RESUMEN

In recent years, an appreciation for the dynamic relationship between glenoid and humeral-sided bone loss and its importance to the pathomechanics of glenohumeral instability has substantially affected modern treatment algorithms. However, comparatively less attention has been paid to the influence of glenoid version on glenohumeral instability. Limited biomechanical data suggest that alterations in glenoid version may affect the forces necessary to destabilize the glenohumeral joint. However, this phenomenon has not been consistently corroborated by the results of clinical studies. Although increased glenoid retroversion may represent an independent risk factor for posterior glenohumeral instability, this relationship has not been reliably observed in the setting of anterior glenohumeral instability. Similarly, the effect of glenoid version on the failure rates of surgical stabilization procedures remains poorly understood.

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RESUMEN

Despite the recent decrease in high tempo combat operations, threats to the medical readiness of Service Members remain a persistent issue. In fact, recent research efforts have demonstrated that musculoskeletal disease nonbattle injury represents perhaps the most immediate threat to the medical readiness of Service Members over the past several years. Innovations in a number of therapeutic options, particularly orthobiologics, have shown substantial promise in accelerating recovery and returning tactical athletes to full, unrestricted duties. Posttraumatic osteoarthritis remains a vexing topic but at the same time an intersectional opportunity for a multidisciplinary approach to better understand its pathogenesis, limit its prevalence, and mitigate the functional consequences of its sequalae. The expansion of a clinical infrastructure capable of the prospective collection of Service Members' functional outcomes across military treatment facilities promises to sharpen clinicians' understanding of both the impact of novel treatments for common injuries and the success of efforts to prevent recurrence (Military Orthopaedics Tracking Injury Network, Bethesda, MD). However, policy makers and stakeholders will increasingly find themselves in an environment of increasingly limited resources, which will necessitate creative strategies to maintain the lethality of a fit, fighting force.

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Posterior glenohumeral instability in overhead athletes presents a unique set of challenges for both diagnosis and treatment. Although a great deal of attention has been focused on the management of injuries to the biceps-labrum complex and rotator cuff in throwers, comparatively less has been written about posterior glenohumeral instability within this unique cohort. Historically, posterior instability has been observed secondary to either acute trauma or repetitive microtrauma, usually among collision athletes, weight lifters, and rowers. However, posterior glenohumeral instability resulting from pathology of the posterior capsulolabral tissues in throwers is a different entity, and the clinical assessment begins with an accurate differentiation between adaptive capsular laxity and labral injury with pathologic instability. Some posterior capsule labrum tears confirmed on arthroscopy will require nothing more than débridement. However, for more extensive lesions, surgical treatment must balance the necessity to repair torn capsulolabral tissues with the tendency to over constrain the shoulder. The literature provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.

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We came in with high expectations, yet the Arthroscopy Association of North America (AANA) Traveling Fellowship far exceeded them. The 4 traveling fellows came from different backgrounds, different parts of North America, and different practice settings, including an independent private practice, a hybrid private-academic practice, the military, and academia. We were lucky to have been ushered along the way by our godfather, the distinguished John Richmond, M.D., Past-President of AANA and Associate Editor Emeritus of Arthroscopy, who was gracious enough to give his time to the expedition. Over the course of the journey, this gang came together quickly and forged relationships that will last a lifetime. We are extremely grateful to AANA for the privilege and will cherish the memories for years to come.

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The heterogeneity of available cadaveric, histologic, and radiographic results related to the anterolateral ligament (ALL) does not support its existence as a discrete anatomic structure. Moreover, focusing narrowly on the ALL in isolation, what has previously been referred to as "ALL myopia," obscures a thorough appreciation for the stability contributions of both capsular and extracapsular structures. We consider injury to the soft tissues of the anterolateral knee-the anterolateral complex-just one component of what is frequently found to be a spectrum of pathology observed in the rotationally unstable, anterior cruciate ligament (ACL)-deficient knee. Increased lateral tibial slope, meniscal root tears, and "ramp" lesions of the medial meniscocapsular junction have all been implicated in persistent rotatory knee instability, and the restoration of rotational stability requires a stepwise approach to the assessment of each of these entities. Through an appreciation for the multifactorial nature of rotatory knee instability, surgeons will be better equipped to perform durable ACL reconstructions that maximize the likelihood of optimal clinical outcomes for patients. The purposes of this review are to provide an update on the relevant anatomy of the anterolateral knee soft tissues and to explain the multifactorial nature of rotatory knee instability in the setting of ACL deficiency.