Shoulder & Elbow.

ISSN 1758-5732

S INVITED REVIEW

Management of anterior shoulder instability without bone loss:

arthroscopic and mini-open techniques
Deepak N. Bhatia∗ & Joe F. de Beer†
∗ Department of Orthopaedic Surgery, Seth GS Medical College and King Edward VII Memorial Hospital, Parel, Mumbai, India
†
Cape Shoulder Institute, Cape Town, South Africa

ABSTRACT
Received Anterior shoulder instability is a complex problem and necessitates accurate pre- and intraoperative
Received 28 June 2010;
assessment of soft-tissue and bony pathology. Soft tissue pathology plays a major role in anterior instability
accepted 21 September 2010
without bone loss, and includes glenoid lesions (glenoid labral tears/avulsions), capsular lesions (plastic
Keywords
Glenohumeral instability, HAGL lesion, deformation and tears), and humeral side lesions (humeral avulsion of glenohumeral ligament lesion
labroplasty, Bhatia portal, should arthroscopy referred to as ‘‘HAGL’’ lesions). Glenoid labral tears and capsular lesions are adequately addressed with
Conflicts of Interest the ‘‘labroplasty’’ procedure. This involves a sequential capsulolabral shift using correctly oriented suture-
None declared anchors, to effectively reduce the capsular volume. In addition, technical maneuvers like the ‘‘double-grasper
Correspondence shift’’ and ‘‘Noose maneuver’’ are crucial to recreate a labral bumper effect at the glenoid edge. HAGL lesions
Joe F. de Beer, Cape Shoulder Institute,
may be difficult to detect, and use of the axillary-pouch portal (Bhatia portal) facilitates identification of the
Suite no. 4, Medgroup Anlin House,
43 Bloulelie Crescent, Plattekloof, tear. A new mini-open subscapularis-sparing technique permits secure repair of the HAGL lesion without a
Cape Town, South Africa. subscapularis tenotomy or even a split. Postoperative rehabilitation is guided by intra-operative tensioning
Tel.: +2721 911 1017. of the capsulolabral tissue.
Fax: +2721 911 1019/41.
E-mail: shoulder@iafrica.com
DOI:10.1111/j.1758-5740.2010.00099.x

INTRODUCTION A standard anaesthesia protocol of a general anaesthetic with

Arthroscopic repairs for anterior shoulder instability are proven to
produce results equal to open surgical techniques in the absence
of significant structural bone deficits (engaging Hill-Sachs lesion
and inverted-pear glenoid) [1,2]. The importance of excluding such
bone lesions cannot be overemphasized because their presence
greatly influences the results of the arthroscopic procedures. The
spectrum of soft-tissue pathology in anterior instability 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). New arthroscopic and mini-open techniques provide
minimally invasive and reliable alternatives to the traditional open
repairs of these lesions [3–6]. We present an overview of our
surgical techniques for the management of soft-tissue lesions
associated with anterior shoulder instability.
GLENOID AND MID-CAPSULAR LESIONS: THE LABRAL
REPAIR AND ‘LABROPLASTY’ PROCEDURE
The ‘Labroplasty’ procedure developed at the Cape Shoulder
Institute is a combination of a sequential anterior–inferior
capsular shift and reconstruction of a ‘neo-labrum’ at the anterior
glenoid rim. Indications include: (i) anteroinferior glenohumeral
ligament tears/avulsions; (ii) mid-capsular tears; (iii) insignificant
bone defects in a noncontact athlete. Contraindications to this
procedure include significant glenoid and humeral bone defects.
an interscalene nerve block is used for postoperative pain relief.
The patient is placed in the lateral decubitus position, with a 20◦
posterior tilt to orient the glenoid parallel to the floor. An upper
limb positioning device (SPIDER limb positioner; TENET Medical
Products, Smith & Nephew, Andover, MA, USA) is used to support
the limb in 20◦ to 30◦ of abduction and 20◦ of forward flexion; this
is simply a position in which the arm is placed and no distal traction
is necessary. A sterile band is placed around the upper arm to exert
mild lateral traction on the upper arm to open the joint space; this
band is attached simply to a drip stand or to an overhead pulley. The
shoulder, arm and hand are prepared and drapes are positioned.
The bony outlines of the clavicle, acromion, spine of the scapula
and coracoid are drawn with a surgical skin marker and portals
are marked. A standard posterior portal, 1 cm to 2 cm inferior and
medial to the posterolateral corner of the acromion, is utilized to
perform a routine glenohumeral and bursal arthroscopy, using a
4-mm arthroscope with a 30◦ angled lens, and an arthroscopic
pump maintaining pressure at 60 mmHg. This posterior portal has
to be placed on the level of the joint because it will become the
accessory working portal for the procedure and instruments have to
reach to the anterior labrum from this portal. An anterior–superior
portal is created, under vision, in the angle made by the long head of
the biceps tendon with its glenoid attachment, using the outside-in
technique, and utilized as a viewing portal. This portal is placed
as medial as possible to avoid the humeral head from obstructing

