20.4.1 Clinical Evaluation

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  A complete patient history is mandatory. This should include patient’s age, associated conditions, such as seizures, neuromuscular disorders, or collagen deficiencies, traumatic events that resulted in instability, arm position at the moment of the accident, energy level of the lesion, how and when the reduction took place, the treatment after the reduction, and the number of dislocations.

  
  
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  Physical examination should assess shoulder instability with provocative tests such as anterior apprehension, the Jobe relocation test, active compression test, load and shift test, sulcus test, and determination of generalized ligamentous laxity.

20.4.2 Imaging

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  Radiographs should include anteroposterior (AP) shoulder views in internal and external rotation, a true AP Grashey view, West Point view, Stryker notch view, axillary view, and the transcapular (Y) view. The AP views in internal and external rotation demonstrate a Hill–Sachs lesion. The true AP demonstrates any erosion of the anterior glenoid rim. The West Point view is useful to study glenoid bone loss. The Stryker notch view is used to evaluate the humeral head Hill–Sachs lesions. Axillary view helps observe bony Bankart lesions and erosion of the anteroinferior portion of the glenoid rim. The transcapular (Y) view permits us to observe anterior or posterior translation of the humeral head with respect to the glenoid.

  
  
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  CT is used for detecting and measuring bone deficiency in the humerus with Hill–Sachs lesions or in the glenoid with bony Bankart lesions ( Fig. 20.1 ).

  
  
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  MRI is helpful for evaluating soft-tissue lesions associated with instability like anterior glenoid labrum lesions, HAGL lesions, Perthes lesions, anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions, glenolabral articular disruption (GLAD) lesions, and increase of joint volume (hyperlaxity; Fig. 20.2 ).

20.4.3 Anesthesia

Regional anesthesia with a single-shot brachial plexus block combined with a mild sedation is the author’s preference. This provides anesthesia for the procedure and analgesia for the postoperative period.

20.4.4 Positioning

The choice of the shoulder arthroscopy position is surgeon dependent. The author prefers to work in the beach-chair position for anterior stabilizations.

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  Beach chair: The patient is placed in the beach-chair position, a foam pillow is placed under the knees, and the head is secured firmly in a neutral position with a helmet or a foam mask to make sure the airway is not obstructed. Then the corresponding shoulder support is removed to ensure full exposure to the anterior and posterior aspect of the shoulder, and the operating table must be adjusted to 30 to 40 degrees of hip flexion to prevent the patient from sliding down the operative table ( Fig. 20.3 ).

  
  
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  Hydraulic arm holder: The patient’s forearm is placed in a padded arm holder that connects directly to a hydraulic arm holder. This allows the arm to be positioned without the use of an assistant ( Fig. 20.4 ).

20.5.1 Portals (Fig. 20.5)

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  Posterior portal (P): It is placed at approximately 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion just at the posterior soft spot that corresponds to the interval between the infraspinatus and teres minor. The trocar should be directed toward the coracoid process, parallel with the floor, and into the glenohumeral joint.

  
  
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  Anteroinferior portal (A): This portal is placed under direct visualization using an outside-in technique with a spinal needle. The needle should be as low as possible directly over the superior border of the subscapularis tendon. The needle can be used to confirm that the inferior glenoid and labrum can be accessed. A 8.25-mm threaded cannula is placed to maintain this portal ( Figs. 20.6, 20.7 ).

  
  
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  Anterolateral portal (AL): This portal is placed under direct vision with an outside-in technique with a spinal needle that enters the glenohumeral joint in the lateral part of the rotator interval right over the biceps tendon, just anterior to the supraspinatus tendon, and a 5.5-mm threaded cannula is placed ( Fig. 20.8 ). Forward flexing and externally rotating the arm can help facilitate making this portal. Also, placing the arthroscopy pump on lavage can also create space between the capsule and the long head of the biceps tendon to avoid iatrogenic injury to the tendon.

  
  
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  Diagnostic arthroscopy: With the arthroscope viewing from the posterior portal and a hooked probe in the anteroinferior portal, a diagnostic evaluation of the joint takes place. The conditions of the cartilage, the biceps tendon, and rotator cuff tendons are assessed. The location and the size of the Hill–Sachs lesion are also evaluated. Next, the inferior axillary recess is evaluated looking for an HAGL lesion or loose bodies. The glenolabral junction is evaluated circumferentially. The arthroscope is placed in either the anterior or the anterolateral portal to fully evaluate the posterior labrum ( Fig. 20.9 ).