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Arthroscopic Management of Shoulder Hagl Lesion - Tips & Tricks to Deal with Such Complex Cases
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Arthroscopic Management of Shoulder Hagl Lesion - Tips & Tricks to Deal with Such Complex Cases
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Language: EN.
Segment:0 .
Hello, my friends, how are you? I'm Dr. Sergio Rowinski from Shoulder Planet here from the city of Sao Paolo in Brazil. And in this video, I'm presenting you a very difficult situation, which is the arthroscopic management of a Hagl lesion humeral aversion of the ligament. This is indeed a difficult surgery in which I am showing you tips and tricks in order to make this difficult procedure more feasible.
So I hope you like the video. Please subscribe to the channel. Leave your comment and let's see the video. Their anterior instability is a very common problem in every shoulder surgeon's office, and nowadays we all know that arthroscopic treatment is the gold standard way of fixing these lesions. Once there is no indication for a bony block procedure, the most common and quite standard lesion involved in these cases is the Bankart lesion.
But some different types of lesion are already described in literature as the lesion or even the Hagl lesion. What stands for humeral evolution of the interior? Gleno humoral ligament Hagl lesions are quite uncommon, and its treatment can be performed microscopically, but it is described in literature to be quite difficult. So this case is about a 35-year-old patient who is a triathlete and who had his first anterior shoulder dislocation about five years ago.
After that, he stood for four years OK with no problems in his right shoulder swimming, OK. But he had second anterior shoulder dislocation about one year ago. After that, he had something like 20 new episodes, and he came to my office in August 2011. So this is his actual MRI. And now we have seen a coronal view in T2 in which we can clearly see a Hagl lesion in the humeral neck head region.
And this is another image still, with two coronal view revealing the Hagl lesion. This is another image, a T2 sagittal view in which we can see no signs of any stand or Bankart lesion. And in this image, and next to cut, we can see that his interior labrum seemed to be quite normal. And finally, this is another image and XSLT to cut again, revealing quite normal anterior labrum.
So the patient was told that we would try to fix his Hagl lesion arthroscopically. And if we found that it was not possible, we would very Fastly stop the Arthroscopy and perform an open Bristow-Latarjet surgery. It's important to say that I only do my shoulder arthroscopy is in the beach chair position, but particularly in this case, we use it the lateral decubitus position. And anyway, this illusion was fixed at topically, and so this is his arthroscopy.
So this is his arthroscopy. This is a right shoulder. So now we have seen the Hill-Sachs lesion that was really not very big in this case and the long hair of the biceps that was pretty OK. Now we've seen the upper border of the cap, and now this is the posterior part of the axillary recess in which we can see the posterior inferior grain of humor or ligament that was quite inflamed.
And here is the place in which we would find Hagl lesion. So the first thing to do was to establish a very standard and simple interior portal, and we use it. carefully, just to open the capsule in a very standard way in, then we enter it with a shaver just to breathe out inflammatory tissue in the synovitis in the axillary recess in the region of the posterior inferior humeral ligament.
There was a lot of inflammatory tissue, especially because the patient dislocated his shoulder 15 days before that surgery. So we would have to remove all the sinusitis, all the inflammatory tissue in the axillary recess. And we continue that with radiofrequency device removing all the sinusitis now and all the inflammatory tissue it is now, we can see that almost all the inflammatory tissue was quite reasonably removed, but we continued because we would have to find Hagl lesion.
And without all that inflammatory tissue, that would be probably much, much easier. So then we would have to establish a trend, some scapularis portal. And this is quite difficult. But we finally did it with a spinal needle and then we enter it with this device and using the messenger and putting some strength in our hands here within the border of the scapularis, we could finally enter with standard cannula.
So now we can see that this is quite difficult because this scapularis is a very strong tendon and a strong muscle, especially in such a strong man. And when the cannula was in place, we enter it through the interior portal with a very delicate spatula and nasty at a very delicate one to try to find a heavier lesion. So here's the Hagl lesion. We have seen a torn ligament in its humerus insertion and the delicate osteotomy was almost entering through that ruptured the torn ligament.
So once we found that lesion lesion, we continue to debris the inflammatory tissue and. We would have to do we to have enough space to try to put an anchor. So we enter it first with a burr. But it was quite difficult, as we are seeing now. With then, we will try to find a place to put to create a bony bed in which we would put our anchor. But we know to say that it was very hard to have a nice view with the camera in the posterior portal.
It was sometimes very difficult to see the burrs, so we change it. The portals now the camera is in the interior portal when we put then the burr without a cannula because it was easier for us to breathe and to move, and we started to create a bony bed in which we would put the first and probably the only anchor in the humerus. So now we are seeing the bony bed that we had just created. It was very reasonable and we have the endochondral bone very nicely exposed.
