Just a technical note. Thank you. Thanks very much. We're going to talk a little bit about humeral avulsion lesions. These are my conflicts. So how many of you in the room have seen or tried to fix an anterior haggle? Raise your hand. For the rest of you, it's seen you. So you've got to start looking. So by definition, this is a humeral avulsion of the glenohumeral ligaments. And when you look at the picture on your left, then you can see this giant hole in the capsule of the glenohumeral ligaments. So major dictatorship just showed you one of those. a minute ago, here's another one that's more chronic and you just see muscle through it. So it's actually not uncommon. Gene Wolfe estimated it was up to about 11% of the time you saw it in instabilities. Larry and I looked at a really large series of instabilities when I was still in Mississippi and we thought it was about one to 3%. So if you've done 100 instability cases, then you've seen one of these or it's been there anyway. If you do plain MRIs, it's not gonna show up. And so sometimes you just find this when you get in there and I'll give you a couple of hints in just a minute, but you have to look at it arthroscopically. And now that I don't remember everything about every patient I've ever operated on, I usually shoot a picture of the lateral capsule attachment front and back on every one of them, just in case I have a problem and a failure and think I might've missed it. So on the raggle, we're not gonna talk about this today, but it is common. It's much easier to fix. It's just like doing a remplissage except you repair the capsule instead of the tendon. So we'll kind of skip over that. So diagnosis is usually collision sports. And it's a little bit of a funny because it's a lower impact type thing. And so then you see this complete avulsion and you're looking at subscap there. You're seeing the capsule down. It's been some scarring that happens. Here's another one where you see the big hole in it further down. Instability will give you on your exam, you'll have the shoulder shifting out and you won't have the crepitation that you have with a labral tear. So it's not gonna be there and you'll see something different. And again, you'll find it on arthroscopy only if you look for it. So this is a six o'clock haggle. People talk about it all the time about it might be harder to fix because it's down there around the corner. I would submit to you on the right, that's one stitch putting it across. It pulls it right back up and you put an anchor in the bare spot. Pretty easy to do when it's right at the bottom. So surgical repair for symptomatic patients. If you're not comfortable working on the lateral capsule, especially inferiorly, you should do it open. It's pretty simple. You take down a little bit of the subscap. You see the capsule, put it back. I obviously favor arthroscopic techniques. So lateral decubitus, rolling back 30 degrees, at least, maybe 40 degrees. So you have a little bit of pressure so that when you put the arm in traction, you're flexing it a little bit and you take pressure off and relax your subscap. Look at the lateral capsule and then set up two portals a little bit more medial than you normally would. So when we do a Bancart repair, those portals are lateral. Otherwise, we're gonna do it medial. And then you have to separate the capsule from the subscapularis because this will be scarred down. So this is a 70 degree scope from the top, looking all the way down and around the corner. And you can see the red area on top. So we'll spend a little time on the next two steps, about a minute each. So here's what it looks like with viewing from the top. That's the subscap to the right. As you go inferiorly, you can see the scarring where it's stuck to the subscap. So you have to free that up. And I like to work with a shaver. You can't turn the shaver towards the capsule. You have to turn the shaver towards the subscap. Nothing else that'll create a little bit of scarring, but you're trying to release that. You can use a little elevator if you want. And then as you go through that, then you'll be able to take this down. You can see the scarring on the bone above. And as we free that up, then it's just a question of tucking it back where it's supposed to be. And so you come in and you make sure you do this. It's a big step. The next step is to braid the humeral head. It's the same patient. We move up and down. And once you've done that, then you've created a healing bed. If you set your portals up correctly, then the next step is gonna be to put your anchor in. You can see the subscap to the right, the big split in the interval at the bottom right. And then as you come across, you can see where that's supposed to go. So you usually put our first anchor at three o'clock. Now we're switching to the other side of the shoulder, a right shoulder over a left. So we're looking from the top, and then we're looking down at the capsule. Our anchor's in place above. We've created that path outside the capsule. So you're not trying to struggle. You're not gonna jam your instruments down into the axillary nerve. And then you can use a retrograde retriever of whatever kind you like. You can shuttle if you want, but I think adding steps causes a billion more complications. And then notice I very clumsily didn't put the suture right where I could slip in and grab it right away. So I have to struggle a little bit to get it because we're working at the bottom of the shoulder. And then we'll bring it back through and we'll tie our sutures between the subscap and the capsule, between the subscapularis and the capsule, and they're outside the joint. So it's a mattress stitch. It's a cross and oblique. And then you can see the first suture there. That's six o'clock at the bottom right. So we're at about five o'clock in 4.30 and we'll come back and do the same thing again to close it back up. So for all of you in the room, you're technically plenty good enough to do this. It's just figuring out where the two or three little tricks are. I don't usually tie the first one. I'll go ahead and pass all four stitches and tie them and keep them on separate sides of the cannula, but you can certainly tie them one at a time. And you can see the big defect there as we come through. All right, we'll go through that. And then this is kind of what it looks like when it's all finished. We tie our knots, everything gets back in place. I always check stability because I always worry if I push hard enough, it's going to come apart, but I need to know that right then. And then that's closed up. And then last couple of things is if you need to, you can close the rotator interval and add to it. Sometimes that helps. You don't have to. And then open is pretty straightforward. This is a longer video where we just kept the scope in and watched us come in from outside. Raggle, we're going to skip. And then with Hagel, Gene and Proter on six cases with good results. When we look back at our Tulane group, we had 35 patients between Mike O'Brien and I, 34 of them healed, and we only lost about three degrees. So I think it's a reasonable thing to do. So again, technically it's easy to do. You just got to know the tricks. And Dean Taylor has a nice long video of me struggling where I showed him one of my first cases. So if you ever want to see what not to do, ask him and he'll show it to you. Thank you very much. Thank you.

humeral avulsion lesions

diagnosis

surgical repair

arthroscopy

scar tissue