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Portal Closure After Segmental Posterior Labral Repair for Posterior Shoulder Instability

ABSTRACT: Posterior instability, although an uncommon shoulder pathology, is reported most frequently in the athletic population. Arthroscopic repair has emerged as the main surgical treatment modality for posterior instability. However, when compared with arthroscopic repair for anterior instability, the results of this procedure remain suboptimal. The creation of iatrogenic defects in the capsule, due to cannula placement, is a possible culprit. Because these defects typically do not heal satisfactorily, they become stress risers within the capsule itself, which may lead to recurrent instability or an otherwise compromised repair construct. Therefore, we find that routine intraoperative repair of these defects after repair can reduce the risk of injury and possibly improve long-term outcomes. In this article, we illustrate the repair of a posterior segmental tear using all-suture knotless implants with closure of the posterior and posterior-inferior portals after stabilization. Technique Video Video 1 Arthroscopic repair of segmental posterior labral tear with portal closure. The patient is in the lateral decubitus position. Both 30° and 70° arthroscopes are used throughout the procedure. The observed segmental labral tear pattern is somewhat similar to a bucket-handle tear, beginning roughly at the 5:30 clock-face position and propagating to the 2-o’clock position. The labral fragment is preserved and incorporated into the repair. After glenoid preparation, knotless all-suture anchors (Arthrex) are placed starting posterior-inferiorly and continuing superiorly. The sutures are only partially tensioned until placement is complete. Final tensioning occurs from the inferior-to-superior direction. Concomitant capsulorrhaphy is also performed with the labral repair. After the repair, closure of the posterior portals is performed because open portals can potentially contribute to postoperative capsular laxity, as well as act as stress risers within the capsule. The accessory posterior-inferior portal is closed first by passing a suture through the portal’s adjacent capsule and tying in a blinded manner just outside the capsule. Finally, the standard posterior portal is closed using analogous steps.

SUBMITTER: Yu V

PROVIDER: S-EPMC10149978 | biostudies-literature | 2023 Mar

REPOSITORIES: biostudies-literature

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Project description:PurposeThe purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up.MethodsA retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis.ResultsWe identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis.ConclusionsThere is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain.Level of evidenceLevel IV, retrospective diagnostic case series.

Project description:The optimal treatment of recurrent shoulder instability in skeletally immature athletes remains controversial, especially if there is significant growth remaining. Some investigators advocate conservative treatment until patients are close to skeletal maturity, whereas others push for earlier surgery to avoid further damage. The objective of this technical note is to describe a technique for labral repair using an anchorless approach to avoid potential damage to the glenoid physis. Technique Video Video 1 The procedure is performed in the left shoulder with the patient in the lateral decubitus position under general anesthesia. Both axial traction and abduction traction are used. Standard posterior, anterosuperior, and anteroinferior portals are established, with the latter 2 portals in the rotator interval. Diagnostic arthroscopy reveals that the labrum is torn from the glenoid inferiorly in a bucket-handle fashion and is displaced into the joint. Although the inferior and posterior capsules remain affixed to the glenoid, the anterior capsule is torn and scarred medially along the glenoid neck. The labrum is reduced, and the rim of the glenoid is abraded with a shaver and rasp to encourage healing. A 7-o’clock portal is established. Starting from posteriorly and working anteriorly, the surgeon uses a 45° curved suture hook to perform retrograde passage of a No. 2 braided absorbable suture through the capsule and through the cartilaginous rim of the glenoid and around the glenoid. Because of the young age of the patient, no anchors are placed and the rim of the glenoid is used as an anchor. The labrum is subsequently tensioned anteriorly while each simple suture is tied. Anteriorly, the capsular tear is scarred medially along the neck and is then elevated and incorporated into the labral repair to properly re-tension the glenohumeral ligaments and stabilize the shoulder. A total of 7 simple sutures are placed at the 8-, 7-, 6-, 5-, 4-, 3-, and 2-o’clock positions, re-establishing labral position, labral height, and capsular tension. Finally, the capsular holes made by the cannulas are repaired.

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Portal Closure After Segmental Posterior Labral Repair for Posterior Shoulder Instability

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