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Shoulder Videos: Instability
Arthroscopic Anatomic Glenoid Reconstruction Hardware Removal
Recurrent shoulder instability is associated with bone loss. Distal tibial allograft reconstruction of the glenoid is an accepted technique for managing bone loss. Bone remodeling occurs within the first 2 years postoperatively. This can lead to prominent instrumentation, particularly anteriorly near the subscapularis tendon, causing pain and weakness. We provide a description of arthroscopic instrumentation removal for prominent anterior screws following anatomic glenoid reconstruction with distal tibial allograft.Glenoid Avulsion of the Glenohumeral Ligament Repair Through a Single Working Portal
Glenoid avulsion of the glenohumeral ligament (GAGL) is a traumatic cause of shoulder instability. GAGL lesions are a rare shoulder pathology most commonly reported as a source of anterior shoulder instability, with no current reports implicating this pathology as a cause of posterior instability. Satisfactory surgical repairs of GAGL lesions with anterior shoulder instability have been well documented; however, this Technical Note highlights the successful repair of a posterior GAGL lesion through a single working portal with suture anchor fixation of the posterior capsule.Arthroscopic Bone Graft Procedure Combined With Arthroscopic Subscapularis Augmentation for Recurrent Anterior Instability With Glenoid Bone Defect
Glenoid bone loss and capsular deficiency represent critical points of arthroscopic Bankart repair failures. The purpose of this Technical Note is to present an all-arthroscopic bone block procedure associated with arthroscopic subscapularis augmentation for treating glenohumeral instability with glenoid bone loss and anterior capsulolabral deficiency. Two glenoid tunnels are set up from the posterior to the anterior side using a dedicated bone block guide, and 4 buttons are used to fix the graft to the glenoid.Arthroscopic Pectoralis Minor Release
The scapula has long been recognized as a key component in shoulder motion and a crucial part of the kinetic chain connecting the body's core and upper extremity. The pectoralis minor (PM) has garnered increasing attention as we better understand scapular kinematics and its role in shoulder pain and dysfunction. This is particularly important in patients with scapular dyskinesis and especially in overhead throwing athletes. The most of these patients achieve their recovery goals through nonoperative management, stretching, and strengthening protocols; however, some patients do not respond to nonoperative modalities.Use of a Knotless Suture Anchor to Perform Double-Pulley Capsulotenodesis of Infraspinatus
In this Technical Note, we describe an arthroscopic remplissage procedure to treat anterior instability. Specifically, we use a technique to perform double-pulley capsulotenodesis of the infraspinatus tendon using a Knotless SutureTak Suture Anchor (Arthrex, Naples, FL). This is a modification of a previously described double-pulley technique. The primary advantage of our technique compared with the previous double-pulley techniques described is that knot tying is not required.Peroneus Longus Tendoscopy at the Sole
Different pathologies can occur in the peroneus longus tendon at the sole. Many of them can be dealt with by peroneus longus tendoscopy of the sole. The purpose of this Technical Note is to describe the details of this minimally invasive approach to the peroneus longus tendon of the sole. This has the advantages of better cosmesis, less soft tissue dissection, less postoperative pain, and less peritendinous fibrosis.The Arthroscopic Bankart-Plus Procedure for Treatment of Anterior Shoulder Instability With Small to Intermediate Glenoid Defects
To date, specific surgical procedures are available for the treatment of anterior shoulder instability with substantial bony glenoid defects, as well as for patients without osseous lesions. However, specific treatment options are lacking for the frequently observed small to intermediate glenoid defects, which may not necessitate glenoid reconstruction surgery according to current guidelines but can still jeopardize the outcome after mere soft-tissue stabilization procedures. This article describes the so-called arthroscopic Bankart-Plus procedure for the treatment of anterior shoulder instability with small to intermediate bony glenoid defects.The Ramp Test: An Arthroscopic Technique for Confirming Intra-articular Subluxation and Instability of the Long Head of the Biceps Tendon Within the Shoulder
Shoulder arthroscopy in expert hands is now a tool for diagnosis and treatment. Diagnostic shoulder arthroscopy begins with a systematic review of the shoulder. This review should include the ramp test for confirming normal superior glenohumeral ligament (SGHL) integrity and function. The ramp test uses manipulation of the biceps tendon to achieve this. A negative ramp test finding means that the SGHL is intact and the biceps tendon moves freely down in a V-type pattern. A positive ramp test finding results when the biceps tendon subluxates through a failed SGHL and therefore presents with a U-shaped pattern indicating pathology.Pre-shaped Allograft for Glenoid Reconstruction in Anterior Shoulder Instability
