0:01

Sliding right into the next case, which is also, uh,

0:05

anterior instability.

0:07

We can see here that this lesion is probably more acute to

0:12

subacute with, uh, some bone marrow edema and, uh, this, uh,

0:17

hill sax deformity. Okay. But also obviously this, uh,

0:22

uh, labral lesion. And maybe, you know, this, this, or, sorry,

0:27

not maybe, but this, uh, uh,

0:30

torn anterior lab Glen, uh,

0:33

glenoid labral tissue is medial lies and,

0:36

and sort of tacked down along the, uh, anterior aspect of the, uh, uh,

0:41

of the glenoid here. Okay? So for these, uh, again,

0:45

I'm also, uh, more descriptive. I don't use, uh,

0:49

any of the acronyms, but I will give, um, a clock face,

0:54

and I will denote in parentheses that, uh, for me,

0:59

the 12 o'clock is, uh, superior,

1:02

and three o'clock is anterior for both shoulders. Some,

1:06

some of my surgeons, uh, flip it depending on which, um, uh,

1:11

you know, how they were trained. Three o'clock may be posterior and anterior,

1:15

but I, for, to keep it straight for everyone, I,

1:18

I always denote 12 as as superior and three o'clock as anterior.

1:22

And I'll put that, especially if I'm dealing with a new surgeon in,

1:26

in my health system. Um, and then, but I'll also tell them that, you know,

1:30

there's tearing of, you know, the superior, uh, anterior superior, uh,

1:35

anterior and anterior inferior labrum, uh, you know, from 12 to six o'clock,

1:40

let's say with the, uh, three o'clock, uh, denoted as anterior,

1:45

something like that. Um, and here also,

1:50

uh, I will, I will say that I don't see a definitive bony bank heart lesion.

1:55

Okay. Um, so, but there's also a,

1:59

a hills sacks lesion, so there's really no, uh, bipolar loss.

2:04

And, and, uh, those are,

2:07

these are some terms that some of your surgeons may be asking you to use.

2:11

And I direct your attention to, um,

2:14

the NYU and HSS group, uh, specifically. Uh, so,

2:19

so, uh, sartorious ge geis, and I'm happy to provide,

2:24

uh, those references to you as well.

2:27

But there's a concept of bipolar loss where you, it where if you have,

2:32

uh, a bony bank heart and a hill sax lesion, if they're sizable,

2:37

the in theory, the, the, uh, hills sac,

2:41

the large hill sac can engage with the cho glenoid and re and lead to

2:46

recurrent anterior glenohumeral joint instability. Okay?

2:50

And you may get asked to do a best fit circle. And what that is,

2:54

is basically measuring, um, the diameter and, and, uh,

2:59

the bone stock loss of the glenoid and the cutoff, depending on who you read.

3:04

Uh, a nice round number that you could remember is about 25. Um,

3:08

uh, what was it, 25, uh, percent or so? Okay.

3:14

Uh, uh, when you have AO uh, a bony bank heart lesion, okay?

3:18

And you do that using the best fit circle, and I'm happy to provide Dr.

3:22

GE Opolis article. He, he's written a, uh, uh,

3:25

extensively about anterior humal joint instability. Okay?

3:30

And the other thing you, you should know about is, uh, hills, sacks, uh,

3:33

the hill sax lesion. There's measurements, there's many measurements for,

3:38

for it. Uh, some people use a radiograph int rotated.

3:42

Some people will use a CT three D reformatted image. Some people use,

3:47

uh, um, measurements, um, in degrees,

3:52

uh, but basically the larger, the hills sax lesion, um,

3:56

that can predispose to, uh, reengagement. As you can imagine,

4:00

if the person were to externally rotate,

4:03

bring this hills sax lesion anteriorly,

4:06

that could en engage with the, uh, deficient glenoid.

4:11

And then as the patient Rett rotates or, uh,

4:16

their shoulder that can lead to re dislocation or,

4:19

or a recurrent anterior glenohumeral joint instability. Okay?

4:24

And that's called an off, uh, off track and on track lesion. And it's,

4:29

it's taken me a while to wrap my head around off track and on track.

4:32

But if you read that literature, just know that off track is bad, okay? Um,

4:37

you wanna stay on track. That is,

4:39

you wanna keep the articular surface or the surfaces of the glenoid

4:44

and, and, and humerus together or on track, similar to, um,

4:50

a train or a subway, if you will. If it's off track, then,

4:54

then that's bad because similar to a train or a subway falling off the track,

4:59

um, the, the, the humeral head can disen or, or reengage, uh,

5:04

the glenoid and fall off the track, or in this case, uh,

5:07

cause recurrent anterior glenohumeral joint instability.

