American Shoulder and Elbow Surgeons
Please rate topic.
Average 4.3 of 60 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 38-year-old former professional football player complains of longstanding left 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?
Superior labrum anterior to posterior (SLAP) repair
Open approach for bone grafting of humeral defect with allograft
Open repair of humeral avulsion of glenohumeral ligament (HAGL) lesion
Arthroscopic Bankart repair and Remplissage procedure
Select Answer to see Preferred Response
The clinical scenario is consistent with a chronic Bankart tear and an engaging Hill-Sachs lesion causing anterior shoulder instability and engagement of the Hill-Sachs lesion in the 90/90 arm position. Arthroscopic Barkart repair and a Remplissage procedure would be the most appropriate treatment at this time.
The Remplissage procedure is indicated for patients with a large (>25%) humeral head deficiency and is performed by advancing 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.
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.
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.
Zhu YM, Lu Y, Zhang J, Shen JW, Jiang CY.
Am J Sports Med. 2011 Aug;39(8):1640-7. Epub 2011 Apr 19. PMID: 21505080 (Link to Abstract)
Zhu, AJSM 2011
Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC.
Arthroscopy. 2008 Jun;24(6):723-6. PMID: 18514117 (Link to Abstract)
Purchase, ASCOPY 2008
Please rate question.
Average 4.0 of 31 Ratings
A 22-year-old collegiate football player has immediate onset of left 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. CT axial image is displayed in Figure A. Which of the following is the MOST appropriate next step in management.
Humeral avulsion of the glenohumeral ligament (HAGL lesion) stabilization and EMG/NCV studies
Immobilization in sling with external rotation and EMG/NCV studies
Anterior labral periosteal sleeve avulsion (ALPSA) stabilization
Bony Bankart lesion stabilization
Transfer of the infraspinatus tendon and greater tuberosity to the humeral head
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.
Burkhart SS, De Beer JF.
Arthroscopy. 2000 Oct;16(7):677-94. PMID: 11027751 (Link to Abstract)
Burkhart, ASCOPY 2000
Itoi E, Lee SB, Berglund LJ, Berge LL, An KN
J Bone Joint Surg Am. 2000 Jan;82(1):35-46. PMID: 10653082 (Link to Abstract)
Itoi, JBJS 2000
Average 4.0 of 23 Ratings
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?
Partial articular sided thickness rotator cuff tear (PASTA)
Anterior labral periosteal sleeve avulsion (ALPSA)
Humeral avulsion of the glenohumeral ligament (HAGL)
Glenoid labral articular defect (GLAD)
Superior labral anterior posterior lesion (SLAP)
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.
Average 4.0 of 18 Ratings
A 25-year-old basketball player sustains an anterior shoulder dislocation during a game that is subsequently reduced with traction. A MRI will most likely show which of the following?
Humeral avulsion of the glenohumeral ligaments
Long head of the biceps tear
Superior labrum anterior to posterior tear
Anteroinferior labral tear
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%).
Arciero RA, Wheeler JH, Ryan JB, McBride JT.
Am J Sports Med. 1994 Sep-Oct;22(5):589-94. PMID: 7810780 (Link to Abstract)
Arciero, AJSM 1994
Bottoni CR, Wilckens JH, DeBerardino TM, D'Alleyrand JC, Rooney RC, Harpstrite JK, Arciero RA
Am J Sports Med. 2002 Jul-Aug;30(4):576-80. PMID: 12130413 (Link to Abstract)
Bottoni, AJSM 2002
Arthroscopic treatment of an anterior shoulder dislocation.
Average 4.0 of 22 Ratings
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, is likely contributing to this patient's recurrent instability?
Superior labrum anterior posterior (SLAP) tear
Supraspinatus partial articular sided tendon avulsion (PASTA)
Engaging (>25%) Hill Sachs defect
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 & 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. Illustration C shows evidence of a 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.
Bui-Mansfield LT, Banks KP, Taylor DC.
Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. PMID: 17420506 (Link to Abstract)
Bui-Mansfield, AJSM 2007
Rhee YG, Cho NS.
J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):188-92. PMID: 17399624 (Link to Abstract)
Rhee, JSES 2007
Average 4.0 of 25 Ratings
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?
Another course of physical therapy
Lesser tuberosity transfer
Pectoralis major transfer
Latissimus dorsi transfer
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.
Elhassan B, Ozbaydar M, Massimini D, Diller D, Higgins L, Warner JJ
J Bone Joint Surg Br. 2008 Aug;90(8):1059-65. PMID: 18669963 (Link to Abstract)
Elhassan, BJJ 2008
Resch H, Povacz P, Ritter E, Matschi W.
J Bone Joint Surg Am. 2000 Mar;82(3):372-82. PMID: 10724229 (Link to Abstract)
Resch, JBJS 2000
Average 4.0 of 40 Ratings
Which patient would be ideal for an open shoulder reduction and glenoid bone augmentation?
