CHA P T E R 7
Arthroscopic Management of Rare
Intra-articular Lesions of the Shoulder
In no other joint is there as much variability in normal
anatomy as in the shoulder. Unusual conditions of the
shoulder must be differentiated from normal variants.
Although most pathologic processes are covered in other
chapters, rare lesions such as pigmented villonodular syno-
vitis, osteochondritis dissecans of the glenoid and humerus,
traumatic chondral fracture, chondrolysis, synovial osteo-
chondromatosis, ganglion and synovial cysts, blending or
bifurcation of the biceps and tearing of the attachment of
a Buford complex, reverse humeral avulsion of the gleno-
humeral ligament with infraspinatus tear, coracoid frac-
ture with extension into the joint, and floating anterior
capsule (combined Bankart lesion and humeral avulsion of
the glenohumeral ligament) are not commonly encoun-
tered within the shoulder.
Each of these entities may require different manage-
ment. The rarity of these problems complicates diagnosis,
preparation, and management. Many are encountered only
on entering the joint. It is the goal of this chapter to discuss
diagnostic studies and tests that can help preoperatively to
identify these conditions correctly and assist with their
management.
Preoperative Considerations
History
Most of these patients present with either no trauma or a
history of only minor trauma. The exception is the articu-
lar fracture, which often has a clear history of a traumatic
ch007-X3447.indd 59
Felix H. Savoie III, MD
event, often a dive to the floor during an athletic event,
after which pain and limitation of activity occur without
physical examination findings. However, in all of these
cases, symptoms frequently are not associated with a spe-
cific activity. Unlike with rotator cuff disease, the pain and
feelings of swelling are not worse at night. Unlike with
instability problems, the symptoms are not associated with
a particular movement or arm position. Unlike with adhe-
sive capsulitis, there is no consistent loss of motion or pain
on inferior glide testing.
Physical Examination
Examination usually reveals palpable swelling within the
glenohumeral joint, most easily felt in the area of the
rotator interval. There is usually some loss of motion, pri-
marily in internal and external rotation. Crepitation is
noted with rotational movements of the glenohumeral
joint. In cases in which the Buford complex has been
avulsed, results of the anterior superior load and shift
examination will be positive.
Imaging
Radiographs are usually normal except in synovial osteo-
chondromatosis, in which multiple loose bodies are noted
(Fig. 7-1). Magnetic resonance imaging is helpful in
osteochondritis dissecans lesions, cases of synovial cysts
(Fig. 7-2), and chondrolysis. Avulsions of a Buford complex,
pigmented villonodular synovitis, and articular cartilage
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 Surgical Techniques for Shoulder Instability
Figure 7-1 Radiologic view of multiple loose bodies in the glenohumeral joint
arising from the synovium of the subcoracoid bursa.
Figure 7-2 Magnetic resonance image of a synovial cyst.
fractures will not show up on most radiographic tests.
Glenohumeral avulsions are visualized by arthrography,
and the coracoid fracture is best noted on computed tomo-
graphic scans.
Indications and Contraindications
Each of these various entities may be managed by arthros-
copy. The main contraindications to arthroscopic surgery
are in the patient with pigmented villonodular synovitis.
Complete excision may require open surgery.
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ch007-X3447.indd 60
Figure 7-3 A normal Buford complex (cord-like middle glenohumeral
ligament) with tearing at the attachment to the glenoid.
Surgical Technique
Anesthesia and Positioning
Most of these cases require general anesthesia, although
experienced regional anesthesiologists may certainly use
interscalene block anesthesia. I prefer the lateral decubitus
position because of its ability to allow easier access to all
areas of the shoulder joint, but the surgeon’s preference is
usually the rule in these cases.
Diagnostic Arthroscopy
Diagnostic arthroscopy usually reveals the pathologic
process. Most of these are readily apparent once the
arthroscope is placed within the joint. The avulsion of the
Buford complex attachment is the most difficult to dif-
ferentiate from normal variants. Chondromalacia of the
glenoid and fraying of the undersurface of the labrum and
outer surface of the glenoid isolated to that area alone and
not farther inferior on the glenoid are key findings
(Fig. 7-3).
Pigmented villonodular synovitis has the character-
istic appearance seen in other joints. However, it is not
readily resected as it penetrates through the lining of the
joint and expands outward into the surrounding structures
(Fig. 7-4). Especially in inferior lesions, the synovial growth
may envelope the axillary nerve, requiring its dissection
either through open surgery or by arthroscopy.
Synovial cysts (Fig. 7-5) may be related to labral
tears or to foreign body reaction. The cyst should be
resected and the associated pathologic lesion repaired or
removed.
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Figure 7-4 Pigmented villonodular synovitis of the shoulder.
Figure 7-5 Arthroscopic view of a synovial cyst arising from a foreign body
near the coracoid.
In cases of synovial chondromatosis (Fig. 7-6), the
multiple loose bodies are readily apparent. It may be useful
to place a much larger cannula, such as that used in uro-
logic procedures, to allow the loose bodies to be removed.
It is important to find the area of synovium producing the
lesions and to excise it. The most common area in which
to find this synovium in my experience is the subcoracoid
bursa and the bicipital groove.
Traumatic chondral defects and osteochondritis of
the humeral head or glenoid result in irritation and swell-
ing within the glenohumeral joint. Finding these loose
articular pieces within the shoulder joint and their removal
ch007-X3447.indd 61
Arthroscopic Management of Rare Intra-articular Lesions of the Shoulder
Figure 7-6 Arthroscopic view of the multiple loose bodies of synovial
chondromatosis arising from the subcoracoid bursa.
Figure 7-7 Traumatic chondral defect of the humeral head.
will help decrease symptoms (Fig. 7-7). The injured bed in
the articular surface should also be located and débrided
and at least marrow stimulation performed.
The most difficult to manage of these various lesions
is chondrolysis of the glenohumeral joint. Although this
has been described to follow thermal surgery, the exact
cause has yet to be elucidated. Arthroscopy reveals an
aggressive destruction of the entire articular surface of the
humeral head and glenoid, severe synovitis and capsular
damage, and almost an avascular necrosis type of destruc-
tion of the humeral head (Fig. 7-8). Biologic glenoid resur-
facing with or without humeral head replacement seems
to provide the best relief.
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 Figure 7-8 Postsurgical avascular necrosis due to thermal chondrolysis.

