Abstract
Anterior labroligamentous periosteal sleeve avulsion lesions heal medially on the glenoid neck, and arthroscopic repair requires sufficient mobilization of the capsulolabral complex before fixation. This Technical Note describes the capsulolabral WAVE sign, a dynamic intraoperative finding used as an adjunct to judge the adequacy of mobilization. With the patient in the beach-chair position, a posterior viewing portal and 2 anterior working portals are established. The medially scarred capsulolabral complex is progressively released from the 6-o’clock position to the biceps anchor and separated from adhesions to the subscapularis. The shaver is then positioned adjacent to the anterior glenoid and used to create controlled alternating suction and fluid-pressure changes. Adequate mobilization produces a wave-like excursion of the capsulolabral tissue followed by spontaneous reduction toward the anterior glenoid rim. If the sign is absent, residual adhesions are sought and released before the maneuver is repeated. The sign may provide a simple, real-time visual adjunct before lower-tension anatomic fixation. It has not been validated against objective tension measurements, interobserver reliability, or clinical outcomes and should not be interpreted as proof of repair adequacy.
Introduction
Anterior labroligamentous periosteal sleeve avulsion (ALPSA) is characterized by avulsion of the anteroinferior labrum with an intact periosteal sleeve and medial healing of the capsulolabral complex on the glenoid neck.1 This nonanatomic, scarred position may make arthroscopic reduction more difficult than repair of a discrete Bankart lesion. Arthroscopic stabilization is established for traumatic anterior instability, but recurrence remains a concern in young patients and in those with hyperlaxity or relevant osseous defects.2-4
A previously reported ALPSA repair technique emphasized extensive release of the medially healed complex, separation from the subscapularis, limited anterior glenoid cartilage resection, and a combined medial and superomedial capsular shift.1 Adequacy of release was assessed by discontinuing pump pressure and observing spontaneous reduction of the tissue toward its anatomic position.1 During use of this technique, a dynamic suction-induced tissue excursion can also be elicited after mobilization. The purpose of this Technical Note is to describe this capsulolabral WAVE sign and its use as an intraoperative adjunct before fixation (Video 1).
Surgical Technique
Patient Positioning and Diagnostic Arthroscopy
After an interscalene block and induction of general anesthesia, the patient is placed in the beach-chair position. The cervical spine is supported, the trunk is secured, and examination under anesthesia is performed. The shoulder and entire upper extremity are prepared and draped, and longitudinal traction is applied with the arm in slight abduction and forward flexion.1 A standard posterior viewing portal is created, and a 30° arthroscope is introduced. Diagnostic arthroscopy includes assessment of the labrum, cartilage, biceps-labral complex, subscapularis, rotator cuff, glenoid bone loss, and Hill-Sachs lesion.
Portal Placement and Capsulolabral Release
Two anterior rotator-interval working portals are established under direct visualization. The anterosuperior portal is placed at the superior border of the interval, anterior to the supraspinatus and biceps tendon. The anteroinferior portal is placed immediately superior to the subscapularis on the humeral side of the interval. AUTHOR TO ADD Identify the cannulas, arthroscope, pump, shaver, ablation device, elevator, suture lasso, and other proprietary products by product name, manufacturer, city, state, and country.
A polydioxanone traction suture is passed through the anteroinferior capsulolabral tissue with a suture lasso. With controlled traction, an arthroscopic elevator is used to free the complex from the anterior glenoid neck. A 90° radiofrequency ablation device and shaver complete the release from the 6-o’clock position toward the biceps anchor.1 Residual adhesions between the capsulolabral complex and subscapularis are released until the tissue can translate toward the glenoid rim without excessive tension. The pump is briefly stopped; failure of spontaneous reduction indicates that further release may be required.
Elicitation and Interpretation of the Capsulolabral WAVE Sign
When release appears nearly complete, the shaver is positioned adjacent to, but not in contact with, the anterior glenoid rim. Controlled alternating suction and fluid-pressure changes are applied while the capsulolabral complex is viewed through the posterior portal. A positive capsulolabral WAVE sign consists of visible wave-like excursion of the mobilized tissue followed by spontaneous movement toward the anterior glenoid rim (Video 1). The maneuver is stopped if the shaver approaches the labrum or capsule. In the absence of the sign, residual adhesions are identified and released, after which the maneuver is repeated. The sign is interpreted only as a visual adjunct suggesting tissue mobility; it does not demonstrate biomechanical adequacy or predict healing.
Glenoid Preparation and Fixation
After mobilization, the anterior glenoid neck is lightly abraded to create a bleeding surface without excessive bone removal. Approximately 2 to 3 mm of anterior glenoid articular cartilage is removed as described previously.1 Three 3-mm double-loaded absorbable anchors are placed from the 5- to 2-o’clock positions, with the inferior anchor inserted first at approximately 45° to the anterior glenoid plane and subsequent anchors placed parallel and at least 1 cm apart.1 AUTHOR TO VERIFY Confirm anchor composition, exact product, manufacturer, and whether this remains the implant used in the accompanying video.
With a curved suture-passing device, the inferior capsulolabral complex is captured at inferolateral and lateral points. The inferolateral bite produces a superomedial shift, and the lateral bite adds medialization. The maneuver is repeated for the superior anchors.1,5 Suture tension is adjusted to restore the labral bumper without overconstraint. When an engaging or off-track Hill-Sachs lesion requires treatment, remplissage may be added according to the surgeon’s usual indications.6 ALPSA lesions associated with engaging Hill-Sachs defects have been linked to recurrent instability.7
Postoperative Rehabilitation
The arm is supported in an abduction sling for 4 weeks. Pendulum and elbow and wrist motion begin immediately. Progressive passive motion begins at 4 weeks and is followed by active motion. Strengthening begins after 3 months, and return to sport is generally considered at 6 months, subject to clinical recovery.1
Discussion
The key technical challenge in ALPSA repair is restoring medially scarred capsulolabral tissue to the glenoid rim without excessive tension. The capsulolabral WAVE sign extends the previously described spontaneous-reduction endpoint by adding a controlled dynamic maneuver immediately before fixation.1 Its practical advantages are that it is visible in real time, uses instruments already present, and may prompt the surgeon to identify residual adhesions before anchor placement (Tables 1 and 2).
The sign has important limitations. Its recognition is subjective, and neither the pressure parameters required to elicit it nor the magnitude of tissue excursion has been standardized. Excessive suction or direct shaver contact may injure mobilized tissue. Additional release performed solely to produce the sign could also cause bleeding, tissue injury, neurovascular risk, or overmobilization. The maneuver should therefore supplement, rather than replace, direct assessment of tissue quality, mobility, bone loss, capsular laxity, and repair tension.
The name also requires distinction from a previously described intra-articular “wave sign” involving the posterior band of the inferior glenohumeral ligament as a landmark during remplissage.8 The present capsulolabral WAVE sign refers instead to dynamic excursion of the mobilized anterior capsulolabral complex during ALPSA release. Explicit use of the qualifier “capsulolabral” is recommended throughout to avoid terminologic confusion.
No inference regarding lower recurrence, improved healing, or better patient-reported outcomes can currently be made. Prospective study should evaluate interobserver agreement, reproducibility under defined pump and suction settings, correlation with objective repair tension, adverse events, postoperative motion, and instability recurrence. Until such validation is available, the capsulolabral WAVE sign should be regarded as a technical adjunct rather than a validated diagnostic test or surrogate outcome.