And then we enter it with a single 5.0 anchor and a metallic one and try to put that in the bony bed that we have just created. It was very difficult and we didn't have space, so we put the camera back in the posterior portal and then it was reasonably easier for us to see the anchor and then we would put the anchor in the bony bed that we had just created in the humerus. And we use it a hammer to very softly, very slowly to make us more entrance for the anchor and then to screw it inside the bone, inside the humerus.
Anyway, it was very difficult and it was very slippery. This is called the killer angle by Burckhardt, but it was very difficult to find a nice angle. It was very slippery. So as we tried to introduce the anchor with a hammer, it was really, really difficult. And every time we fought that the anchor was in place. It, it was. It would slip again.
And at that moment, so we decided to put through the transom scapularis portal a puncture and to create a hole using a hammer where softly, very slowly in the same way we do in the greater tuberosity. So now we are using a hammer to put it inside the humerus. And once we created that hole in which we would insert the anchor, we enter again with the anchor. The camera is in the posterior portal when the anchor is in the trench scapularis portal with no cannula but with a knee cannula because it was easier for us to manage.
But we couldn't find the hole that we had just done. We had just created. And it was slippery again in the same way, so we felt the hole. But when we tried to enter with their metallic anchor, the anchor was slippery again, so we changed the portals of the camera once more. Now the camera is in the anterior portal. We try to have a direct vision of the hole that we had just created.
It was very difficult to see. The literature says. This is a very difficult part of the surgery. So we enter it for the transfer portal with a soft tissue shaver to try to see the hole that we had just done in the bony bed, in the humerus. And then finally, with my hands almost in the patient's eyes, I could finally introduce the anchor. But we decided to check it.
So we put at that moment the camera back in the posterior portal, when for the anterior portal, we enter it with the probe just to try to feel with our hands. If the anchor was in place, that was difficult, too. So we entered for the anterior portal with a soft tissue shaver to remove all the cartilage of the humerus. In order for us to see if the anchor had really enter it in the humorous, finally, we could see that the anchor was inside the humor as we can see the black markings, so we remove it.
And at that moment, we would have to isolate in the very standard fashion. The sutures to try to fix the Hagl lesion. Then for the transcript scapularis portal, we enter it with a very simple suture passer and with a perilymph suture, a number two proline suture, and we would put one part of that perilymph suture out of the anterior portal. And in a retrograde fashion, we would put the first suture the white one person through the Hagl lesion.
Out of the transom scapularis portal, and now both parts of the white suture were outside the shoulder through the transfer portal, and then we would have to isolate that wide suture in the anterior portal to tie the first knots. And then we tied first knots and anons slightly knot in order to bring the antero- inferior ligament to the bone bed that we had just done, just created in the humerus. And after the note was done, then it would have to be cut and we would have to isolate the two parts of the blue suture in the anterior portal.
And at that moment, they were isolated in the initial report, and then we try to see if the patient had a Bankart lesion. And for our surprise, he really had in spite of having nothing in the original MRI. So at that moment, we decided to unload their dead, anchoring the humerus because it would be much better to fix that Bankart lesion. And then we would fix that Bankart lesion in a very standard and simple fashion.
So we enter it again with the delicate, austere. And we started to detach. That reasonably large Bankart lesion from the anterior inferior rim of the interior late night in a very standard and simple fashion. And we would have to fix it in a standard fashion too. So once we had detach it, we entered with a shaver just to create a bony bed, a bleeding base in the central inferior part of the glenoid and especially including the central superior part of the eye, too.
And after that, we entered with one anchor in something like the three or the 4 o'clock position, and we would put a standard 2.9 absorbable below that anchor. So now the anchor is being put. And once the anchor wasn't in place, we enter, we decided to create a new port because we are using to fix our standard Bankart with two anterior portal portals.
And then we would have to isolate the sutures in a very standard fashion not to make a mess with them. And then we enter it with a bird beak through the anterior portal and we pull, we pull it the first blue suture, passing through the Bankart lesion. And before tying that one, we would do the same thing and put. Putting the white suture patient through.
The Bankart legion and out of the shoulder, so then we would have to tie the knot. So we first tied the blue one, putting a lot of compression in the Bankart lesion. And once the note was done, it would have to be cured, then we would have to tie the second one. After that week, we just would have to cut it and then we palpate it. Our construction, it was very stable with a single anchor, and the labrum was very nicely fixed to the interior glenoid and we wouldn't have to do to put another anchor.
Then we tested the biceps and it was very OK with no signs of slip. And the tension of the humeral ligament was very nice, and at that moment, the surgery was finished. So, my friend, I hope you like the video. Don't forget, subscribe in the channel. Leave your comment and we keep on talking. Shoulder Planet never stop flying. I'm Dr. Sergio from Brazil.