25-year-old with first time acute traumatic dislocation
78-year-old with a rotator cuff tear arthropathy with superior escape
24-year-old with chronic dislocation and large engaging Hill-Sachs lesion
30-year-old with an acute bony Bankart fracture-dislocation
27-year-old with a chronic anterior dislocation and inverted pear-shaped glenoid
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.
Sahajpal DT, Zuckerman JD.
J Am Acad Orthop Surg. 2008 Jul;16(7):385-98. PMID: 18611996 (Link to Abstract)
Sahajpal, JAAOS 2008
Beran MC, Donaldson CT, Bishop JY.
J Shoulder Elbow Surg. 2010 Jul;19(5):769-80. Epub 2010 Apr 14. PMID: 20392650 (Link to Abstract)
Beran, JSES 2010
Average 4.0 of 15 Ratings
The pathology seen in Figure A is most likely to result from trauma that occurred with the shoulder in which of the following positions?
Adduction, internal rotation
Adduction, external rotation
Abduction, external rotation
Extension, internal rotation
Axial traction in adduction
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.
Sanders TG, Morrison WB, Miller MD.
Am J Sports Med. 2000 May-Jun;28(3):414-34. PMID: 10843139 (Link to Abstract)
Sanders, AJSM 2000
Average 4.0 of 21 Ratings
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?
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.
Sanders TG, Miller MD.
Am J Sports Med. 2005 Jul;33(7):1088-105. PMID: 15983127 (Link to Abstract)
Sanders, AJSM 2005
A patient sustains the injury seen on the radiograph in Figure A. Which nerve is most likely to be injured?
Upper or lower subscapular
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.
Visser CP, Coene LN, Brand R, Tavy DL.
J Bone Joint Surg Br. 1999 Jul;81(4):679-85. PMID: 10463745 (Link to Abstract)
Visser, BJJ 1999
Toolanen G, Hildingsson C, Hedlund T, Knibestöl M, Oberg L.
Acta Orthop Scand. 1993 Oct;64(5):549-52. PMID: 8237322 (Link to Abstract)
Toolanen, ACTA 1993
Average 3.0 of 19 Ratings
An athlete has recurrent anterior shoulder instability despite non-operative treatment including PT and bracing. He is noted to have anterior glenoid bone loss and a coracoid transfer (Latarjet) procedure is recommended. This is believed to improve stability through which of the following mechanism(s)?
Increasing the glenoid bony support and excursion distance prior to dislocation.
The conjoined tendon passing through the subscapularis becomes a supportive sling.
Answers 1, 2 and 5 are correct.
Both 1 and 2 are correct.
The remnant of the CA ligament can be used to aid in repair of the capsular tissues.
The Latarjet coracoid transfer has been described as creating a triple blocking effect due to the function of the conjoint sling, bony augmentation, and CA ligament support to the capsule.
The Latarjet procedure is used for recurrent anterior instability, especially in revision cases or when there is significant anterior glenoid bone loss. The coracoid is transferred through a split in the subscapularis and fixed to the anterior face of the glenoid. One of the most common indications is glenoid bone deficiency (which is defined as 20 -30 % glenoid bone loss) which has a high failure rate when addressed with a soft tissue or capsular procedure only. Glenoid bony deficiency should be addressed with a bony procedure.
In a biomechanical study by Wellmann et al, it was 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.
Wellmann M, Petersen W, Zantop T, Herbort M, Kobbe P, Raschke MJ, Hurschler C.
Am J Sports Med. 2009 Jan;37(1):87-94. Epub 2008 Dec 4. PMID: 19059896 (Link to Abstract)
Wellmann, AJSM 2009
Average 3.0 of 28 Ratings
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?
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.
Orthop Clin North Am. 2003 Oct;34(4):475-83. PMID: 14984187 (Link to Abstract)
Wolf EM, Cheng JC, Dickson K.
Arthroscopy. 1995 Oct;11(5):600-7. PMID: 8534304 (Link to Abstract)
Wolf, ASCOPY 1995
Average 3.0 of 24 Ratings
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?
Rotator cuff tear
Humeral avulsion of glenohumeral ligaments (HAGL)
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 anteroinferior 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.
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).
Taylor DC, Arciero RA.
Am J Sports Med. 1997 May-Jun;25(3):306-11. PMID: 9167808 (Link to Abstract)
Taylor, AJSM 1997
Hintermann B, Gächter A.
Am J Sports Med. 1995 Sep-Oct;23(5):545-51. PMID: 8526268 (Link to Abstract)
Hintermann, AJSM 1995
What nerve is the most frequently injured in the condition shown in the radiograph?
The axillary nerve is the mostly commonly injured nerve during a 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 through 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 posteriorly around the humerus and its close proximity to the humeral head during anterior shoulder dislocation.
Average 4.0 of 19 Ratings
What factor has highest risk for recurrent instability following a traumatic anterior shoulder dislocation?
