Arthroscopic Repair for Posterior Shoulder Instability

doi:10.1016/j.arthro.2012.03.011

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 28, Issue 10, October 2012, Pages 1337-1343

https://doi.org/10.1016/j.arthro.2012.03.011 Get rights and content

Purpose

The purpose of this study was to evaluate outcomes of a consistent arthroscopic stabilization technique for recurrent posterior instability.

Methods

Thirty-four consecutive shoulders with symptomatic recurrent posterior instability were treated with arthroscopic repair and evaluated at a mean follow-up of 36 months (range, 12 to 67 months). Two patients were excluded because of prior surgery, leaving 32 for further analysis. The mean age was 21.4 years (range, 15 to 33 years). There were 26 male and 6 female patients, and in 59% the dominant shoulder was affected. A known traumatic injury had occurred in 25 (78%), but only 2 (6%) had a documented dislocation. Arthroscopic repair was performed with the patient in the lateral decubitus position through an anterosuperior 12-o'clock viewing portal. Suture anchor repairs were performed in 30 cases and plication to the intact labrum in 4. A sling and derotation wedge were used for 4 weeks, followed by progressive active range of motion, with weight lifting at 3 months and return to contact sports at 6 months. Of the 34 cases, 22 met the inclusion and exclusion criteria and had complete preoperative and postoperative shoulder outcome scores.

Results

Significant improvement (P = .001) from preoperatively to final follow-up was seen for American Shoulder and Elbow Surgeons scores, from 68 to 93; Simple Shoulder Test scores, from 9.3 to 11.6; and visual analog scale scores, from 3.5 to 0.8. All patients returned to their previous level of athletic activity. Two patients reported postoperative instability; none required reoperation. There were no other postoperative complications.

Conclusions

This study represents a consecutive series of patients with recurrent posterior instability who underwent arthroscopic posterior stabilization. In this population arthroscopic posterior labral repair and capsular plication provided significant clinical improvement and low rates of recurrent instability and revision surgery.

Level of Evidence

Level IV, therapeutic case series.

Section snippets

Patient Selection

After receiving approval from the Institutional Review Board, we performed a retrospective review of cases from 2004 to 2009 and identified a total of 127 consecutive patients who underwent arthroscopic stabilization by the senior author. After review, 34 patients were found to have undergone isolated posterior stabilization. Exclusion criteria included multidirectional instability, prior surgery, history of a seizure or neuromuscular disorder, or absence of preoperative shoulder outcome

Arthroscopic Findings

Thirty-four arthroscopic posterior stabilization procedures were performed. The rates of suture anchor use, the number of cases undergoing plication alone, and associated findings are listed in Table 2. In 6 cases (18.8%) there was evidence of SLAP lesions, the most common associated finding.

Outcomes

Twenty-two patients had complete preoperative and postoperative shoulder outcome scores. In this group the mean visual analog scale score significantly decreased from 3.5 ± 2.1 preoperatively to 0.8 ± 1.3

Discussion

This study consisted of a consecutive series of patients with isolated posterior glenohumeral instability repaired arthroscopically by a single surgeon. Postoperative instability was reported in 2 patients (8%), whereas no patients required reoperation for stabilization. Validated shoulder outcome methods were significantly improved from preoperative measurements, and all patients were able to return to their preoperative level of competitive activity.

Arthroscopic instability repairs can be

Conclusions

References (21)

E.M. Wolf et al.
Arthroscopic capsular plication for posterior shoulder instability
Arthroscopy
(1998)
B.R. Wolf et al.
Open posterior stabilization for recurrent posterior glenohumeral instability
J Shoulder Elbow Surg
(2005)
E. Schwartz et al.
Posterior shoulder instability
Orthop Clin North Am
(1987)
F.H. Savoie et al.
Arthroscopic management of posterior instability: Evolution of technique and results
Arthroscopy
(2008)
H.B. Boyd et al.
Recurrent posterior dislocation of the shoulder
J Bone Joint Surg Am
(1972)
M.T. Provencher et al.
Posterior instability of the shoulder: Diagnosis and management
Am J Sports Med
(2011)
C.M. Robinson et al.
The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder
J Bone Joint Surg Am
(2011)
R.G. Pollock et al.
Recurrent posterior shoulder instabilityDiagnosis and treatment
Clin Orthop Relat Res
(1993)
J. Fronek et al.
Posterior subluxation of the glenohumeral joint
J Bone Joint Surg Am
(1989)
R.J. Hawkins et al.
Recurrent posterior instability (subluxation) of the shoulder
J Bone Joint Surg Am
(1984)

There are more references available in the full text version of this article.