Anteroinferior glenoid bone loss plays a significant role in recurrent glenohumeral instability. Current surgical strategies to reconstruct the glenoid include coracoid transfer (Bristow-Latarjet procedure), iliac crest autograft, and allograft (osteochondral and iliac crest). These may carry drawbacks of technical difficulty, increased surgical time, neurovascular injury, and nonanatomic reconstruction. We report a technique to manage glenoid bone loss using a pre-shaped, predrilled allograft (Glenojet; Arthrosurface) that matches the native contour of the glenoid.Arthroscopic Latarjet Procedure Combined With Bankart Repair: A Technique Using 2 Cortical Buttons and Specific Glenoid and Coracoid Guides
The arthroscopic Latarjet procedure is challenging because it can be difficult to place 2 screws parallel to the glenoid surface and a medial portal (dangerous for the brachial plexus) is mandatory. In addition, precise positioning of the coracoid bone block flush with the joint line and in a subequatorial position as recommended is troublesome without the use of a guiding system because of the arthroscopic lens distortion. To improve the reproducibility of the arthroscopic Latarjet procedure and to minimize the risk of nerve complications, we developed a guiding system to optimize the positioning of the coracoid bone block and 2 cortical buttons to facilitate its fixation.Arthroscopic Load-Shift Technique for Intraoperative Assessment of Shoulder Translation
Shoulder instability represents a spectrum of disease, ranging from subluxation to dislocation. It may present acutely after trauma or chronically as a result of multiple events. Physical examination is a key component in evaluating the degree of instability and laxity present; however, in-office guarding or apprehension may limit the examination. In addition, patient anatomy or operator technique may limit the accuracy and reproducibility of examination maneuvers such as the load-shift test. We propose an arthroscopic modification to the load-shift technique involving direct visualization to assess the direction and degree of shoulder instability.Arthroscopic Transfer of the Conjoined Tendon–Coracoid Tip Complex for Anterior Shoulder Instability
In the treatment of anterior shoulder instability, there are various conditions in which a sling effect is needed to enhance anterior stability. The traditional Bristow-Latarjet procedure provides a sling effect but destroys or does not purposely protect the coracoacromial (CA) arch, which may result in superior instability. To preserve the CA arch and create a sling to enhance the anterior-inferior side of the shoulder, we introduce an arthroscopic technique to transfer the conjoined tendon–coracoid tip complex (CTCTC) with the intention to keep the CA ligament intact to the utmost.Dynamic Anterior Stabilization Using the Long Head of the Biceps for Anteroinferior Glenohumeral Instability
Anteroinferior glenohumeral instability can be treated by variants of the Bankart repair, remplissage, and the Latarjet procedure, although all options remain associated with complications, including recurrence, stiffness, persistent pain, apprehension, and dislocation arthropathy. The authors therefore thought of a concept of dynamic anterior stabilization to treat anteroinferior glenohumeral instability by transferring the long head of the biceps within a subscapularis split to the anterior glenoid margin, thereby creating a “sling effect” by using a conservative technique.Arthroscopic Management of Posterior Instability due to “Floating” Posterior Inferior Glenohumeral Ligament Lesions
The “floating” posterior inferior glenohumeral ligament (floating PIGHL) is an uncommon cause of posterior shoulder instability. This pathologic lesion, defined as detachment of both the origin of the PIGHL (posterior Bankart lesion) and insertion of the of the PIGHL from its humeral head insertion site, often results in significant and persistent shoulder instability symptoms. An effective surgical technique for arthroscopic repair of a floating PIGHL lesion is described and demonstrated.Middle Glenohumeral Ligament Abrasion Causing Upper Subscapularis Tear
The middle glenohumeral ligament (MGHL) typically contributes partially to the anterior stability of the shoulder. In a very limited number of cases, the MGHL can cause abrasion on the upper edge of the subscapularis causing persistent pain symptoms for patients. The condition is exacerbated by internal rotation of the arm. In this Technical Note, we describe this entity and call it the SAM lesion (Subscapularis Abrasion from the MGHL). We present a technique of addressing this lesion.Arthroscopic Anterior Shoulder Stabilization With Incorporation of a Comminuted Bony Bankart Lesion
Bony Bankart lesions are a common finding in patients with anterior glenohumeral dislocation. Although there are no defined guidelines, small bony Bankart fractures are typically treated arthroscopically with suture anchors. The 2 main techniques used are double- and single-row suture anchor stabilization, with debate over superiority. Biomechanical studies have shown improved reduction and stabilization with the double-row over the single-row suture anchor technique; however, this has not been reported for small or comminuted bony fragments.Arthroscopic Transfer of the Subscapularis Tendon for Treatment of a Reverse Hill-Sachs Lesion
Posterior shoulder instability occurs less often than anterior shoulder instability but is increasingly recognized as a relatively common condition. The reverse Hill-Sachs lesion is present in some patients with posterior instability and is best described as an impaction fracture of the anterior humeral head. These reverse Hill-Sachs lesions can predispose the patient to recurrent instability events and may need to be addressed directly at the time of surgery. Multiple open and arthroscopic procedures have been described to transfer bone or soft tissue structures into this reverse Hill-Sachs defect.Figure-of-8 Reconstruction Technique for Chronic Posterior Sternoclavicular Joint Dislocation
