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161 BulletinoftheHospitalforJointDiseases Volume63,Numbers3&4 2006

Abstract

A case of a 26-year-old male with symptoms resulting from loose bodies residing in a sublabral recess is presented. Op-erative intervention using the standard arthroscopic portals in addition to an accessory posterior portal was successful in removing the loose bodies and approximating the edges of the sublabral foramen. The shoulder is a complex region made up of numerous anatomic structures, which if dam-aged may be responsible for a patient’s pathology. Normal anatomic variations also exist, which in certain situations, may contribute to a patient’s presentation. One example of a normal anatomic variation is the sublabral foramen, which represents an unattached anterosuperior labrum.

Asublabralforamenisacongenitallyunattachedanterosuperior labrum, typically at the twoo’clockposition1foundin12%ofindividuals.2

Reports in the literature demonstrate that the normalanatomiclimitofthesublabralforamenistheanteriorglenoidnotch.3-7Sublabralforaminaprovideanopeningtothesublabralrecessthroughwhichdebriscanmigrate.Shoulderstabilityistypicallynotcompromisedbythiscongenitaldefect,butphysiciansshouldbecognizantthatitspresenceshouldbeincludedaspartofthedifferentialdiagnosisofshoulderpathology.8,9

CaseA26-year-oldmalepresentedwithrightshoulderpainofseveralmonthsduration.Thepatienthadahistoryofarightshoulderdislocationsevenyearspriortothispresentation

andforwhichhehadundergoneclosedreduction.Sincethattime,thepatienthadnocomplaintsofpain,locking,catch-ing,apprehension,orinstabilityintherightshoulder. Severalmonthspriortotheinitialvisit,thepatientwasplaying basketball and began to feel some catching andlockinginhisrightshoulder.Thepatientdidnotrecallanyspecifictraumaticeventpriortotheonsetofpain.Thepa-tienthadbeentakingnaproxenpriortohisinitialvisitwithnoreliefofsymptoms.Thepainwasoccasional,sharp,andpersistentinnatureandwasmadeworsewithgeneralactivityandtherewerenoalleviatingfactors. Physicalexaminationdemonstratednoevidenceofgrossclicking or catching. However, the patient experiencedpainwithforwardelevationofhisarmandmildlypositiveimpingementsigns.Obrien’s,crank,andbicepsloadtestswere negative.The remainder of the physical exam wasunremarkable. Radiographsoftherightshoulderdemonstratedevidenceofloosebodies(Fig.1).TheMRIdemonstratedaquestion-abledefectintheanteriorarticularhyalinecartilageoftheglenoidatthemidportionwithanintactglenoidlabrum.Lowsignalintensityfociwereseenwithinthejointfluid,whichwereconsistentwithloosebodies(Fig.2). Physicaltherapyinadditiontoanti-inflammatorymedi-cationwasunsuccessfulintreatingthispatient’sacutepainandrightshoulderarthroscopywasthereforeindicated. Examinationunderanesthesiademonstratednormalrangeofmotionthroughouthisrightupperextremity.Thepatientwasplacedinalateraldecubituspositionwith15poundsofbalancesuspensiontraction. Thestandardposteriorandanteriorarthroscopicportalswerecreated.Initialintra-articularinspectiondemonstrateda sublabral foramen with an additional glenoid articularcartilagedefectatthatlevel(Fig.3). Upon inspection of the sublabral foramen, six loosebodies were noted to reside in the sublabral recess (Fig.

Loose Bodies in a Sublabral RecessDiagnosis and Treatment

Kevin Kaplan, M.D., Deenesh T. Sahajpal, M.D., F.R.C.S.C., and Laith Jazrawi, M.D.

Kevin Kaplan, M.D., Deenesh T. Sahajpal, M.D., F.R.C.S.C., and Laith Jazrawi, M.D., are from the NYU-Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York.Correspondence: Kevin Kaplan, M.D., NYU-Hospital for Joint Diseases Department of Orthopaedic Surgery, 301 East 17th Street, New York, New York 10003.

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3).Thus,twoanteriorworkingportalswerecreatedintherotator interval to assist in their removal. In addition, anadditionalaccessoryposteriorportalwascreatedtoassistintheremovalofseveralloosebodiesthatwereunabletoberecoveredwiththeanteriorportalsalone(Fig.4).Atthis

point,thesublabralforamenwasarthroscopicallyrepairedwitha3.0mmBiosuturetak(Arthrex,Naples,FL),whichwasinsertedinstandardfashiontopreventreaccumulationofadditionalloosebodies(Fig.5). The previously noted full cartilage defect at the three

Figure 1 AP, Scapular Y, and Axillary views of the right shoulder with evidence of loose bodies.

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Figure 2 Magnetic resonance images demonstraiting loose bodies in the sublabral recess.

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o’clockpositionwasdebridedoflooseflapstoableedingbonybedtoencouragenewfibrocartilageformation.Inad-dition,therewasnoevidenceofarotatorcufftearorSLAPtear.Thearthroscopicinstrumentswerethenremoved,andtheportalswereclosedwith#3-0nylonsuturesandasteriledressingapplied. Thespecimensconsistedoffourtantowhiteloosebod-iesmeasuringinaggregate2x0.5x0.3cm(twoadditionalloose bodies were lost to suction) (Fig. 6). Microscopicexaminationrevealedtheloosebodiestobecomposedofosteocartilaginousmaterial. Thepatientwasplaced inaphysical therapyprogramandreportedcompletereliefofhissymptoms.Attwoyears

followup,thepatienthasafullpainlessrangeofmotionandhasreturnedtohispreviouslevelofactivity.