Cited by (68)

No Difference in Recurrent Instability Between Knotted and Knotless Repair Techniques in Arthroscopic Treatment of Isolated Posterior Labral Tears: A Systematic Review
2024, Arthroscopy, Sports Medicine, and Rehabilitation
To compare clinical failure, recurrent instability, patient-reported outcome measures (PROMs), and return to sport (RTS) between knotted and knotless fixation methods in arthroscopic posterior labral repair for isolated posterior shoulder instability (PSI).
Multiple databases were queried according to Preferred Reported Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies with Level I to IV evidence, including knotted and knotless suture anchors for arthroscopic posterior labral repair. Combined anterior and posterior instability, multidirectional instability, SLAP injuries, unspecified repair techniques, majority open procedures, and revision surgery were excluded.
Screening yielded 17 full-text articles reporting on 852 shoulders undergoing posterior labral repair. Recurrent instability ranged from 0% to 21%, and the rate of revision surgery ranged from 0% to 11% in knotted only, 0% in knotless only, and 2.0% to 8.1% in knotted and knotless studies. Six studies with both pre- and postoperative visual analog scale scores and 7 studies with both pre- and postoperative American Shoulder and Elbow Score scores all showed improvement in scores after intervention regardless of repair technique. Thirteen studies reported RTS or duty rates with a minimum of 79%.
Overall recurrent instability after posterior labral repair for isolated PSI was low with improvement in PROMs and favorable RTS rates regardless of fixation method. There was no clear difference in recurrent instability or revision surgery between knotted and knotless fixation methods for isolated posterior labral repair. However, the current literature is predominantly limited by Level III and IV evidence. The quality of literature and lack of standardization on the definition of clinical failure and recurrent instability among surgeons preclude any definitive conclusion regarding one clinically superior fixation method.
Level IV, systematic review of Level III and IV studies.
The influence of posterior acromial morphology on outcomes and return to pushups in young patients undergoing arthroscopic posterior capsulolabral repair
2023, JSES International
Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR.
We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform.
Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P = .001. The recurrent instability rate was 3/32 (9%). Patients with PAH > 23 (N = 17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N = 15) 0% (0/15), worse WOSI scores (P = .41), and a lower number of pushups (P = .48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60).
Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.
Pediatric Shoulder Arthroscopy is Effective and Most Commonly Indicated for Instability, Obstetric Brachial Plexus Palsy, and Partial Rotator Cuff Tears
2023, Arthroscopy, Sports Medicine, and Rehabilitation
The purpose of this review was to systematically evaluate the literature on pediatric shoulder arthroscopy and outline its indications, outcomes, and complications.
This systematic review was carried out in accordance with PRISMA guidelines. PubMed, Cochrane Library, ScienceDirect, and OVID Medline were searched for studies reporting the indications, outcomes, or complications in patients undergoing shoulder arthroscopy under the age of 18 years. Reviews, case reports, and letters to the editor were excluded. Data extracted included surgical techniques, indications, preoperative and postoperative functional and radiographic outcomes, and complications. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.
Eighteen studies, with a mean MINORS score of 11.4/16, were identified, including a total of 761 shoulders (754 patients). Weighted average age was 13.6 years (range, 0.83-18.8 years) with a mean follow-up time of 34.6 months (range, 6-115). As part of their inclusion criteria, 6 studies (230 patients) recruited patients with anterior shoulder instability and 3 studies recruited patients with posterior shoulder instability (80 patients). Other indications for shoulder arthroscopy included obstetric brachial plexus palsy (157 patients) and rotator cuff tears (30 patients). Studies reported a significant improvement in functional outcomes for arthroscopy indicated for shoulder instability and obstetric brachial plexus palsy. A significant improvement was also noted in radiographic outcomes and range of motion for obstetric brachial plexus palsy patients. The overall rate of complication ranged from 0% to 25%, with 2 studies reporting no complications. The most common complication was recurrent instability (38 patients of 228 [16.7%]). Fourteen of the 38 patients (36.8%) underwent reoperation.