Segment:0 .
Hello, my friends, how are you? I'm Dr. Sergio Rowinski from Shoulder Planet here from the city of Sao Paolo in Brazil. And in this video, I'm presenting you a very difficult situation, which is the arthroscopic management of a Hagl lesion humeral aversion of the ligament. This is indeed a difficult surgery in which I am showing you tips and tricks in order to make this difficult procedure more feasible.
So I hope you like the video. Please subscribe to the channel. Leave your comment and let's see the video. Their anterior instability is a very common problem in every shoulder surgeon's office, and nowadays we all know that arthroscopic treatment is the gold standard way of fixing these lesions. Once there is no indication for a bony block procedure, the most common and quite standard lesion involved in these cases is the Bankart lesion.
But some different types of lesion are already described in literature as the lesion or even the Hagl lesion. What stands for humeral evolution of the interior? Gleno humoral ligament Hagl lesions are quite uncommon, and its treatment can be performed microscopically, but it is described in literature to be quite difficult. So this case is about a 35-year-old patient who is a triathlete and who had his first anterior shoulder dislocation about five years ago.
After that, he stood for four years OK with no problems in his right shoulder swimming, OK. But he had second anterior shoulder dislocation about one year ago. After that, he had something like 20 new episodes, and he came to my office in August 2011. So this is his actual MRI. And now we have seen a coronal view in T2 in which we can clearly see a Hagl lesion in the humeral neck head region.
And this is another image still, with two coronal view revealing the Hagl lesion. This is another image, a T2 sagittal view in which we can see no signs of any stand or Bankart lesion. And in this image, and next to cut, we can see that his interior labrum seemed to be quite normal. And finally, this is another image and XSLT to cut again, revealing quite normal anterior labrum.
So the patient was told that we would try to fix his Hagl lesion arthroscopically. And if we found that it was not possible, we would very Fastly stop the Arthroscopy and perform an open Bristow-Latarjet surgery. It's important to say that I only do my shoulder arthroscopy is in the beach chair position, but particularly in this case, we use it the lateral decubitus position. And anyway, this illusion was fixed at topically, and so this is his arthroscopy.
So this is his arthroscopy. This is a right shoulder. So now we have seen the Hill-Sachs lesion that was really not very big in this case and the long hair of the biceps that was pretty OK. Now we've seen the upper border of the cap, and now this is the posterior part of the axillary recess in which we can see the posterior inferior grain of humor or ligament that was quite inflamed.
And here is the place in which we would find Hagl lesion. So the first thing to do was to establish a very standard and simple interior portal, and we use it. carefully, just to open the capsule in a very standard way in, then we enter it with a shaver just to breathe out inflammatory tissue in the synovitis in the axillary recess in the region of the posterior inferior humeral ligament.
There was a lot of inflammatory tissue, especially because the patient dislocated his shoulder 15 days before that surgery. So we would have to remove all the sinusitis, all the inflammatory tissue in the axillary recess. And we continue that with radiofrequency device removing all the sinusitis now and all the inflammatory tissue it is now, we can see that almost all the inflammatory tissue was quite reasonably removed, but we continued because we would have to find Hagl lesion.
And without all that inflammatory tissue, that would be probably much, much easier. So then we would have to establish a trend, some scapularis portal. And this is quite difficult. But we finally did it with a spinal needle and then we enter it with this device and using the messenger and putting some strength in our hands here within the border of the scapularis, we could finally enter with standard cannula.
So now we can see that this is quite difficult because this scapularis is a very strong tendon and a strong muscle, especially in such a strong man. And when the cannula was in place, we enter it through the interior portal with a very delicate spatula and nasty at a very delicate one to try to find a heavier lesion. So here's the Hagl lesion. We have seen a torn ligament in its humerus insertion and the delicate osteotomy was almost entering through that ruptured the torn ligament.
So once we found that lesion lesion, we continue to debris the inflammatory tissue and. We would have to do we to have enough space to try to put an anchor. So we enter it first with a burr. But it was quite difficult, as we are seeing now. With then, we will try to find a place to put to create a bony bed in which we would put our anchor. But we know to say that it was very hard to have a nice view with the camera in the posterior portal.
It was sometimes very difficult to see the burrs, so we change it. The portals now the camera is in the interior portal when we put then the burr without a cannula because it was easier for us to breathe and to move, and we started to create a bony bed in which we would put the first and probably the only anchor in the humerus. So now we are seeing the bony bed that we had just created. It was very reasonable and we have the endochondral bone very nicely exposed.
