1. Arthroscopic Posterior Bankart Repair +/- Capsular Plication
Technique
Posterior Portal
- make slightly inferior and lateral compare to normal
- inspect joint
- place anterior portal +/- ASL portal
Remove cameral and place thorough anterior portal
- place 8 mm cannula through posterior cameral portal (over switching stick)
Often need second portal lateral and inferior to place inferior anchor
- can use simple stab incision here
Assess labrum and capsule
- repair posterior bankart
- plicate redundant / patulous capsule
Results
Kim et al JBJS Am 2003
- 27 patients with unidirectional posterior instability
- all with labral injuries, most with capsular laxity
- all had arthroscopic posterior labral repair and capsular shift
- only one recurrence
Pennington Arthroscopy 2010
- 28 athletes with pure posterior labral pathology
- 93% return to sport
Bradley et al Am J Sports Med 2006
- 91 athletes with 100 shoulders with unilateral posterior instability
- variations of suture anchor labral repair / anchor capsulolabral repair / capsular plication sutures
- 30% posterior labral tear, 43% patulous capsule with no labral pathology
- remainder combination injuries including partial labral tears
- 8% failure rate, all with capsular laxity
- patients had evidence of chondrolabral retroversion
2. Open Posterior Capsular shift
Open Technique
Position
- lateral
Incision
- vertical incision
- posterior axillary fold
Superficial dissection
- split deltoid to expose infraspintous
- elevate IS off capusle
- L shaped incision infraspinatous after tagging sutures medial
- T shaped capsulotomy of capsule for posterior shift (vertical limb on humeral insertion)
Dangers
- no more than 1.5cm medial to glenoid to protech SS nerve
- axillary nerve through quadrangular space below Tm
Procedure
- labral detachment reattached if present
- graft glenoid with bone from spine / iliac crest if defect
- inferior capsule shifted superiorly
- reinforced with superior limb of capsule
- may augment with IS tensioning
3. Posterior Glenoid Osteotomy
Reserved for in setting of severe posterior retroversion with instability