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 S Management of anterior shoulder instability
the view. An anteroinferior portal is created, just superior to the
superior border of the subscapularis, as lateral as possible, using an
8.5-mm cannula (Clear-Trac Cannula, 8.5 mm × 90 mm; Smith &
Nephew), and is utilized as a working portal. By placing this portal
as lateral as possible, an adequate angle for drilling the holes for
the anchors is ensured (Fig. 1a, b).
Diagnostic arthroscopy
The initial part of the procedure is diagnostic and performed with
air arthroscopy: 50 mL of air is pushed into the joint using a syringe
and the interior of the joint is viewed. First, the presence/absence of
a superior glenoid labrum lesion (SLAP) lesion, biceps pathology,
rotator cuff pathology or any chondral defects of the joint are
noted. The presence of anterior and posterior Bankart lesions with
or without bony lesions is noted (Fig. 1c). Hill–Sachs lesions are
evaluated for size and position. At this point, the arm is taken out
of traction and put in the abducted and externally rotated position
as an in vivo test for anterior engagement of the Hill-Sachs lesion
over the edge of the glenoid. The presence of such engagement
would be a contraindication to soft tissue repair Next, the scope
Bhatia and de Beer
is inserted through the anterosuperior portal to accurately assess
the anterior glenoid edge for bone loss. It is often surprising how
this view from the front gives a much better view of bone loss than
from posterior [2] (Fig. 2). The presence of significant bone deficits
is a contraindication for this procedure. The capsule is also checked
for a HAGL lesion; it is noteworthy that, with HAGL lesions, there is
immediate severe extravasation of water into the soft tissues with
concomitant swelling, making the air arthroscopy advantageous
in such cases. When this diagnostic exercise has been completed,
the pump is switched on and the rest of the procedure is carried
out with water pressure.
If a SLAP lesion is present, this is usually repaired first using two
bone anchors. With the arthroscope in the anterior–superior portal
and instrumentation through the anterior portal, the anterior
capsule is separated from the posterior surface of the subscapularis
using a blunt dissecting instrument. The detached labrum
with its glenohumeral ligaments is separated from the glenoid
rim and posterior surface using a periosteal elevator/liberator. The
separation is continued to the mid-inferior rim of the glenoid
(6 o’clock position) using a hooked/curved radiofrequency probe

(a) (b)

(c)

Fig. 1 (a) External view of arthroscopy portals for labroplasty procedure (A1, anteroinferior portal; A2, anterosuperior portal; P, posterior portal).
(b) Internal view of arthroscopy portals for labroplasty procedure (A1, anteroinferior portal; A2, anterosuperior portal; G, glenoid; H, humeral head;
BT, long biceps tendon; ST, subscapularis tendon). (c) Visualization of the Bankart lesion via anterosuperior portal (H, humeral head; G, glenoid;
L, anteroinferior labrum).

