The Buford complex: a review of embryology, imaging, technical considerations, and clinical significance

The Buford complex, defined as a cord-like middle glenohumeral ligament with an absence of the anterosuperior labrum, is the rarest anatomical labral variant of the shoulder and occurs in 1.5% to 6.5% of the general adult population. Misidentifying the Buford complex for a pathological anterosuperior labral tear can result in pain, stiffness, and limited external rotation if accidentally surgically repaired. While the Buford complex was historically thought to be a benign anatomical variant, recent evidence has suggested that patients with a Buford complex may be at a higher risk for sustaining superior labrum anterior-posterior tears compared to those without a Buford complex. In addition, it remains unknown if the Buford complex is a congenital variant or one that pathologically develops from untreated shoulder instability in early childhood. Given these recent findings and their potential implications on management, it is important for surgeons to have a thorough understanding of the Buford complex. The current review aims to describe the anatomy, development, preoperative imaging, technical considerations, and clinical significance of the Buford complex.