Combined Posterior Bankart Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligaments Associated With Recurrent Posterior Shoulder Instability

Recurrent posterior glenohumeral instability is uncommon and is often misdiagnosed. Damage to the posterior capsule, posteroinferior glenohumeral ligament, and posterior labrum have all been implicated as sources of traumatic posterior instability. We describe a case of traumatic recurrent posterior instability resulting from a posterior Bankart lesion accompanied by posterior humeral avulsion of the glenohumeral ligaments. The Bankart lesion was repaired using a single arthroscopic suture anchor at the glenoid articular margin. The posterior humeral avulsion of the glenohumeral ligaments was addressed with 3 suture anchors placed at the capsular origin at the posterior humeral head. Using these anchors, the posterior capsule was advanced laterally and superiorly for a secure repair. Arthroscopic anatomic reconstruction of both lesions resulted in an excellent clinical outcome.     

Arthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion

We describe 3 cases of an all-arthroscopic technique for repair of a humeral avulsion of the glenohumeral ligament (HAGL) lesion and the postoperative clinical outcomes. From a technical perspective, the most critical part of the surgeries was the anchor insertion at an optimal position on the humerus in order to achieve proper tension of the glenohumeral ligament. The arm-free beach-chair position, which facilitates maximum internal rotation, use of a 70° angled arthroscope, and an anterior-inferior trans-subscapularis tendon portal were considered key factors to accomplish this procedure.     

Mini-Open Repair Technique of HAGL (Humeral Avulsion of the Glenohumeral Ligament) Lesion

This article describes a limited open technique to repair humeral avulsions of the glenohumeral ligament (HAGL). The main feature of this technique is the sparing of the superior 50% of the subscapularis tendon. Essentially, an L-type incision is made in the lower third of the subscapularis tendon approximately 1 cm medial to the lesser tuberosity. The transverse limb of this incision is made just superior to the anterior circumflex vessels. Beginning inferiorly, the subscapularis tendon is lifted up, exposing the humeral ligament avulsion. The HAGL lesion is then repaired with 2 or 3 suture anchors anatomically. The advantages of this technique are preservation of the important superior tendinous portion of the subscapularis tendon, thereby preserving strength, easier rehabilitation, and return to full activity.     

The “Subscapularis-Sparing” Approach: A New Mini-Open Technique to Repair a Humeral Avulsion of the Glenohumeral Ligament Lesion

Anterior approaches to the shoulder involve partial or complete detachment of the subscapularis muscle. We have developed a new technique that permits adequate access to the humeral attachment of the inferior glenohumeral ligament (IGHL) without any detachment of the subscapularis, and have used this to successfully repair humeral avulsions of glenohumeral ligament lesions. Preliminary diagnostic arthroscopy using air insufflation of the glenohumeral joint is used to identify and grade the lesion. A 1-inch axillary incision is used to access the subscapularis tendon through the deltopectoral approach. Thereafter, anatomic landmarks are identified to expose the lateral aspect of the inferior border of the subscapularis muscle. Blunt dissection is used to separate the musculocapsular plane, and the subscapularis is retracted in an anterosuperior direction. Adequate exposure for visualization and repair of the avulsed IGHL is possible in a majority of cases where this approach is attempted. The use of arthroscopic instruments and suture anchors facilitates suture passage through the mid and posterior regions of the IGHL. If exposure is inadequate, the approach can be easily converted to a conventional L-shaped tenotomy approach through the lower or upper region of the subscapularis.     

Capsular Tear in Line With the Inferior Glenohumeral Ligament: A Cause of Anterior Glenohumeral Instability in 2 Patients

Anterior glenohumeral instability typically involves lesions associated with the inferior glenohumeral ligament complex. Multiple lesions have been described in this setting, including Bankart, humeral avulsion of the inferior glenohumeral ligament complex, and mid-substance capsular tears. These lesions are indicative of the high-force traumatic nature of anterior shoulder dislocation. Two cases of recurrent anterior shoulder instability are presented with a capsular tear perpendicular to the usual orientation and not consistent to the amount of force involved in a dislocation. Arthroscopy revealed a capsular defect from the glenoid to the humeral head in the anterior inferior glenohumeral ligamentous complex in both. This lesion is an unusual circumstance, providing another pathology to include in the differential diagnosis of anterior glenohumeral instability.     

A Shearing Osteochondral Fracture of the Humeral Head Following an Anterior Shoulder Dislocation in a Child

A dislocation of the shoulder joint is rare in children with an open physis. The fractures associated with an anterior dislocation generally reported in the literature have been Hill-Sachs lesions, avulsions of the greater tuberosity and glenoid fractures. We present a case of a previously unreported shearing osteochondral fracture, which is distinct from a classic Hill-Sachs lesion of the humeral head, in 12-year-old boy. The patient suffered a traumatic anterior shoulder dislocation with a spontaneous reduction along with this associated fracture. The fracture subsequently healed with no further evidence of persistent instability.     

