Arthroscopy

Definition

Humeral Avulsion of Glenohumeral Ligament

Incidence

Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%

Anatomy

Size

2 x as strong as ACL

About the same length as ACL 38 mm

Cross sectional area 150% of ACL

13 mm diameter (thicker) 

2 Bundles

1.  Anterolateral

- most important

- double the size of the posteromedial

- tight in flexion

- try to reconstruct this bundle

Causes

Most common

- fascia lata on greater trochanter

- iliopsoas on lesser trochanter

1.  Intra-articular structures

- labrum

- ligamentum Teres

- loose bodies

- synovial chondromatosis

- osteochondoma

2.  Extra-articular structures

- fascia lata on greater trochanter (common) 

Management Summary

Stage 0

Natural history mixed

- depends on size of lesion and diagnosis

- treat if becomes asymptomatic

- may benefit from bisphosphonates

Stage 1 / Normal X-ray, abnormal MRI

Forage: 80% G/E

Bisphosphonates

Stage 2 / Abnormal X-ray with cysts and sclerosis

A:  As for Stage I

Clinical

Pain & Stiffness

- often more pain than FT tears

Bursal side tears more painful than articular

Articular side more common

May see in young patient overhead throwing

Examination

Painful arc

Impingement signs

No weakness

- function good

Anatomy

Largest and most powerful rotator cuff

- arises coastal border of scapula

- superior 2/3 tendon inserts into LT

- inferior 1/3 inserts into proximal humerus

Action

- IR (with T major, P major, Lat Dorsi)

- part of force couplet depressing humeral head

Incidence

Definition

Full thickness tear (FTT)

- variable amount retraction from insertion

Partial thickness tear (PTT)

- incomplete

- bursal or articular sided

Definition

Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia

Aetiology

2 groups of patients

Position

1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

- tilt top shoulder posteriorly 30° so that glenoid is parallel wwith bed

- mark bony landmark

- prep & free drape

Indications

1. Removal Loose body

2. Excison of osteophytes

- coronoid

- olecranon

- aiming to improve ROM / prevent impingement