5:11

So those are some terms that, that you may be get, you may be asked to use as,

5:16

uh, recently, uh, particularly in, uh, with the new orthopedic and anatomic and,

5:21

and surgical literature. So bipolar loss and, uh,

5:26

on and off track. So those are some, uh, good things to, uh,

5:30

maybe know about for, uh, anterior gland humal joint instability, uh,

5:34

besides describing your labral tears, as well as, um, your inferior gland,

5:39

humeral ligament complex. And here, um, with, with this, uh,

5:44

in this case, the, uh, inferior glenohumeral ligament complex, um,

5:49

looks, uh, looks better. There is some synovitis and maybe some, uh,

5:54

perhaps some partial tearing at the, uh, glenoid, uh,

5:57

aspect of the inferior glen humeral ligament complex. But, uh,

6:00

as I mentioned early in previous weeks too, this is why I,

6:03

I also like to evaluate the labrum,

6:07

starting with the superior and inferior. But then when I look at my axials,

6:12

I also start, uh, at the posterior,

6:14

because sometimes you get a high attachment of the anterior band,

6:18

of the inferior glandular humeral ligament complex, which, which can mimic, um,

6:23

uh, anterior labeled tear. So, lot of, lot of, uh,

6:27

topics hopefully that I hit there in a, in a short amount of time for, uh,

6:31

anterior glandular humeral joint instability. And with that, I'll, uh,

6:35

I'll take any questions,

6:39

Eddie? Eddie, would you describe that as a gha

6:44

XV pouch?

6:45

A a gha? I, I, I don't, jha Yeah, I don't describe, uh,

6:51

um, I'm not aware of, uh, actually pouch, uh,

6:56

classification. Um, and I, and I don't, I I have not been asked, and I don't,

7:00

I don't classify it. No.

7:04

And when you talk about the glenohumeral ligaments, uh,

7:07

they are components of the capsule of the shoulders, Ted.

7:10

Yeah. So some pe So some people think they're, they're true ligaments.

7:14

Some people think that they're just thickening of a capsule.

7:18

So yeah.

7:20

So descriptively, um,

7:22

you can't really define a shoulder capsule on MRI.

7:26

It is just the conglomeration of these ligaments, isn't it?

7:30

Uh, I, I, I think of the, I think of the ligaments as thickening of the capsule.

7:35

Okay. Or, or the, like, sort of like the ligaments embedded within the capsule,

7:40

if that makes sense.

7:43

Okay.

7:44

But the thin capsule in itself is hard to define on an

7:49

Mr.

7:50

Uh, no. You, I mean, you, you can certainly see it, you know, I mean, you know,

7:54

if anything pressed, yeah, I would say like, this is the capsule right here,

7:57

right? This is the posterior capsule right here, you know? Okay. I think,

8:01

I think we can see it. Yeah. I mean, especially when, you know, when it's,

8:06

you know, the articular surface is sort of, you know, it's well delineated by,

8:10

you know, contrast or, or native fluid. Um, obviously when, you know,

8:15

there's no fluid, and sometimes that as, as some of you have noticed, you know,

8:19

there's, there's no fluid at all. And sometimes there's, uh,

8:22

invagination of the capsule, and sometimes even, like, for instance,

8:25

the subscapularis tendon into the anterior aspect of the glandular humeral

8:29

joint, that occurs too. And sometimes it's just, you know,

8:32

sometimes the patients internally rotate and you just can't define things. Well,

8:36

but I think in this case, uh, you know, whether it's, uh, arthogram or, or,

8:41

uh, you know, just native fluid, or if you're doing, you know,

8:44

indirect arthrograms, I, I think you can, you can tell the, the capsule, uh,

8:48

oftentimes. Sure.

8:52

Um, the other thing is with the oid, um,

8:56

passage to this dysmorphic cricoid space Mm-Hmm.

9:01

And this,

9:02

you always talk about the acrom being a hook acromion causing rotor pathology.

9:07

Yeah. Yeah. So, so I, the, go ahead.

9:11

Yeah.

9:12

I would like to get some explanation about how the COR code contributes to this

9:16

pathology.

9:17

Uh, so, so I just look for narrowing of the, uh,

9:21

of the I look. So that's in theory, gonna cause uh, uh,

9:26

impingement upon the subscapularis muscle intended. And, and again,

9:31

I just like, I like that to be a little bit more narrow than it is here. Okay.