History of contralateral shoulder dislocation
Young age (<25-years-old) at time of dislocation
Dislocation of the dominant shoulder
Family history of shoulder instability
History of patella instability
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.
Hovelius L, Olofsson A, Sandström B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, Nowak J, Sennerby U.
J Bone Joint Surg Am. 2008 May;90(5):945-52. PMID: 18451384 (Link to Abstract)
Hovelius, JBJS 2008
HPI - 37 year old Male s/p shoulder dislocation and closed reduction.
How would you classify this bony bankart?
Average 4.0 of 16 Ratings
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?
Glenolabral articular disruption (GLAD)
Humeral avulsion of the glenohumeral ligament (HAGL)
Superior labrum tear from anterior and posterior (SLAP)
Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)
Partial articular-sided supraspinatus tendon avulsion (PASTA)
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. More recent studies support that arthroscopic treatment of HAGL lesions can still be effective in skilled hands.
The Neviaser article discusses good results for arthroscopic debridement of GLAD lesions for pain relief.
Stein DA, Jazrawi L, Bartolozzi AR.
Arthroscopy. 2002 Oct;18(8):912-24. PMID: 12368791 (Link to Abstract)
Stein, ASCOPY 2002
Arthroscopy. 1993;9(1):22-3. PMID: 8442825 (Link to Abstract)
Neviaser, ASCOPY 1993
Average 2.0 of 23 Ratings
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?
Anteroinferior labral nonunion
Unrecognized humeral avulsion of the glenohumeral ligament (HAGL)
Anteroinferior glenoid bone defect
Engaging Hill Sachs defect
Untreated SLAP lesion
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.
Burkhart SS, Debeer JF, Tehrany AM, Parten PM.
Arthroscopy. 2002 May-Jun;18(5):488-91. PMID: 11987058 (Link to Abstract)
Burkhart, ASCOPY 2002
Edwards TB, Boulahia A, Walch G
Arthroscopy. 2003 Sep;19(7):732-9. PMID: 12966381 (Link to Abstract)
Edwards, ASCOPY 2003
Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA 3rd.
J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28. PMID: 19218054 (Link to Abstract)
Lynch, JSES 2009
Average 2.0 of 15 Ratings
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?
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
What is the most common finding during surgery for traumatic anterior shoulder instability?
Anterosuperior labral tear
Posterosuperior labral tear
Posteroinferior labral tear
Hill Sachs lesion
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.
Average 3.0 of 27 Ratings
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?
Posterior labral tear
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.
Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G.
Am J Sports Med. 2002 Jan-Feb;30(1):116-20. PMID: 11799007 (Link to Abstract)
Kralinger, AJSM 2002
Average 2.0 of 35 Ratings
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HPI - A 21-y/o RHD male c/o recurrent left shoulder instability. He reports ~20 instability events (all self-reduced) prior to arthroscopic Prior Bankart repair + remplissage. Now 9 months s/p stabilization, he reports recurrent instability that began ~5 months post-op. Now reports instability while sleeping. He has taken a medical leave from college due to symptoms.
He plays golf, soccer, and basketball.
How would you treat this patient?
HPI - 33 yr old with traumatic initial dislocation about a year ago. Passed out and shoulder hit a dresser. Was reduced in ER. Since then has been managed non op by other surgeons. Has had about 7 dislocations since almost all of them have to be reduced under sedation bc of engaging hill sachs. Presents to me after seeing two other orthopods.
After reviewing images it seems there is a large engaging hill sachs. The anterior glenoid rim is without large bony bankart. MRI does show labral tearing.
I believe this needs surgical fixation. My question is how to address the engaging hill sachs. Will remplissage be enough or should I be thinking about allograft / bony procedure?
Thank you in advance for the input and advice.
How would you address the instability?
HPI - Patient was involved in a car accident 1 year ago with severe head injury, coma for 1 month, neglected humeral head fracture for 10 months, underwent open rotator cuff repair 2 months ago.
How would you treat the patient at this time (P1 images above)?
HPI - Patient fell and sustained a dislocation of the shoulder 3 weeks ago.
Shoulder reduced on its own.
Non-contact, recreational athlete.
HPI - 26 yr old Male with hx of traumatic dislocation in high school. Had open Bankart repair 10 yrs ago. Did well until this year had snowboarding injury and dislocated. Rehabbed for a few months but dislocated again while playing softball.
Continued to with rehab but does have recurrent instability.
MRI and CT show large anterior inferior bony Bankart fragment.
Question is revision Bankart repair (open vs arthroscopic) or think about bony procedure such as LaterJet?
How would you manage this patient?
HPI - Patient presented with anterior dislocation right shoulder joint
Closed reduction done same day .post reduction Xray satisfactory
Serial Xray show inferior sublaxation increasing
MRI shoulder done at 3 weeks shows posterior sublaxation and rotator cuff tear
What would be your next step in treatment for this patient?