0:00

The first case we're going to tackle today

0:02

is a 54- year-old woman with complaints of slight pain,

0:08

popping, decreased range of motion

0:10

that's been ongoing for years.

0:12

Now, the purpose of this meeting is not

0:15

only to review these cases,

0:17

but also to evaluate the comments that have been

0:21

provided to me regarding some of

0:24

your diagnoses and questions.

0:27

So, in my approach to a case like this,

0:30

I usually start out with either a

0:32

set of coronals or the axial.

0:35

I would say more commonly than not,

0:38

I begin with the axial because it's often

0:41

the first image that you're shown.

0:44

And just for expediency,

0:46

I put up what I'm given first.

0:48

However, to get comfortable,

0:50

to see the architecture of the shoulder,

0:53

the conformity,

0:54

the best fit of the humeral head circle

0:57

relative to the glenoid cup.

0:59

Nothing could beat the coronal projection

1:01

as an initial foray into that.

1:04

Now, one of your first comments was that there

1:08

was an anteroinferior labral tear.

1:11

And as you look at this study,

1:15

yes, there is inflammation of the rotator cuff,

1:20

both deep to it, superficial to it, and here,

1:23

I think you would be totally appropriate in

1:26

using the term generalized tendinopathy.

1:28

What you'll also notice, though,

1:31

is the coronal slope of the acromion, which,

1:34

by the way, I never measure.

1:36

It's the relationship of the architecture and

1:41

angle of the clavicle and the acromion,

1:44

which you can see is this way right here.

1:47

Let me get my drawing tool out.

1:49

I'm going to draw it for you.

1:51

So it's clear.

1:52

So this way versus the orientation of the glenoid

1:57

cup, which you can see is this way.

2:02

And that should not be a 90-degree angle.

2:06

Typically, that should be about a 60 or 70-degree angle.

2:11

So the fact that the glenoid cup...

2:15

Let's look at it on the T1. I'm going

2:17

to blow up the T1 for a moment,

2:21

and let's see if I can find my magnifying glass.

2:24

Here we go.

2:24

Going to blow up the T1. Look at the

2:27

architecture of the glenoid.

2:29

And then it has this little dippity-do right

2:31

in the middle, which shouldn't be there.

2:34

Yes, there is a bare area of the glenoid in the middle,

2:37

but there should not be a depression of this size.

2:41

There is a little notch,

2:42

but it shouldn't angle down like this.

2:44

And that little notch is about two to three most.

2:48

This is way too large, way too broad.

2:51

And then it comes back a little bit, but not all the way.

2:54

In other words,

2:56

this glenoid cup should look

2:58

like it's a small pincer.

3:02

It should grab on the bottom and then grab at

3:04

the top. When I take my yellow line away,

3:06

you'll see it's not grabbing the

3:08

humeral head on the bottom.

3:10

I hope you all appreciate that.

3:12

So it's insufficient.

3:14

And there's only two things

3:15

that could really do this.

3:17

Glenoid dysplasia and a dislocation that has

3:22

just worn down and deformed the bone.

3:24

And the patient has no history of a dislocation.

3:28

Yes, she is popping,

3:30

but that's not the same as clinical

3:32

history as a dislocation.

3:33

And then we scroll backwards and we say, well,

3:35

is there a Hill-Sachs?

3:37

No, there's no Hill-Sachs.

3:39

Your volume averaging right here.

3:41

So no Hill-Sachs.

3:43

And let's look at the inferior labral ligamentous

3:47

complex. Now, that looks a little strange.

3:50

If I blow it up on the water-weighted image,

3:53

the band, the glenoid band of the IGHL,

3:57

the inferior glenohumeral ligament.

3:59

There are three bands: an anterior band,

4:02

a posterior band, and an axillary band.

4:06

And this is the glenoid component.

4:11

This is the humeral component.

4:12

This would be the inferior band.

4:14

So when you're anterior, let's go anterior.

4:17

I'll show you the anterior band.

4:19

Anterior band,

4:20

short and stubby.

4:23

Middle band, or axillary band.

4:25

This one's kind of distended.

4:27

And then the posterior band is sort of

4:30

intermediate between the two, right here.

4:32

That one's also distended in the back.

4:35

So the IGHL is stretched out a bit.

4:39

And then we go back to this area right here.

4:42

This entire process,

4:44

which is known as the glenoid labro-ligamentous

4:48

complex, should be one single snug structure.

4:53

I'm going to draw it for you right here.

4:56

Nice and dark.

4:57

I'm making it yellow so you can see it,

4:59

but it should be nice and dark.

5:01

And then you should have the glenoid

5:03

component coming down like this.

5:05

And then the humeral component.

5:07

As you're in the front,

5:09

it's the anterior band in the middle axillary

5:11

band in the back posterior band.

5:14

So that is aberrant.

5:15

There's something wrong with that.

5:18

Now, let's keep going.

5:20

One of you said posterior glenoid dysplasia

5:23

with glenoid retroversion.

5:25

With almost circumferential tearing of the labrum,

5:29

predominantly involving the posterior aspect.