Figure 7-9 Floating anterior capsule; both the Bankart lesion and the
humeral avulsion are pictured. A, lateral edge of capsule; B, labrum and
medial capsule.

A B

C D
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Figure 7-10 Reverse humeral avulsion of the glenohumeral ligament. A, Arthroscopic view of the capsule and tendon injury. B, Anchor placement in preparation
for repair. C, First set of sutures tied. D, Final view of repaired capsule.

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Humeral avulsions of the anterior glenohumeral liga-
ments are covered elsewhere in this text. However, one may
occasionally find this lesion in conjunction with a Bankart
lesion (Fig. 7-9). In these cases, the Bankart lesion is
repaired first, and then the humeral avulsion is repaired.
This also represents an excellent indication for open surgery
by Matsen’s approach to elevate the lateral subscapularis
and use the humeral avulsion to access the Bankart lesion.
The capsulolabral complex is repaired to the glenoid, and
the humeral avulsion is repaired as part of the reattach-
ment of the lateral capsule and subscapularis tendon.
Reverse humeral avulsion of the glenohumeral liga-
ment is even more uncommon. In high-energy trauma, the
A B
Figure 7-11 A, Coracoid fracture on CT. B, Arthroscopic view showing the
intra-articular extension. C, Arthroscopic view of repaired coracoid.
C
ch007-X3447.indd 63
Arthroscopic Management of Rare Intra-articular Lesions of the Shoulder
lateral capsule and the infraspinatus tendon may both be
involved, necessitating repair of both the capsule and the
tendon with anchors and sutures (Fig. 7-10).
Coracoid fractures are relatively rare lesions in which
the fracture may extend into the articular surface of the
glenoid. The symptoms are pain, tenderness around the
coracoid, and swelling. The fracture is readily visualized on
magnetic resonance imaging or computed tomographic
scans. Although immobilization often results in union,
active individuals may require stabilization. Arthroscopy
of the glenohumeral joint may allow monitoring of the
articular extension while also allowing reduction and fixa- 7
tion (Fig. 7-11).
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 Surgical Techniques for Shoulder Instability

Summary
There are many more unusual lesions of the shoulder that
may or may not require stabilization. Incorporation of all
or part of the biceps into the rotator cuff is a normal
variant (Fig. 7-12), just like the Buford complex, hypermo-
bile superior labrum, and absent anterior labrum. Before
a lesion is repaired, it is incumbent on the surgeon to
review the injury, the symptoms, and the physical exami-
nation findings to see whether they match the pathologic
process that is being viewed. If the mechanism is sufficient
to produce the pathologic process being visualized, and the
pathologic lesion can produce the symptoms the patient is
complaining of, repair is warranted. Elimination of the
symptoms after repair may be the only confirmation that
the surgeon has performed the correct operation.
Figure 7-12 Normal variant of the biceps with sling and incorporation into
the rotator cuff.

Suggested Readings

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of pigmented villonodular synovitis pseudotumor of the shoulder: a
case report with three year follow-up. Rev Chir Orthop Reparatrice
Appar Mot 2005;91:470-475.
Debeer P, Brys P. Osteochondritis dissecans of the humeral head: clinical
and radiological findings. Acta Orthop Belg 2005;71:484-488.
Hamada J, Tamai K, Doguchi Y, et al. Case report: a rare condition
of secondary synovial osteochondromatosis of the shoulder joint
in a young female patient. J Shoulder Elbow Surg 2005;14:653-
656.
Jerosch J, Aldawoudy AM. Chondrolysis of the glenohumeral joint fol-
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Epub June 24, 2006.
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