Dislocation of the sternoclavicular joint is a rare injury and typically requires high-energy forces applied through the joint. Initial treatment is dependent on the direction of dislocation, with acute reduction indicated for posterior dislocations presenting with signs of tracheal, esophageal, or neurovascular compression. Although most patients do well with conservative treatment after the initial trauma, some can have persistent pain and scapular dyskinesia due to instability or locked dislocation of the sternoclavicular joint.Arthroscopic Labral Repair in the Setting of Recurrent Posterior Shoulder Instability
Posterior shoulder instability, although relatively rare in the general population, is more commonly seen in athletes, especially those in contact sports. Although nonoperative treatment has been associated with satisfactory results in the setting of posterior shoulder instability, conservative management may ultimately fail and lead to recurrence particularly in young, male patients. Both arthroscopic and open repair techniques to address posterior instability have been described, with each showing positive patient-reported outcomes, low risk of recurrence, and considerably high return-to-sport rates.Graft Transfer Technique in Arthroscopic Posterior Glenoid Reconstruction With Distal Tibia Allograft
Posterior glenoid reconstruction using distal tibia allograft is an available technique for the treatment of posterior shoulder instability with glenoid bone loss. A key aspect to this procedure relies on maintaining complete control of the graft during insertion and securement to the posterior glenoid. Although there are commercially available products to aid with graft control, we describe a novel graft transfer technique that is compatible with all cannulated systems for maintaining positive graft control.Arthroscopic Transfer of the Long Head of the Biceps Brachii for Anterior Shoulder Instability
In the treatment of anterior shoulder instability, there are various conditions in which a sling effect is needed to enhance anterior stability. The traditional Latarjet procedure provides a sling effect but destroys the coracoacromial arch, which may result in superior instability. To preserve the coracoacromial arch and create a sling to enhance the anterior-inferior side of the shoulder, we introduce an arthroscopic technique to transfer the long head of the biceps (LHB) brachii. Indications of LHB transfer are patients younger than 45 years of age who participate in competitive sports, require forceful external rotation and abduction movement of the shoulder, and/or have capsule-ligament insufficiency, as well as patients 45 years o or older who have combined SLAP lesions (type II or IV).Arthroscopic Posterior Glenoid Fracture Fixation Using Knotless Suture Anchors
Shoulder instability after a posterior glenoid rim fracture is rare and potentially difficult pathology to treat. Operative techniques often involve a large dissection to view the fragments resulting in local soft tissue injury. Internal fixation is often achieved with interfragmentary screws; however, this may not be possible with small or multifragmentary fracture patterns. We describe an arthroscopic technique for posterior glenoid rim fracture fixation using knotless suture anchors. These anchors can be inserted without cannulas allowing easier access to the posterior glenoid.Single Working Portal Technique for Knotless Arthroscopic Bankart Repair
Arthroscopic Bankart repair is widely accepted as the method of choice in restoring the labrum to the glenoid rim. It has been shown to have comparable outcomes with open stabilization. This usually involves the use of 2 portals anteriorly: one anterosuperior accessory portal and another anteroinferior working portal. The aim of this Technical Note is to present a simple and reproducible technique for Bankart repair using a single working portal anteriorly without an accessory portal.Combined All-arthroscopic Hill-Sachs Remplissage, Latarjet, and Bankart Repair in Patients With Bipolar Glenohumeral Bone Loss
Patients presenting with recurrent shoulder instability and bipolar glenohumeral bone loss are at risk of failed standard soft-tissue repair techniques. Even isolated bony-stabilization procedures such as the Latarjet or remplissage technique may not provide sufficient stability in the face of combined bone loss. We use a combined all-arthroscopic remplissage, Latarjet, and Bankart repair for patients with significant combined glenohumeral bone loss and/or in the revision setting. This allows reconstruction of both the Hill-Sachs and glenoid bone defects and repair of the capsulolabral complex in a minimally invasive manner.Arthroscopic Bone Grafting of the Humeral Head for Treatment of a Deep Hill-Sachs Lesion
Recurrent anterior shoulder dislocation often leads to the presence of a Hill-Sachs lesion. A large Hill-Sachs lesion compromises shoulder stability and should be addressed with bone augmentation when it is too deep. Here, we introduce a method of arthroscopic bone grafting of the humeral head for the treatment of a deep Hill-Sachs lesion in patients with anterior shoulder instability. Our indication for this procedure is a deep off-track Hill-Sachs lesion measuring at least 8 mm in depth and 10 mm in width.
