Management of Anterior Shoulder Instability without Bone Loss: Arthroscopic and Mini-Open Techniques

Abstract

Anterior shoulder instability is a complex problem and necessitates accurate pre- and intraoperative assessment of soft-tissue and bony pathology. Soft tissue pathology plays a major role in anterior instability without bone loss, and includes glenoid lesions (glenoid labral tears/avulsions), capsular lesions (plastic deformation and tears), and humeral side lesions (humeral avulsion of glenohumeral ligament lesion referred to as “HAGL” lesions). Glenoid labral tears and capsular lesions are adequately addressed with the “labroplasty” procedure. This involves a sequential capsulolabral shift using correctly oriented suture-anchors, to effectively reduce the capsular volume. In addition, technical maneuvers like the “double-grasper shift” and “Noose maneuver” are crucial to recreate a labral bumper effect at the glenoid edge. HAGL lesions may be difficult to detect, and use of the axillary-pouch portal (Bhatia portal) facilitates identification of the tear. A new mini-open subscapularis-sparing technique permits secure repair of the HAGL lesion without a subscapularis tenotomy or even a split. Postoperative rehabilitation is guided by intra-operative tensioning of the capsulolabral tissue.