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 S Management of anterior shoulder instability
Fig. 2 Glenoid bone loss as visualized via the anterosuperior portal
(H, humeral head; G, glenoid; BS, bare spot).
(LIGAMENT CHISEL probe, VULCAN generator; Smith & Nephew),
if necessary. This extended release is crucial to achieve a capsular
shift. Adequacy of the capsular–labral release is indicated by
visualization of the muscle fibres of the subscapularis, medial to the
labro–ligamentous complex. Associated or isolated mid-capsular
tears require meticulous dissection and mobilization of the capsular
tissue to avoid further damage. Next, the anterior neck of the
glenoid is roughened using an arthroscopic glenoid rasp/burr
(DYONICS POWER shaver system; Smith & Nephew) to create a raw,
Bhatia and de Beer
bleeding surface for the labro–ligamentous complex. Drill-holes
are placed on the articular surface of the glenoid, adjacent to
the anterior glenoid rim. The first drill-hole is placed at the 5.30
o’clock position (for the right glenohumeral joint). The second
and third drill-holes are placed at 3.30 and 2.30 o’clock positions,
after the previous anchors have been placed and knots tied.
A bioabsorbable ‘tap-in’ type of anchor (BIORAPTOR 2.9 suture
anchor; Smith & Nephew) preloaded with one or two polyethylene
sutures (ULTRABRAID #2 suture; Smith & Nephew) is ‘tapped’ into
the first hole (5.30 o’clock position). The orientation of the eyelets
is crucial to achieve optimal approximation of tissues and optimal
sliding of the suture within the eyelet of the anchor (Fig. 3) [4].
The eyelet is oriented in line with the direction in which the suture
will be passed through the labral tissue. Thus, the eyelet holes
of the inferior-most anchor are oriented obliquely and inferiorly.
After anchor insertion, the suture strand to be passed through the
labro–ligamentous complex (the ‘post strand’) is retrieved through
the posterior cannula for suture management; this strand should
always be the one in the outer eyelet hole of the anchor (the strand
closest to the tissue that will be passed through the tissue) because
this places the knot over the tissues. Successive anchors are placed
after previous knots have been tied.
The inferior glenohumeral ligament and labrum is now grasped
with an arthroscopic grasper introduced through the anterior
portal, at the 6 o’clock position, 5 mm to 10 mm inferior to the
glenoid rim, and is shifted in a south to north direction upto
the inferior-most anchor (5.30 o’clock position). A second grasper,
introduced through the posterior cannula, grasps this tissue just
inferior to anterior grasper, to maintain the shift when the suture
is passed through the tissue (‘double-grasper shift’) (Fig. 4). A 70◦
angled suture grasper is introduced through the anterior portal;
the angled tip is passed through the labro–ligamentous tissue

(a) (b) (c)

Fig. 3 Suture eyelet orientation. (a) A hole placed at an angle to the direction of the loop can create friction for the suture in the hole, which in turn
creates unnecessary obstruction to tissue approximation to bone. (b) The outside strand is passed through the capsule and the inside strand is on the
side of the joint. The outside strand should be used for the ‘post strand’ because this places the knot outside the joint and rolls the soft tissue onto the
edge of the joint, creating a pseudolabrum or buttress anteriorly. (c) Using the inside strand for the ‘post strand’ causes the knot to be directed toward
the inside of the joint and ends up between the tissue and the anchor. Reproduced with permission [4].

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 S Management of anterior shoulder instability Bhatia and de Beer

(a) (b)

Fig. 4 The ‘double-grasper shift’. (a) An anterior grasper (G1) shifts the inferior glenohumeral ligament (IGHL) superiorly. A posterior grasper (G2) is
advanced to maintain this shift. (b) The posterior grasper (G2) maintains the superior shift of the IGHL, whereas a suture passer introduced through the
A1 portal shuttles sutures (B, long biceps tendon).