9:36

Um, and, uh, here, I mean, it's measuring,

9:45

you know, 14 millimeters. I think the cutoff is I think,

9:49

like four to six millimeters when,

9:51

when you raise the possibility that it's narrowing and correlate for

9:55

subcoracoid impingement. But again, the other thing too is, you know, that's,

9:59

that's, that's, that's another tool where I think ultrasound,

10:02

if you're doing ultrasound, would be a good use. 'cause you can see that,

10:06

you know,

10:06

abrupt catching of the subscap subscapularis and potentially subor bursa,

10:11

and then abrupt transition as it, as it as those structures get released,

10:16

if the, uh, corco process is, is narrowing that space and impinging upon it.

10:21

Um, but, you know, I, unless it's more narrow than this, I, I,

10:26

I really don't bother. Um, and, and in that case,

10:30

unless I'm asked and, and, and whatnot, and, and on this case, to me,

10:35

uh, this, for this one at least, the, the corticoid looks, looks pretty good.

10:39

Um, uh, and, and for me too, it's, it's hard, uh,

10:43

in my patient population, I have a, I I, I take care of a, of a,

10:49

of a indi indigent population that, that, unfortunately,

10:53

they don't take care of themselves. So I see, uh, uh, and I, I work with a,

10:58

a, a lot of, uh, a high level trauma center. So I, I tend to see a lot of,

11:03

um, um, abnormal looking mal united bones.

11:08

So it's hard for me to say when something is dysplastic,

11:11

because it turns out for, for me, at least in my practice, a lot of it turns,

11:14

turns out to be, uh, prior injury. Um, and yeah,

11:19

for some reason here, uh, at my institution, there's just a,

11:23

a population of patients that unfortunately don't, are, aren't,

11:26

don't seek medical care or, or, or, uh, aren't,

11:30

aren't taking good care of themselves and, and, or get lost to follow up. So,

11:34

so we see a lot of dysmorphic, dysplastic, uh,

11:38

processes and bones that just turned out to be old trauma. So,

11:43

yeah,

11:45

Just

11:45

Hopefully I answered that question.

11:47

Yeah. Thanks, IIV. There was, that was good.

11:49

Of course.

11:51

Uh, with the terms macro instability and micro instability, um,

11:56

micro instability I would seem to understand is repeated microtraumas

12:01

over time, which injure the rotary cuff and glenohumeral ligaments,

12:05

I would assume.

12:06

Yeah. Yeah. So, so, so, so the, so the terminology you want to Google, or,

12:11

or lookup Okay. Are gonna be, um, uh,

12:15

ambry and tubs. Okay. And, and that should, that should give you a lot of, uh,

12:19

uh, review articles. But, but, uh, tubs stands for, what was it? Uh,

12:25

oh goodness. Uh, traumatic unilateral, um,

12:30

traumatic unilateral Bang Heart. Um,

12:34

and I forget what the s stands for. Uh, shoulder instability perhaps.

12:38

And then ambry is, um, a traumatic multi-directional,

12:44

uh, requires, uh, rehabilitation. Oh, so sorry.

12:48

Tubs is surgery requires surgery. So, so, yes.

12:52

So macro instability is typically gonna be post-traumatic younger

12:57

males who anally dislocate. 'cause that's the most common, right?

13:01

Ambry is gonna be, um, uh,

13:04

along with micro and micro instability is gonna be older patients who have

13:09

degeneration, um, you know, lab label degeneration,

13:13

lab tears that way, chondral loss and things like that. And then, um,

13:18

they're gonna have a sensation of, um, uh,

13:21

clinically translation or micro instability, but basically,

13:25

basically small shifts millimeters, uh,

13:28

during physi physiologic load, right? Um,

13:32

but those are typically being treated by re rehabilitation.

13:36

So you wanna read about tubs, TUBS and ambry, uh,

13:40

A-M-B-R-I, so that, that sort of, and,

13:45

and it's hard to define. There's many definitions radiographically anatomically,

13:49

clinically surgically of, of micro instability. Um,

13:54

but in our literature, the, the, uh, article by, uh,

13:58

Christine Chung from our group and,

14:00

and Eric Chang reviews micro instability,

14:03

and they sort of group it as anything that, uh, involves the,

14:08

the labrum and, and, uh, uh, the cal glenohumeral joint from,

14:13

um, the, the superior half, particularly that the labrum, okay,

14:17

so anterior, anterior, superior, superior, uh,

14:21

posterior superior and posteriorly, so that, that they consider,

14:26

uh, but really micro translate or tran little bit of translation, uh,

14:30

clinically, uh, that's, that's what some people term micro instability,

14:35

but there's a lot of debate with those terms. But, but typically, yeah, so,

14:39

so I would say look up tubs and ambry and that that should give you a rabbit

14:43

hole to, uh, plenty of reading or, or review for you to read.