Among pediatric patients, shoulder arthroscopy was indicated most commonly for instability, followed by brachial plexus birth palsy, and partial rotator cuff tears. Its use resulted in good clinical and radiographic outcomes with limited complications.
Systematic review of Level II to IV studies.
Single-Portal Arthroscopic Posterior Capsulorrhaphy for Recurrent Shoulder Capsule Laxity and Instability
2022, Arthroscopy Techniques
Arthroscopic stabilization for posterior shoulder instability is well documented in the literature, offering good to excellent clinical outcomes after injury with favorable return-to-sport and patient satisfaction rates. Posterior capsulorrhaphy addresses recurrent laxity by decreasing the size of the posterior capsule through arthroscopic placement of sutures, in addition to addressing posterior labral tears and any intra-articular pathology within the joint. This technical note describes an arthroscopic posterior capsulorrhaphy for recurrent posterior shoulder capsule laxity and instability in an active patient. This technique uses a single posterior working portal and 2 suture anchors to tighten the posterior capsule onto the intact labrum.
The Cartilage Wear Index: a new evaluation method to improve patient selection in surgical treatment of recurrent posterior glenohumeral instability
2022, JSES International
The purpose of this study was to validate glenoid cartilage lesions as a negative prognostic factor and to define a new image-based preoperative evaluation method to identify surgical candidates for arthroscopic labral refixation with suture anchors in posterior shoulder instability.
Twenty-six patients who underwent arthroscopic posterior labral repair for shoulder instability were evaluated. Only patients with structural dynamic posterior instability were included. We evaluated on preoperative magnetic resonance arthrogram: glenoid version, humeral head subluxation, type of capsular insertion, and the cartilage lesions using the new Cartilage Wear Index (CWI). Two subgroups were analyzed with regard to the preoperative CWI and shoulder outcome scores: Single Assessment Numerical Evaluation (SANE) and Western Ontario Shoulder Instability Index (WOSI).
The median age at operation was 28 (interquartile range = 21-33) years. Median overall postoperative outcome assessment demonstrated a SANE of 90 and a WOSI of 385. The median CWI was 1.02. Subgroup analysis revealed worse median WOSI and SANE scores in patients with a CWI >1.02 and a strong correlation between a high preoperative CWI and a higher postoperative WOSI score (R = 0.58; P = .038).
The CWI can be useful to identify patients who might obtain better outcomes when treated with arthroscopic labral repair in posterior shoulder instability.
Single-Portal Arthroscopic Posterior Shoulder Stabilization
2021, Arthroscopy Techniques
Posterior shoulder instability occurs when the labrum detaches posteriorly from the glenoid owing to significant trauma and is a relatively uncommon type of shoulder dislocation. Although posterior instability has often been treated with open shoulder stabilization, modern arthroscopic procedures are being rapidly pursued by surgeons as an improved option because of decreased invasiveness and reduced operative times. Arthroscopic stabilization of the posterior glenoid labrum typically involves 2 working portals, but the procedure still yields successful results when performed with a single posterior portal and a suture passer. Our technique involves 1 less portal to reduce invasiveness, lower the risk of nerve damage, and decrease the operative time and postoperative pain. The purpose of this article is to describe an arthroscopic posterior stabilization technique with a single working portal.

View all citing articles on Scopus

: The authors report that they have no conflicts of interest in the authorship and publication of this article.

View full text

Original ArticleArthroscopic Repair for Posterior Shoulder Instability

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Patient Selection

Arthroscopic Findings

Outcomes

Discussion

Conclusions

Arthroscopy

J Shoulder Elbow Surg

Orthop Clin North Am

Arthroscopy

Recurrent posterior dislocation of the shoulder

J Bone Joint Surg Am

Posterior instability of the shoulder: Diagnosis and management

Am J Sports Med

The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder

J Bone Joint Surg Am

Recurrent posterior shoulder instabilityDiagnosis and treatment

Clin Orthop Relat Res

Posterior subluxation of the glenohumeral joint

J Bone Joint Surg Am

Recurrent posterior instability (subluxation) of the shoulder

J Bone Joint Surg Am

Original Article
Arthroscopic Repair for Posterior Shoulder Instability