The Axillary Pouch Portal: A New Posterior Portal for Visualization and Instrumentation in the Inferior Glenohumeral Recess

Arthroscopic access to the inferior glenohumeral recess is necessary in several surgical procedures on the shoulder. Posteroinferior portals described for access to this region may pose a theoretic risk to the posterior neurovascular structures (outside-in technique) and to the articular cartilage (inside-out technique). The first author (D.N.B.) has devised a new posterior portal that permits direct linear access to the entire inferior glenohumeral recess. The portal is placed higher and more lateral compared with the previously described portals; this places it further away from the posterior neurovascular structures and facilitates linear access to the axillary pouch. The portal is created via an outside-inside technique, with a spinal needle to ascertain the correct portal site and angulation. The portal is placed at a mean distance of 20.45 ± 4.9 mm (range, 15 to 35 mm) directly inferior to the lower border of the posterolateral acromial angle and 21.3 ± 2 mm (range, 20 to 25 mm) lateral to the posterior viewing portal. The spinal needle or cannula is angulated medially at a mean of 30.6° ± 4.7° (range, 25° to 40°) in the axial plane and slightly inferiorly (mean, 2°; range, 20° superiorly to 20° inferiorly). Use of 30° and 70° arthroscopes through the axillary pouch portal facilitates visualization of the entire recess and of the humeral attachment of the inferior glenohumeral ligament complex for evaluation of humeral avulsion of the glenohumeral ligament lesions. The portal also permits instrumentation in combination with the standard posterior or anterosuperior viewing portal for removal of loose bodies, synovectomy, capsular shrinkage, capsulotomy, and anchor placement in the posteroinferior glenoid rim.     

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.     

Current practices in the management of anterior glenohumeral instability in rugby union players

BackgroundRugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices.MethodsA survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test.ResultsNinety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p < 0.05), but not recurrent dislocation (p > 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p < 0.05), but not following conservative treatment or the Latarjet procedure (p > 0.05).ConclusionsThere remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety.Level of evidenceLevel 4 (case series).     

Glenohumeral interposition of a torn rotator cuff in a young motorcyclist

This report describes the rare case of a traumatic rotator cuff tear in a young patient which led to a pseudoparalysed shoulder by interposition of the tendon stump into the glenohumeral joint. The patient underwent an open rotator cuff repair and regained an almost normal shoulder function after 12 weeks. A review of the literature is presented.     

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.     

Arthroscopic Repair of Anterior Talofibular Ligament Using the Pull-Out Technique for Chronic Ankle Instability: Case Report

Arthroscopic repair of the lateral ankle ligament using the anchor system has been increasingly reported. We treated a 39-year-old woman who suffered from pain and instability in her left ankle joint. She was diagnosed with chronic ankle instability and an osteochondral lesion of the talar dome. For this patient, arthroscopic repair of the anterior talofibular ligament (ATFL) was performed. Standard anteromedial and anterolateral portals were placed, and excision of the osteochondral fragment and microfracture were performed. Then, an accessory anterolateral (AAL) portal was placed. No. 2 nylon sutures were inserted into the ATFL remnant through the AAL portal. Two bone tunnels were created at the footprint of the fibula attachment toward the posterior edge of the lateral malleolus using a passing pin, and nylon sutures anchored in the ATFL were retrieved toward the posterior fibula. The foot was held in neutral position with eversion, and nylon sutures were tied at the posterior fibula. At 1 year after surgery, the Japanese Society for Surgery of the Foot scale was improved from the preoperative value of 48 points to a postoperative value of 100 points. Stress radiography showed no difference of talar tilt angle between the involved and noninvolved ankles. Joint position sense was also improved at 3 and 6 months after surgery. This arthroscopic repair of the ATFL using the pull-out technique enabled achievement of an improved clinical score and stability of the ankle and proprioception, and there was no concern about complications of the anchor system.