when the shift is maintained, and the suture in the posterior

cannula is retrieved into the anterior portal. The Nicky’s knot
is used as a sliding, locking knot to achieve approximation of
the tissues [5]. The strand through the tissue becomes the ‘post
strand’ and this will place the knot on the tissue away from the
joint. As the knot is being slid down the cannula, closing the
suture loop, the grasper in the posterior cannula retensions the
labral–ligamentous complex through the ‘noose’ of the Nicky’s
knot, and the knot is secured (‘noose manoeuver’) (Fig. 5). The
shifted capsule is ‘piled-up’ at the edge of the glenoid articular
surface. Successive anchors utilize similar principles to sequentially
shift and retension the capsule, thereby creating a ‘neo-labrum’
(Fig. 6). Mid-capsular tears can usually be incorporated in creation
of the neo-labrum; alternately, capsular stitches may be placed
to repair the tear before the capsular shift. Note that the capsule
is sequentially shifted from ‘South to North’ and not from ‘East
to West’, thus decreasing the volume of the inferior capsular
pouch and even shifting the tissue from posteroinferior to anterior,
thereby decreasing the posteroinferior laxity. To optimize the
capsular shift, the following tip is recommended: after placing the Fig. 5 The ‘Noose maneuver’. A posterior grasper (G2) pulls up the
inferior glenohumeral ligament tissue into the noose (N) formed by the
first anchor, the bite of soft tissue taken is mainly labrum and a
approaching sliding knot (K), just before the final tightening, thereby
bit of capsule because the labrum has a limited distance through creating a ‘neo-labrum’.
which it will move and, if a large bite of capsule were taken with it,
the labrum will limit the degree of shift. Then, after the first stitch
has been tied, the second bite of tissue for the second anchor can A rotator interval closure may be performed, if necessary, based
be through a generous bite of capsule and rotated round the first on preoperative and intra-operative assessment of the instability.
anchor as a pivot point; this usually results in an excellent shift This is indicated when a wide, thin interval is noted during
of the inferior ligament and the axillary pouch can be seen to be arthroscopy and especially if there was a marked positive sulcus
eliminated with this shift. sign present during clinical examination.

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 S Management of anterior shoulder instability
Fig. 6 Schematic representation of the sequential capsular shift (arrows,
anchor points; MGHL, middle glenohumeral ligament; RI, rotator interval;
A, anterior; P, posterior).
At the end of the procedure, the arm is taken out of traction
and slowly pushed into abduction, then external rotation; when
viewing the repair site, the arm position at which there appears to
be tensioning at the repair site, is noted. One of us (J.F.de B.) has
carried this out on a series of 60 patients (unpublished data) and
the average position where the repair is being strained is: arm in
90◦ of abduction and 60◦ of external rotation. This implies that, in
most cases, a sling is not required as long as this range of motion
is respected.
HAGL LESIONS: ARTHROSCOPIC AND MINI-OPEN
(SUBSCAPULARIS SPARING) APPROACHES
Humeral avulsion of the inferior glenohumeral ligament complex
(HAGL lesion) is an uncommon pathology in traumatic shoulder
(a)
Fig. 7 (a) Arthroscopic demonstration of the ‘Axillary pouch portal’ visualized through a standard posterior viewing portal (C, canula in axillary pouch
portal; IGHR, inferior glenohumeral recess; H, humeral head). (b) Arthroscopic view of a HAGL lesion (IGHL, torn inferior glenohumeral ligament;
H, humeral head).
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Bhatia and de Beer
instability. Both mini-open and arthroscopic techniques may be
used to repair these lesions. The recently described mini-open
subscapularis-sparing approach for repair of these lesions provides
adequate access to the anteroinferior region of the capsule without
detachment of the subscapularis [6].
A preliminary diagnostic arthroscopy is performed to evaluate
the pathology. In the presence of a lax capsule, the axillary
recess can be visualized through the standard posterior portal. If
the humeral attachment of the inferior glenohumeral ligament
is not adequately visualized (e.g. chronic HAGL tears), then an
‘axillary-pouch portal’ (Bhatia portal) is used to explore the inferior
glenohumeral recess as described by Bhatia and de Beer [7,8].
This portal is placed approximately 2 cm inferior and directly
below the inferior border of the posterolateral angle of the
acromion (Fig. 7). Once the HAGL lesion is visualized and assessed,
a decision regarding an arthroscopic or mini-open approach is
made. We prefer a mini-open ‘subscapularis sparing’ approach for
isolated HAGL lesions. A concomitant glenoid sided lesion (labral
tear, SLAP lesion) is probably better addressed simultaneously
by arthroscopic techniques. A standard deltopectoral approach
through an axillary incision is used. The skin and subcutaneous
tissues are undermined to aid retraction. Inferior retraction of
the pectoralis major insertion exposes the inferior border of the
subscapularis. This is then mobilized and retracted superiorly to
provide access to the anteroinferior humeral neck and the torn
ligaments are visualized. In a HAGL lesion, the capsule is detached
from the humeral neck, with the bone appearing smooth and bare
on the neck. A light decortication of the bone is performed to
enhance healing of the capsule. Arthroscopic suture anchors and
suture passers (facilitating passage of sutures in the relatively small
space) are utilized to secure the torn ligaments to the humeral
neck. The approach can be converted to a subscapularis L-shaped
tenotomy if exposure is inadequate (Fig. 8).
Alternately, an all-arthroscopic anterior and/or posterior
approach, as described recently by Page and Bhatia, may be
(b)
5
 S Management of anterior shoulder instability Bhatia and de Beer