DiscussionTheglenoidlabrumiscomposedoffibrocartilaginoustis-suethatservestobroadenthearticularsurfaceandincreaseload distribution in the shoulder joint.10 In addition, theglenohumeralligamentsandcapsuleattachtothefibrocar-tilaginouszoneofthelabrum.Superior,middle,andinferiorglenohumeral ligaments contribute to the stability of theglenohumeralcomplex. The anterior glenohumeral ligament complex consistsof the superior glenohumeral ligament (SGHL), middle

Figure 3 Sublabral foramen with loose bodies deep in the re-cess.

Figure 4 Retrieval of loose bodies.

Figure 5 Repair of the sublabral foramen.

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Figure 6Loosebodiesretrievedfromthesublabralrecess.

glenohumeralligament(MGHL),theanteriorbandoftheinferiorglenohumeralligament(AIGHL),andtheanteriorlabrum.ThesuperiorglenoidtubercleistheattachmentfortheSGHL,whilethemiddleandsuperiorlabrumistheat-tachmentfortheMGHL.Finally,theAIGHLattachesontotheanteriorlabrum.11

Thereportsintheliteratureindicatethattherearevaria-tions in theanatomyof theanterosuperiorportionof theglenoidlabrum.2,12FivenormalvariationsbasedontheshapeofthelabrumwerediscussedbyDetrisacandJohnson.13Inaddition,Cooperandassociatesdescribedthevariationsinmorphologybetweenthesuperiorandinferiorportionsoftheglenoid.12,14Theydescribearoundedinferiorsurfaceandamobile,meniscoidsuperiorlabrum.Onesuchvariationisthepresenceofasublabralforamen,whichisfoundin12%of individualsandis thought tobeacongenitalphenom-enon.2Magneticresonancestudieshavedemonstratedthattheunattachedlabrumassociatedwithasublabralforamendoesnot extendbelow the regionof theanteriorglenoidnotch.3-7,15Inaddition,thesublabralforamenliesanteriortothebiceps-labralcomplex.ThisvariationdiffersfromaBufordcomplex,whichisanabsentanterosuperiorlabrumincombinationwithacord-likemiddleglenohumeralliga-ment. McNieshandCallaghanutilizedcomputedtomographyarthrographytoidentifysublabralforamina.Intheirstudy,contrast dye materialized between the labrum and theglenoid.16As stated previously, the sublabral foramen isconsideredanormalanatomicvariantandtheshoulderjointfunctionsappropriatelyinthepresenceofsuchadefectgiventhattheglenohumeralligamentsandrotatorcuffmusclesareintact.2Habermeyerandcoworkersfurtheredthisdiscussionbyprovingthattheintraarticularpressuregradient,whichcan be considered a marker for an intact glenohumeralcapsularstructure,remainedunaffectedinpatientswitha

sublabral foramen.17 Furthermore, Schulz and colleaguesdemonstratedthatanisolatedsublabralforamenhasnoaffectonanteriororinferiorglenohumeralinstability.9However,Raoandassociatesdemonstratedthatanterosuperiorlabralvariations couldbe associatedwith specific intraarticularabnormalitiesandfindingsonphysicalexam.Specifically,patients with these anatomic variations had an increasedincidenceofanterosuperiorlabralfraying,posterosuperiorlabralfraying,subscapularistendontears,andtype-IISLAPlesions.14 Althoughmuchoftheliteratureregardingsublabralfora-mensuggeststhatthestabilityoftheshoulderisunaffectedandthatthisdefectshouldbetreatednon-operatively,8,9asublabral foramen can predispose a patient to pathologythatcanbepreventedviasurgicalclosure.However, it isimportanttorecognizethatrepairofnormalanatomicvari-antscanalsocausesomeincreasedpainandrestrictedrangeofmotion.Itwasfeltinthiscasethatthesublabralforamenmayhavecontributed to thepatient’spathologyandwasclosedtopreventpotentiallyfutureloosebodyproductionoraccumulation. Retrievalofloosebodiesinasublabralrecessissimplifiedbyusinganaccessoryposteriorportal.Thestandardposteriorportalistypically2cminferiortoand1cmmedialtotheacromion at its posterolateral edge.18The anterior portalcanthenbeplacedunderdirectvisualization.Theseportalsdonotallowadequateaccesstotheinferiorandposteriorrecessesof theglenohumeral jointwithoutdamaging thearticularcartilage.19DiFeliceandassociates,usingcadavericspecimens,demonstratedthatanaccessoryposteriorportalisasafeandeffectivewaytoprovideunlimitedaccesstotheglenohumeraljoint.Theseinvestigatorsdescribedthisportaltobeapproximately2cminferiortothestandardposteriorportal at the 8 o’clock or 4 o’clock position.20 DavidsonandRivenbrughalsodescribedanaccessoryposteroinferiorportal at the7o’clockposition for access to the inferiorcapsularrecess.21Bothstudiesstresstheimportanceofrec-ognizingtheproximityoftheaxillarynerveanditsbranchtotheteresminor,whichliesinferiortotheglenohumeraljointcapsule.AstudybyBryanandcoworkersdemonstratedthat theaveragedistanceofanaccessoryposteriorportalfromtheaxillarynerveisapproximately1.89cm(range:0.5to4.0cm).22Theposterioraccessoryportalinthiscase,asdescribedbyDiFeliceandcolleagues,20providedexcellentvisualization to the sublabral foramen and recess, whichaidedinthesuccessfulretrievalofloosebodiesandrepairofthesublabralforamen.

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