Overview
Isolated posterior labral tears
- usually history of trauma
- often have posterior shoulder pain rather than instability
- do well with surgery
Recurrent posterior shoulder instability
- typically posterior subluxation rather than dislocation
- often have element of ligamentous laxity / capsular stretching
- crossover with MDI
- arthroscopic management of 136 shoulders with posterior instability
- 51% had reverse Bankart lesion
- 67% had posterior capsular stretching
- 15% had both
Pathology
| Soft tissue | Bony |
|---|---|
| Posterior labral tears | Reverse Hill Sachs |
| Ligamentous laxity / capsular laxity | Posterior bony bankart |
|
Posterior / reverse HAGL |
Glenoid retroversion |
Reverse Hill Sachs / Posterior bony Bankart / Glenoid retroversion
History
Recurrent subluxation / feelings of posterior instability
Traumatic posterior dislocation - MVA / seizures / electrocution
Posterior shoulder pain - more common than instability with posterior labral tears
Examination
Ligamentous laxity / sulcus sign
Posterior stress test - patient supine / adduct, forward flex and IR arm / posterior force / apprehension test
Load and Shift / Posterior Drawer
Altchek Grading
Grade 0 No translation
Grade 1+ Up to glenoid rim
Grade 2+ Beyond rim with spontaneous reduction
Grade 3+ Translation beyond rim without spontaneous reduction
CT
1. Hill Sach's lesion
2. Glenoid bone defect
3. Glenoid version
MRI
Posterior labral tears / bankart lesion
- Kim lesion
- incomplete and concealed avulsion of the posteroinferior labrum
- superficial portion attached, deep portion detached
- labrum flat with loss of normal height resulting in retroversion of the chondrolabral glenoid
Posterior labral tears + cyst
www.boneschool.com/posterior-labral-cysts-suprascapular-nerve-compression
Posterior labral tears / cysts / posterior osteoarthritis
Beware early posterior glenoid OA presenting as posterior labral tear
Operative management
Indications
Pain - typical with posterior labral tears
Instability - often capsular laxity / ligamentous laxity
Options
| Arthroscopic | Open |
|---|---|
|
Posterior labral repair +/- capsular shift - posterior labral tears |
Open capsular plication +/- infraspinatus shift - revision procedures - ligamentous laxity with no labral tear |
|
Capsular plication - no labral tear - ligamentous laxity with posterior instability |
Posterior capsule reconstruction - revision procedures - ligamentous laxity with no labral tear |
|
McLaughlin procedure / Reverse remplissage - reverse Hill Sachs - add to above procedures |
Posterior glenoid reconstruction / bone block - posterior glenoid bone loss - revision procedures |
Arthroscopic posterior labral repair / capsular plication
Technique
Vumedi arthroscopic posterior labral repair video
Vumedi arthroscopic posterior labral repair + reverse remplissage video
Vumedi arthroscopic posterior labral repair + McLaughlin video
Vumedi arthroscopic posterior capsular plication video
Lateral or beach chair
- posterior cannula with anterosuperior viewing portal
- often need to insert anchors via accessory stab incision
- curved anchors very useful
- anteroinferior viewing portal useful for suture management
- posterior labral repair
- isolated capsular plication often difficult due to limited room and poor tissue
- postoperative external rotation brace useful
Posterior labral repair
Posterior capsular plication
Results posterior labral repair
Pennington et al Arthroscopy 2010
- 28 patients with isolated posterior labral tears undergoing arthroscopic labral repair
- all had history of trauma to shoulder
- 26/28 (93%) satisfied and returned to sport
Results posterior shoulder instability
- 200 shoulders with unidirectional posterior instability
- treated with capsulolabral repair / plication
- 90% return to sport
- better outcome with capsule plication with anchors versus capsule plication without anchors
Open posterior capsular plication
Indication
Revision instability surgery
Technique
AO surgical foundation posterior approach glenoid / scapula
Lateral Position
- vertical incision over glenohumeral joint
- elevate deltoid
- interval: between supraspinatus and infraspinatus
- interval: between infraspinaus and teres minor
- can detach infraspinatus tendon and elevate off capsule
- suprascapular nerve 1.5cm medial to glenoid
- axillary nerve below teres minor
- perform capsular plication / capsular shift
- +/- lateral advancement of infraspinatus
Posterior glenohumeral capsule reconstruction with allograft
Indication
Recurrent posterior instability
Ligamentous laxity
Technique
Arthroscopic posterior capsule reconstruction with acellular dermal allograft PDF
Results
Posterior glenoid reconstruction / bone block procedure
Indication
Posterior glenoid bone loss
Revision posterior instability
Critical posterior glenoid bone loss
- compared successful posterior labral surgery with unsuccessful
- 11% glenoid bone loss - 10 x failure rate
- 15% glenoid bone loss - 25 x failure rate
Technique
Arthroscopic posterior glenoid reconstruction technique
Open posterior glenoid reconstruction PDF
Open posterior glenoid bony reconstruction PDF
Beach chair or lateral position
- posterior approach / L shaped incision
- elevate or detach deltoid from scapular spine
- detach infraspinatus
- iliac crest or distal tibial allograft
Identify and elevate deltoid / detach from scapular spine / identify infraspinatus
Identify interval between infraspinatus and teres minor, detach and reflect infraspinatus to expose posterior capsule and glenoid
Results
- systematic review of posterior glenoid bone block for posterior instability
- 11 studies and 225 shoulders
- recurrent instability 10%
- complications: 11% hardware, 0.5% wound, 0.5% nerve
- residual pain 12%
Glenoid Osteotomy
Indication
Posterior instability with retroversion > 10 degrees / glenoid dysplasia
Young patient with no osteoarthritis
Technique
Arthroscopic glenoid osteotomy technique PDF
Beach chair or lateral
- posterior approach / detach deltoid / tentomy infraspinatus
- capsulotomy to expose glenoid
- osteotomy preserves anterior 1 cm of glenoid to prevent iatrogenic fractures
- open 4 - 5 mm and insert bone graft
- +/- fixation
Results
- 9 glenoid osteotomies for posterior shoulder instability
- good functional outcome and reduction in pain
- residual instability in 75%
- osteotomy did not recenter humeral head
- progression of osteoarthritis continues
- 7 glenoid osteotomies for posterior shoulder instability
- 4/7 good or excellent results
- residual instability in 6/7 (86%)
- 5/7 patients osteotomy did not recenter humeral head
- 100% progression of osteoarthritis continues