And then we enter it with a single 5.0 anchor and a metallic one and try to put that in the bony bed that we have just created. It was very difficult and we didn't have space, so we put the camera back in the posterior portal and then it was reasonably easier for us to see the anchor and then we would put the anchor in the bony bed that we had just created in the humerus. And we use it a hammer to very softly, very slowly to make us more entrance for the anchor and then to screw it inside the bone, inside the humerus.
Anyway, it was very difficult and it was very slippery. This is called the killer angle by Burckhardt, but it was very difficult to find a nice angle. It was very slippery. So as we tried to introduce the anchor with a hammer, it was really, really difficult. And every time we fought that the anchor was in place. It, it was. It would slip again.
And at that moment, so we decided to put through the transom scapularis portal a puncture and to create a hole using a hammer where softly, very slowly in the same way we do in the greater tuberosity. So now we are using a hammer to put it inside the humerus. And once we created that hole in which we would insert the anchor, we enter again with the anchor. The camera is in the posterior portal when the anchor is in the trench scapularis portal with no cannula but with a knee cannula because it was easier for us to manage.
But we couldn't find the hole that we had just done. We had just created. And it was slippery again in the same way, so we felt the hole. But when we tried to enter with their metallic anchor, the anchor was slippery again, so we changed the portals of the camera once more. Now the camera is in the anterior portal. We try to have a direct vision of the hole that we had just created.
It was very difficult to see. The literature says. This is a very difficult part of the surgery. So we enter it for the transfer portal with a soft tissue shaver to try to see the hole that we had just done in the bony bed, in the humerus. And then finally, with my hands almost in the patient's eyes, I could finally introduce the anchor. But we decided to check it.
So we put at that moment the camera back in the posterior portal, when for the anterior portal, we enter it with the probe just to try to feel with our hands. If the anchor was in place, that was difficult, too. So we entered for the anterior portal with a soft tissue shaver to remove all the cartilage of the humerus. In order for us to see if the anchor had really enter it in the humorous, finally, we could see that the anchor was inside the humor as we can see the black markings, so we remove it.
And at that moment, we would have to isolate in the very standard fashion. The sutures to try to fix the Hagl lesion. Then for the transcript scapularis portal, we enter it with a very simple suture passer and with a perilymph suture, a number two proline suture, and we would put one part of that perilymph suture out of the anterior portal. And in a retrograde fashion, we would put the first suture the white one person through the Hagl lesion.
Out of the transom scapularis portal, and now both parts of the white suture were outside the shoulder through the transfer portal, and then we would have to isolate that wide suture in the anterior portal to tie the first knots. And then we tied first knots and anons slightly knot in order to bring the antero- inferior ligament to the bone bed that we had just done, just created in the humerus. And after the note was done, then it would have to be cut and we would have to isolate the two parts of the blue suture in the anterior portal.
And at that moment, they were isolated in the initial report, and then we try to see if the patient had a Bankart lesion. And for our surprise, he really had in spite of having nothing in the original MRI. So at that moment, we decided to unload their dead, anchoring the humerus because it would be much better to fix that Bankart lesion. And then we would fix that Bankart lesion in a very standard and simple fashion.
So we enter it again with the delicate, austere. And we started to detach. That reasonably large Bankart lesion from the anterior inferior rim of the interior late night in a very standard and simple fashion. And we would have to fix it in a standard fashion too. So once we had detach it, we entered with a shaver just to create a bony bed, a bleeding base in the central inferior part of the glenoid and especially including the central superior part of the eye, too.
And after that, we entered with one anchor in something like the three or the 4 o'clock position, and we would put a standard 2.9 absorbable below that anchor. So now the anchor is being put. And once the anchor wasn't in place, we enter, we decided to create a new port because we are using to fix our standard Bankart with two anterior portal portals.
And then we would have to isolate the sutures in a very standard fashion not to make a mess with them. And then we enter it with a bird beak through the anterior portal and we pull, we pull it the first blue suture, passing through the Bankart lesion. And before tying that one, we would do the same thing and put. Putting the white suture patient through.
The Bankart legion and out of the shoulder, so then we would have to tie the knot. So we first tied the blue one, putting a lot of compression in the Bankart lesion. And once the note was done, it would have to be cured, then we would have to tie the second one. After that week, we just would have to cut it and then we palpate it. Our construction, it was very stable with a single anchor, and the labrum was very nicely fixed to the interior glenoid and we wouldn't have to do to put another anchor.
Then we tested the biceps and it was very OK with no signs of slip. And the tension of the humeral ligament was very nice, and at that moment, the surgery was finished. So, my friend, I hope you like the video. Don't forget, subscribe in the channel. Leave your comment and we keep on talking. Shoulder Planet never stop flying. I'm Dr. Sergio from Brazil.
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