5:32

And that's pretty spot-on, actually.

5:35

So...

5:36

Let's take a look at that.

5:38

Now...

5:39

I think one of the problems that I have with that

5:42

statement is when you say nearly circumferential.

5:45

You're saying that the anterior labrum is torn,

5:50

and I don't think that's the case.

5:52

Let's start up high.

5:54

Start up high.

5:55

And we have this large cord-like structure.

5:57

And what is that?

5:59

That is the conjoint takeoff of the superior

6:03

glenohumeral ligament and then a very thick cord-like

6:07

middle glenohumeral ligament

6:09

with no labrum superiorly.

6:12

And that's a common variation known

6:14

as the Buford variation.

6:16

You can see there's some inflammation around it,

6:18

and that's because the patient has micro

6:21

instability and this glenoid dysplasia.

6:24

Now, let's stop here for a minute.

6:27

We'll take this comment,

6:29

and we'll elaborate on it for a moment.

6:31

We'll get back to the labrum in 1 second.

6:34

But when I look at the glenoid orientation,

6:37

I showed it to you coronally.

6:39

In the axial projection,

6:40

you should be able to put a point

6:42

in the middle of the humerus,

6:43

drop an angle down along the scapular spine,

6:47

and then your glenoid cup should be perpendicular

6:51

to that. Should be a right angle.

6:54

When I take that away,

6:56

I think you'll see that that is not a right angle.

7:00

That there's the angle.

7:02

Now I'm going to take the lines away.

7:04

The angle is more like this.

7:07

Whoops.

7:10

The angle is more like this.

7:17

So you've got a retroverted glenoid cup.

7:23

In other words,

7:23

the anterior portion of the cup is more lateral

7:27

than the posterior portion of the cup.

7:30

Now, I'll allow this about six degrees,

7:32

but this one's more like 15 to 20 degrees.

7:35

So this patient has retroversion

7:38

of the glenoid cup,

7:39

which is forcing the humeral head posteriorly.

7:43

And some of you might appreciate that the humeral

7:46

head almost looks like it bulges a little

7:49

bit more in the back than the front.

7:52

And as we go back up to the top,

7:54

we see this little structure here,

7:57

which is a postero superior labral tear.

8:00

There's also an anterior to posterior labral tear,

8:04

which you can see on the coronal right here.

8:06

This should be snug.

8:08

So your colleague's comment about there being a

8:12

large tear, a nearly circumferential tear,

8:15

is sort of correct. The superior labrum is off.

8:19

The superior labrum is off.

8:21

Again.

8:21

The posterior labrum is beginning to come

8:23

into view. It's still off right there.

8:26

It's still off.

8:27

And now it gets even more profound.

8:29

I'm going to center it a little bit.

8:31

It's still off.

8:33

And now you see it's dissecting over the glenoid

8:36

cup lifting up some capsule periosteal

8:40

tissue right there.

8:41

I'm going to make it a little smaller so

8:43

you can appreciate it a little easier.

8:44

There it is. Still torn.

8:46

Still torn.

8:48

Still too deep and torn.

8:51

Continues, continues, continues.

8:55

So the entire posterior glenoid rim is torn.

8:58

So why am I taking issue with that statement?

9:01

Well, let's go to the front.

9:03

There's a nice triangular-shaped middle glenohumeral

9:06

ligament that's simulating a labrum.

9:08

It's a labral substitute. Let's keep following it.

9:12

There it is. The MGHL is a labral substitute.

9:16

That is not a tear.

9:17

Look at the normal architecture of the bone.

9:20

Look at how smooth everything is.

9:22

That's a fake tear. Let's keep going down.

9:26

Down. That's still a cord.

9:28

That is a cord-like MGHL that is functioning

9:32

as a labrum. Let's come down still.

9:34

We see it again. It is not torn.

9:38

Now, the labrum has taken over.

9:41

The labrum right about here.

9:42

Here's your middle glenohumeral ligament.

9:44

Now, labrum has taken over,

9:46

and the labrum is snug as a bug in a rug.

9:49

Labrum is intact. Intact, intact.

9:53

Now it's starting to get a bit deficient.

9:56

Now you can't really see.

9:58

Now you need your coronal projection to determine

10:01

what's going on in the axillary space where we

10:03

already know that the inferior labroligamentous

10:08

complex, as it is called,

10:10

is peeled away from this dysplastic

10:13

inferior glenoid.

10:15

So your colleague's comment is almost correct.

10:17

Except the anterior labrum, from top to bottom,

10:21

with the exclusion of the anteroaxillary labrum,

10:25

is intact.

10:26

All of that is part of the Buford complex,

10:29

so that is an overstatement.

10:32

Now,

10:33

I said there was something called a notch

10:35

right here called the notch of Ozaki.

10:38

If I was going to draw that in,

10:39

it would be about this big.

10:41

But in this dysplasia, you could say we

10:44

have a notch of Ozaki on steroids.

10:47

It's just way too big and too broad.

10:50

Should be about two or 3 mm right in the barrier.

10:53

So that is an abnormal dysplastic notch.

