The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 2

Letters to the Editor | February 01, 2004

Anatomical Variants in the Anterosuperior Aspect of the Glenoid Labrum

Omer A. Ilahi, MD¹

¹ Texas Arthroscopy andSports Medicine Institute6560 Fannin Street, Suite 1016Houston, TX 77030oilahi@mysurgeon.com

The author did not receive grants or outside funding in support of his research or preparation of this work. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 Feb 01;86(2):432-a-433

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To The Editor:I was intrigued by the article entitled "Anatomical Variants in the Anterosuperior Aspect of the Glenoid Labrum. A Statistical Analysis of Seventy-three Cases" (2003;85:653-9), by Rao et al. The authors indicate that, upon review of a number of arthroscopic shoulder procedures performed by Dr. McFarland, there was a significant association between what are considered to be normal variants of the anterosuperior glenoid labrum and superior labral pathology. My experience agrees with this finding. In fact, a study demonstrating a significant association between these variants and superior labral lesions was published in the October 2002 issue of Arthroscopy1. Therefore, the statement by Rao et al. that "...the current study showed for the first time that these anterosuperior labral variations are associated with specific intra-articular abnormalities..." is not completely true. I do commend the authors for their diligent review of a large number of arthroscopic shoulder procedures (546 procedures performed over a six-year period from 1994 to 2000). Dr. McFarland's group also reported significant associations between the presence of these labral variants and an abnormal superior glenohumeral ligament as well as increased internal rotation. To the best of my knowledge, this has not been previously reported. I have some specific questions for the authors based on my own experience with shoulder arthroscopy.

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To The Editor:

I was intrigued by the article entitled "Anatomical Variants in the Anterosuperior Aspect of the Glenoid Labrum. A Statistical Analysis of Seventy-three Cases" (2003;85:653-9), by Rao et al. The authors indicate that, upon review of a number of arthroscopic shoulder procedures performed by Dr. McFarland, there was a significant association between what are considered to be normal variants of the anterosuperior glenoid labrum and superior labral pathology. My experience agrees with this finding. In fact, a study demonstrating a significant association between these variants and superior labral lesions was published in the October 2002 issue of Arthroscopy¹. Therefore, the statement by Rao et al. that "...the current study showed for the first time that these anterosuperior labral variations are associated with specific intra-articular abnormalities..." is not completely true. I do commend the authors for their diligent review of a large number of arthroscopic shoulder procedures (546 procedures performed over a six-year period from 1994 to 2000). Dr. McFarland's group also reported significant associations between the presence of these labral variants and an abnormal superior glenohumeral ligament as well as increased internal rotation. To the best of my knowledge, this has not been previously reported. I have some specific questions for the authors based on my own experience with shoulder arthroscopy.

First of all, Figure 1 in the manuscript by Rao et al. nicely depicts some of these variants, including (1) a sublabral foramen with a sheet-like middle glenohumeral ligament, (2) a sublabral foramen with a cord-like middle glenohumeral ligament, and (3) a Buford complex. However, not included in the drawing or in the text is another scenario, in which there is a cord-like middle glenohumeral ligament but no variants of the anterosuperior glenoid labrum. This is an unusual finding, but it has been reported¹. Has Dr. McFarland encountered this? If so, does he believe that this is part of a single spectrum of variants of anterior shoulder anatomy or a separate and unrelated variant?

I am also curious as to exactly what the authors mean when they refer to "an abnormal superior glenohumeral ligament," as this structure is quite variable in appearance and is not discernible as a distinct structure in a substantial percentage of shoulders. Indeed, I have not found any association between the presence of anterosuperior glenoid labral variants and the morphology of the superior glenohumeral ligament¹.

Finally, I have, on rare occasions, performed shoulder arthroscopy on patients who were known to have an anterosuperior glenoid labral variant in the contralateral shoulder that was noted at the time of a previous procedure. Although the number of such cases in my practice has been too small to allow me to draw firm conclusions, I have noted that if a variant of the anterosuperior glenoid labrum is present in one shoulder, it tends to be present in the contralateral shoulder as well¹. If Dr. McFarland has had opportunities to arthroscopically visualize the contralateral shoulder of individuals who do have labral variants, I would like to know whether he has noticed a similar trend in which these variants, if present in one shoulder, also tend to be present in the contralateral shoulder.

E.G. McFarland, A.G. Rao, T.K. Kim, and E. Chronopoulos reply:

We thank Dr. Ilahi for his comments and questions regarding our manuscript. We would like to acknowledge his article, which was published at a time when our paper was already in press. We think that it is a valuable addition to the literature and we certainly commend his effort.

We did not see any patients with a normal anterosuperior labrum and a cord-like middle glenohumeral ligament as he describes. While the middle glenohumeral ligament may vary considerably in width and thickness, the cord-like middle glenohumeral ligament seems to be more commonly associated with other superior labral variants as demonstrated in Dr. Ilahi's study and in our study. Other variations aside from those reported by us may exist, but they probably will prove to be uncommon.

Even though the superior glenohumeral ligament is a quite constant anatomical structure^2,3, we agree that it is often difficult to define the ligament arthroscopically. We graded it as abnormal only when there was a discrete ligamentous structure with identifiable tears.

Finally, our study did not include enough patients who had surgery on both shoulders to allow us to make any conclusions about the presence of bilateral variants. A cadaveric study might be the best way to study this question.

Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosuperior glenoid labrum and associated pathology. Arthroscopy.2002;18: 882-6.18882 2002 [PubMed][CrossRef]

O'Brien SJ, Allen AA, Fealy S, Rodeo SA, Arnoczky SP. Developmental anatomy of the shoulder and anatomy of the glenohumeral joint. In: Rockwood CA Jr, Matsen FA III, editors. The shoulder. 2nd ed. Philadelphia: WB Saunders; 1998. p 1-33.1 1998

Cole BJ, Warner JJP. Anatomy, biomechanics, and pathophysiology of glenohumeral instability. In: Iannotti JP, Williams GR, editors. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams and Wilkins; 1999. p 207-32.207 1999

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Glenoid labrum

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Omer A. Ilahi; Anatomical Variants in the Anterosuperior Aspect of the Glenoid Labrum. The Journal of Bone & Joint Surgery. 2004 Feb;86(2):432-a-433.

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