(a) (b)

Fig. 8 (a) Subscapularis (SSc) muscle separation and anterosuperior retraction (R) from the underlying capsule is restricted to the lateral aspect of
the coracoid (C) and the anterior glenoid rim. Adequate visualization of the torn inferior glenohumeral ligament and the anteroinferior humeral neck
(arrows) is possible (A, acromion; B, long biceps tendon; C, coracoid process; CL, clavicle; H, humerus; S, supraspinatus; Sp, scapula). (b) Diagrammatic
representation of the completed capsular (inferior glenohumeral ligament) repair (arrows) via the subscapularis-sparing approach is shown (A, acromion;
B, long head of biceps tendon; C, coracoid process; CL, clavicle; G, glenoid; H, humerus; R, anterosuperior retraction of the inferior subscapularis border;
S, supraspinatus; SSc, subscapularis). Reproduced with permission [6].

utilized individually or in combination to repair different types DISCUSSION

of HAGL lesions [9]. The anterior arthroscopic approach utilizes
the 5 o’clock portal as the working portal for anchor passage and
suture management. The posterior arthroscopic technique uses
the Bhatia portal, as described earlier, for anchor passage and
retrieval of sutures and for knotting sutures.
POSTOPERATIVE MANAGEMENT
Postoperatively, the arm is placed in a sling for comfort, and this
can be removed as soon as pain permits. As noted above, there is
no traction on the repair with the arm by the side, with the repair
only being stressed in the abducted and externally rotated position
of the arm. The physiotherapist is instructed regarding the range
of motion permitted for active and passive mobilization based on
the intra-operative tensioning of the capsule–labral complex. A
detailed postoperative rehabilitation protocol for arthroscopically
repaired HAGL lesions has been described by Page and Bhatia [9].
This consists of two phases, each of 4 weeks duration (i.e. passive,
active assisted and active exercises) and a further third phase (i.e.
muscle strengthening exercises) for up to 6 months. The same
protocol may be applicable to arthroscopically repaired labral tears
and labroplasty procedures, although an individualized approach
is advisable.
Surgical treatment of anterior shoulder instability is complex
and necessitates adequate intra-operative assessment and
correction of the soft-tissue and bony pathology [10]. The choice
between arthroscopic and open approaches is based on several
factors that can be identified pre- and/or intra-operatively. The
Instability severity index score described by Balg and Boileau
is based on risk factors, including patient age under 20 years,
competitive/contact/forced overhead activity sports, shoulder
hyperlaxity, a Hill-Sachs lesion present on an anteroposterior
radiograph of the shoulder in external rotation and/or loss of the
sclerotic inferior glenoid contour [11]. A recent study prospectively
analyzed the results of arthroscopic Bankart repairs for anterior
instability and found that patients under age 25 years, with
ligamentous laxity, and with a large (>250 mm3 ) Hill-Sachs lesion,
were at the greatest risk of recurrence [12]. Our experience with
a high failure rate of arthroscopic Bankart repairs in the presence
of significant bone defects has necessitated a meticulous pre-
operative and intra-operative assessment of associated soft-tissue
and bony pathologies, and their treatment as elaborated in the
present review. In cases where such bony pathology was excluded,
the arthroscopic labroplasty procedure has been most successful
in restoring joint stability.

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