10:55

So, with regard to the labrum,

10:59

we have an extensive labral tear from the

11:04

superior quadrant all the way to the

11:08

posterior superior quadrant,

11:09

all the way around the back rim,

11:11

extending into the axillary labrum,

11:14

but sparing the entire chunk

11:16

of the anterior labrum.

11:18

So if I was going to draw it

11:19

for you on a sagittal,

11:20

I would say that let's get

11:22

the glenoid cup up here.

11:24

I would say the tear is here.

11:28

I'm not showing you the tear.

11:30

I'm just showing you the architecture

11:31

of where the tear is located.

11:33

And then the whole front end is spared.

11:36

So this part from there to there is spared.

11:41

Okay,

11:42

let's keep commenting now on the remainder

11:45

of your questions on this case,

11:48

because it is a rather extensive case.

11:50

Full-thickness chondral fissuring of the glenoid.

11:54

Well, that's true.

11:56

Here's the cartilage of the glenoid.

11:59

It's not everywhere.

12:00

It just happens to be more central and posterior.

12:03

And when you say full-thickness,

12:06

I assume you mean full depth.

12:08

Yes, it is.

12:09

But when you're in the knee and other structures,

12:11

one of the most important distinctions to make

12:13

is whether a lesion is less than 50% depth,

12:18

more than 50% depth,

12:19

or goes through the osteochondral plate.

12:21

If it goes through the osteochondral plate,

12:24

it's going to be in the bone.

12:25

It's going to be here,

12:27

which so far this patient does not have.

12:31

As far as fissuring goes, well,

12:35

that's a fissure right there.

12:36

Fissure is something linear.

12:38

So I would call this high-grade focal

12:42

chondromalacia due to dysplasia, full

12:46

depth without bone penetration.

12:50

Someone has commented on thickening of

12:54

the coracohumeral ligament. Well,

12:56

let's find that ligament. Here it is.

12:59

And I wouldn't take much issue with that.

13:03

I think it is a bit thickened.

13:04

You see it a little too easily here.

13:07

I'd say it's a minor issue with regard

13:09

to this case, as is the AC joint.

13:12

I don't think the AC joint is

13:14

very germane to the case.

13:16

Just center myself up here a little bit.

13:19

But what is germane to the case is this

13:23

huge fissure in the superior labrum.

13:26

Now,

13:27

I don't mind if you had something

13:28

like this on one cut anteriorly,

13:30

but on the next cut, as I move posterior,

13:32

I want it to disappear.

13:34

Especially in a Buford complex,

13:36

you get a lot of large, deep sulci and fissures,

13:40

but they're anterior, so this is anterior.

13:43

That's the biceps laboral anchor complex.

13:45

Now we go posterior. Look at my line.

13:48

We're going posterior.

13:49

Still there's a line there.

13:52

Still there's a line there.

13:54

There's still a line there.

13:55

And the labrum, the superior labrum itself is torn.

13:59

So it's torn here,

14:01

but it's also torn away from the glenoid.

14:04

So it's a rather complex tear,

14:06

and then it rolls right around the back,

14:08

just as we discussed earlier.

14:10

So this is a huge slap lesion that goes all the

14:15

way from antero-superior to postero-superior

14:19

to postero-inferior to antero-inferior.

14:22

Some other comments that were made.

14:25

Downsloping of the lateral acromion with a bony

14:29

spur contributes to bursitis and fraying

14:32

of the bristle surface of the labrum.

14:34

Well, I can't tell you there isn't fraying.

14:37

Perhaps there's a little fraying right there.

14:40

Yes, there is bursitis. Yes,

14:43

there is a little bit of downsloping

14:44

of the acromion.

14:50

I wouldn't take a lot of issue with that.

14:52

However,

14:52

I would bury something like that

14:54

in the body of the report,

14:57

or I probably wouldn't comment on the fraying.

15:00

But I think that's fair.

15:02

It's a fair comment,

15:03

but it certainly wouldn't appear in my conclusion.

15:06

My conclusion would read glenoid dysplasia with a

15:10

complex labral tear sparing only the anterior

15:14

quadrant of the labrum and involving approximately

15:17

220 to 240 degrees of the labral architecture.

15:22

And then I would have mapped it out in the body

15:24

of the report. I will pull up the sagittal.

15:28

You'll see how much swelling there is.

15:30

I'm not sure there's a lot more

15:32

the sagittal has to give.

15:34

I do like to look at the glenoid cup architecture

15:38

and make sure that I have a pear-shaped glenoid.

15:43

Now,

15:43

it's not a perfect pear because this glenoid is

15:45

dysplastic, but this is what I mean by a pear.

15:48

And when you have a dislocator,

15:51

you start to lose bone in the

15:53

front of the glenoid.

15:55

So you get anterior glenoid deficiency syndrome.

15:58

This patient does not have that.

16:00

They have posterior glenoid deficiency syndrome.

16:03

And you can see that right here.

16:05

The posterior glenoid is attenuated in its position.

16:09

Remember, it should look like this,

16:12

not this.