID:18669963 (Link to Abstract)
Hintermann B, Gachter A: Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995; 23:545-551 PMID:8526268 (Link to Abstract)
Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002 Jan-Feb;30(1):116-20. PMID:11799007 (Link to Abstract)
Resch H, Povacz P, Ritter E, Matschi W. Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am. 2000 Mar;82(3):372-82. PMID:10724229 (Link to Abstract)
Rhee YG, Cho NS. Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):188-92. PMID:17399624 (Link to Abstract)
Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997; 25:306-311 PMID:9167808 (Link to Abstract)
Visser CP, Coene LN, Brand R, Tavy DL. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br. 1999 Jul;81(4):679-85. PMID:10463745 (Link to Abstract)
Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995 Oct;11(5):600-7. PMID:8534304 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000 Jan;82(1):35-46. PMID:10653082 (Link to Abstract)
Abrams JS: Arthroscopic repair of posterior instability and reverse humeral glenohumeral ligament avulsion lesions. Orthop Clin North America 2003: 34: 475-483 PMID:14984187 (Link to Abstract)
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. PMID:17420506 (Link to Abstract)
Burkhart SS, Debeer JF, Tehrany AM, et al: Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002;18:488-391. PMID:11987058 (Link to Abstract)
Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA 3rd. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28. PMID:19218054 (Link to Abstract)
Sanders TG, Miller MD. A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med. 2005 Jul;33(7):1088-105 PMID:15983127 (Link to Abstract)
Sanders TG, Morrison WB, Miller MD. Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med. 2000 May-Jun;28(3):414-34. PMID:10843139 (Link to Abstract)
Sanders TG, Morrison WB, Miller MD: Imaging techniques for the evaluation of glenohumeral instability. Am J Sports Med 2000;28:414-434 PMID:10843139 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Gamradt SC, Warren RF. Glenohumeral instabilities. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:909-986.
Wright RW, Brophy RH, McCarty EC, Bishop JY. Acute shoulder injuries. In: Kibler WB, ed. Orthopaedic Knowledge Update: Sports Medicine 4. Rosemont, IL: American Academy of Orthopaedic Surgeons: 2009:3-18.

Undefined

Zhu YM, Lu Y, Zhang J, Shen JW, Jiang CY. 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. Am J Sports Med. 2011 Aug;39(8):1640-7. PMID:21505080 (Link to Abstract)
Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994 Sep-Oct;22(5):589-94. PMID:7810780 (Link to Abstract)
Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994 Sep-Oct;22(5):589-94. PMID:7810780 (Link to Abstract)
Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elbow Surg. 2010 Jul;19(5):769-80. Epub 2010 Apr 14. Review. PMID:20392650 (Link to Abstract)
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 301-311
Hovelius L, Olofsson A, Sandström B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, Nowak J, Sennerby U. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 2008 May;90(5):945-52. PMID:18451384 (Link to Abstract)
Neviaser TJ. The GLAD lesion: Another cause of anterior shoulder pain. Arthroscopy 1993;9:22-23. PMID:8442825 (Link to Abstract)
Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs ‘remplissage’: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy. 2008 Jun;24(6):723-6. PMID:18514117 (Link to Abstract)
Shahajpal DT, Zuckerman JD: Chronic glenohumeral dislocation. J Am Acad Orthop Surg 2008;16:385-398 PMID:18611996 (Link to Abstract)
Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: A review of the literature. Arthroscopy 2002;18:912-924. PMID:12368791 (Link to Abstract)
Toolanen G, Hildingsson C, Hedlund T, et al. Early complications after anterior dislocation of the shoulder in patients over 40 years. An ultrasonographic and electromyographic study.Acta Orthop Scand. 1993 Oct;64(5):549-52. PMID:8237322 (Link to Abstract)
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Traumatic Anterior Shoulder Instability (TUBS)

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