Humeral BMD can be Measured With DXA and Is Lower in the Surgical Arm After Total Shoulder Arthroplasty

Background: As arthroplasty leads to bone loss, we hypothesized that humeral bone mineral density (BMD) is lower after total shoulder arthroplasty (TSA) in the operative versus non-operative arm. However, there is no clinical approach to measure humeral BMD with dual-energy x-ray absorptiometry (DXA). The purposes of this pilot study were to develop DXA methodology to measure humerus BMD, propose humerus regions of interest (ROIs), compare TSA BMD to the non-operative arm, correlate humeral BMD with standard sites, and evaluate measurement reproducibility. Methodology: Thirty-eight adults 1-5 years post-TSA had standard clinical DXA scans plus full humerus scans using the atypical femur fracture feature; precision was assessed in a subset (n = 32). Six custom ROIs were used to measure BMD throughout the humerus. Radius and humeral BMD were compared between arms by paired t-test and correlated ipsilaterally using Pearson's Correlation. Custom ROI BMD precision was assessed using the International Society for Clinical Densitometry (ISCD) advanced precision calculator. Results: Study included 38 subjects (24M/14F), with mean (SD) age and time post-surgery of 69.6 (7.7) years and 2.5 (1.3) years respectively. BMD was lower (p < 0.01) at all custom humerus sites (3.8% to 8.2%) on the surgical side but not different at radius sites. Humeral BMD correlated positively with ipsilateral ultra-distal and 1/3 radius (r = 0.54 to 0.86; p < 0.05). Custom BMD precision (%CV) ranged from 6.0-16.0%. Conclusions: Humerus BMD can be measured using DXA and is lower in the TSA arm. Radius BMD correlated with humeral BMD but was not lower in the surgical arm. BMD precision was worse than usual clinical sites; use of software optimized for the femur is a notable limitation and likely contributes to suboptimal precision. Further study to assess the clinical utility of humeral BMD is needed. Automation and optimization of these measurements should improve precision.     

Avulsion of the Ischial Tuberosity in a Young Soccer Player: Six Years Follow-Up

In this case a seventeen-years-old male soccer player, who sustained an injury while playing football, diagnosed as ischial tuberosity avulsion was reported. Following six-months of a conservative rehabilitation program, the athlete returned to his sports’ activities. Six years along he had no complaints and his athletic performance was not deteriorated. In this case report diagnosis, treatment and six-years follow-up results were discussed.Key Words: Apophysis, avulsion, ischial tuberosity, soccer     

Non Traumatic Dislocation of Shoulder with Rupture of Axillary Vessel Branch in a Paraplegic Patient: A Case Report

ABSTRACT

Spinal cord injured (SCI) patients utilize the shoulder joints for wheelchair propulsion, for transfers in and out of wheelchairs and for wheelchair “push-ups” for pressure relief, to prevent pressure sores. Accurate incidence of shoulder dislocation in SCI patients is not known. A majority of the dislocations seen are secondary to trauma. A 66-year-old, T10 paraplegic since 1942, developed severe osteoarthritic changes in both shoulders and experienced nontraumatic, recurrent dislocation of his right shoulder with a rupture of the axillary vessel branch. This case is reported here because of its rarity. (J Am Paraplegia Soc 1990; 13: 15–17)     

Editorial Commentary: Surgical Treatment of Shoulder Instability With Subcritical Glenoid Bone Loss Requires Innovation: Bankart May Risk Significant Recurrence and Latarjet May Risk Significant Complications

The patient with a history of shoulder dislocation and subcritical (10%-15%) glenoid bone loss presents a complicated scenario. The “safest” procedure (arthroscopic Bankart repair) may result in a high rate of failure and risk of further surgery. The most successful procedure for avoiding recurrence (Latarjet) comes with potentially high complication rates (of up to 20%), a steep learning curve, risk of permanent nerve injury (up to 15%), and substantial risk of subscapularis deficit. Innovation is most needed in surgery when current treatments lack success or risk significant complications. As surgeons, we are constantly striving to walk the line between using innovative techniques for our patients to better their lives and following the principle “first do no harm.” This recent article describes the outcomes of a 2-cm segment of scapular spine harvested through a small incision and stabilized with suture anchors along the anterior glenoid, combined with an arthroscopic labral repair. The technique appears to be safe, and practical, bearing in mind that excellent reported outcomes must be shown to be reproducible. Ideally, we should not have to choose between relatively high failure rates with arthroscopic Bankart repair or the greater reported complication rates with Latarjet. Innovation will pave the way to our greater success.